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The key word in medicine.

The Key Word in Medicine

Within a couple of decades Japanese industry has come from almost nowhere to dominate world competition. The Japanese can produce goods that are simultaneously cheaper than those of their competitors and of higher quality. What is the secret? Important factors include cheap capital; a long term orientation; a family atmosphere within companies, where workers and managers work together rather than against each other; heavy expenditure on research and development; and government support. But if one factor must be picked out it is kaizen a commitment throughout most Japanese corporations to continual improvement in quality. Kaizen is one of the most commonly used worlds in Japan, and now it is beginning to be heard in corporations from San Francisco to Singapore. The idea is also emerging within medicine, and there is every prospect that kaizen might do for health care what it has done for Japanese industry.

The idea at the heart of kaizen is that poor quality arises from bad systems rather than bad people. The product is defective not because the workers is lazy or stupid but rather because he or she is inadequately trained, has poor tools, or has insufficient time to do the job - or because of a myriad of possible system defects. To make kaizen work managers must create an environment in which people are enthusiastic to identify deficiencies and work together to right them. Fear must be abolished. "Every defect is a treasure" because once the defect is recognised work can begin on putting it right. Similarly, every patient complaint is a treasure because another key idea with kaizen is that the customer or patient defines quality. These are not the current attitudes within medicines.

Although the customer or patient is king or queen, kaizen begins with process rather than outcome. Ironically, the originators of many of the ideas that have come together to form kaizen were Americans, and they emphasised data and statistical techniques. You start by charting the steps of your process (which is often revelatory in itself) and then measure those steps. You identify where the biggest improvements can be made and begin there on a process of measuring, trying an improvement, measuring again, and so on forever. Perfection is never reached, although you will arrive at a point where there will be more potential for improvement in another part of the system. The aim is to shift the whole process towards greater quality rather than attempt to improve quality by discarding the outliers. Outliers are not, however, ignored, and reasons why the measurements from a particular person, process, or machine are so far removed from the mean will be explored.

This process, which may sound annoyingly theoretical, can be imagined working in circumstances as familiar as British general practice. Imagine that the team wants to improve its preventive care. It defines and measures what it is doing and may decide that the biggest improvements could come in, say, managing high blood pressure. The team again measures what it is doing and discovers, say, that it records the blood pressure in only a small proportion of the men over 40 in the practice; it notices too that some partners do much worse than other. The reasons why some partners perform poorly will need to be explored, but at a team meeting the receptionist might suggest a system of marking the records of those whose blood pressure has not been measured, or maybe the nurse will suggest that she starts a well man clinic An improvement - and often an unglamorous one - will be tried, and measurement will be repeated. And so the process will continue in an environment that sets great store by continual improvement, encourages people to look for and report defects, and feels happy to measure constantly what is happening. Although I use the fashionable word kaizen, some general practitioners will recognise these activities from their own practices. There are more unusual and probably more difficult in hospitals.

Kaizen's emphasis on process seems to conflict with health care's current emphasis on outcome. This conflict is mistaken, I believe, and we need both kaizen and outcome measures. Although kaizen concentrates on process, it does so merely as the most effective means to the end of a better outcome or produce. And Japanese industry exists within an environment where the outcomes of profit, market share, and stock price are visible to all and where the outcomes of bankruptcy or hostile takeover await those who perform poorly. Similarly, kaizen in healthcare may make more sense and be more likely to occur in an environment where outcome measures of hospitals and practices are known to all.

But surely kaizen should be more attractive to health workers than the pursuit and punishment of bad apples. We know how difficult it is always to perform well, how much we depend on teams and back up, and how crucial it is to keep learning and trying new ways. A system that helps us in these endeavours must be better than one that waits until we perform badly and then punishes (or even retrains) us. Furthermore, quality is a banner that all are willing to rally round.

Despite these attractions health workers have been even slower than Western industry to come to kaizen. Partly this is because health workers are unused to learning from business. Another problem is that doctors "have difficulty seeing themselves as participants in processes, rather than as lone agents of success or failure." R. Jaffe (personal communication) has identified three broad reasons why doctors defining quality narrowly as medical decision making, and thinking (wrongly) that better quality must mean higher expenditure; many doctors are uncomfortable with systematic analysis of data; and implementation may be difficult because doctors are too used to controlling others.
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Title Annotation:the concept of kaizen, meaning commitment to continual improvement in quality as applied to health care
Publication:Economic Review
Date:Sep 1, 1991
Previous Article:Health and nutrition.
Next Article:National Institute of Leprosy.

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