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Total quality management: care dealers vs. car dealers.

According to Leland Kaiser, "Curing is a problem of medical science. Healing is a problem of human love and nurturance....I think the hospital of the future will say that it heals everyone who comes through its doors. Those it can cure, it cures."(2) Healing (vs. curing) is activated by the art (vs. the science) of medicine, which Weil defines as the "ability of a practitioner to select and present to individual patients those treatments most likely to elicit healing from within."(3) Healing is activated by the humane treatment that patients receive. Total quality management in health care must account for this difference between curing production (medical) problems and healing human beings. Without healing, our health care delivery organizations become assembly lines. The development of a healing culture requires total commitment to a new concept and rigorous application of three very old and basic tools.

A New Concept

The concept may be called "behavioral quality assurance" (BQA).(4) A specific example will help distinguish BQA from total quality management and from traditional quality assurance.

Charlie had a stroke and landed in the hospital. He's annoyed that he can't read anymore--the letters on the page don't make any sense to him--but he's in good spirits. He'd like to get a decent night's sleep and not be awakened by somebody giving him a sleeping pill or by another resident chewing out a nurse. Charlie doesn't care that his hospital is associated with a respected medical school. He wants only to get well and to go home, not necessarily in that order. His prognosis is fair. The future depends partly on Charlie's will to live and on his 82-year-old body's ability to mend itself.

Traditional quality assurance efforts focus on the general question, "Have the hard technologies and science of medicine been appropriately and skillfully applied in the service of curing?" More specifically, "Did Charlie receive the medically calledfor injections to thin his blood? Was the angiogram performed according to accepted medical procedures? Were all the necessary steps taken to avoid toxic staff infections?"

In contrast, BQA efforts focus on the general question, "Have all the hands laid on Charlie been appropriately and skillfully applied in the service of healing?" More specifically, "Did the person injecting Charlie empathize in the process? Did the provider who skillfully performed the angiogram sense and treat Charlie's anxiety over the procedure? Were all the necessary steps taken by the provider organization to ensure that Charlie was not the victim of toxic interpersonal staph infections?"

Nothing can cure Charlie's inability to read, but a healing culture can help him learn to live his life to the fullest one day at a time. Did his docter take the time to explain with compassion that, although Charlie can't play gin rummy or read anymore, he can still enjoy a high-quality life? Did anyone just hold Charlie's hand so he could grieve these mini-deaths? Did anyone ask Charlie whether he felt he had been treated with TLC and what, specifically, that meant to him?

A "yes" to these questions would only be ensured if the art of medicine (as well as the science) were being monitored. That's where BQA comes in. BQA focuses on the quality of our interpersonal relationships- Behavioral quality assurance is to the art of medicine and healing what traditional quality assurance is to the science of medicine and curing. BQA is a necessary component of total quality management in health care. Patients will heal faster with heavy doses of BQA and TLC-5 Although shorter hospital stays save money for everyone, traditional technical and managerial quality assurance systems have not encouraged this high-touch component of healing. From a defensive point of view, vast financial and emotional resources could be saved because, "The malpractice problem is essentially a human relations problem."(6) When patients feel cared about, they don't sue for revenge when something goes wrong.

When the health care industry embraces BQA, patients will know that they are contacting "a handholding company"(7) when they are ill. Otherwise, the best that they can hope for is a super-efficient, costeffective assembly line. "The 20th Century hospital cured the body; the 21st Century hospital cures the body and heals the person. The body-repair shop metaphor of the 20th Century has broken down: The hospital no longer just repairs the car; it also works on the driver"(8) Every employee in a health care organization is a driver when it comes to the creation of a healing culture. BQA keeps all these drivers aligned with the mission of healing.

Back to Basics Awareness

Our ABCs, Awareness of Behavior and its Consequences, are the three keys to continually improving the quality of any relationship. Awareness means more than sensitivity, which itself is crucial. We have the capacity to make conscious choices as to how we behave. Awareness is the beginning of building higher quality relationships. If the resident caring for Charlie takes a split second to think before he chews out a nurse, he might choose a new behavior. If he calmly suggests a new way to perform a procedure, his relationship with the nurse will be less stressful in the future. A different behavior yields a different consequence.

My colleagues and I have found that people draw from a generic pool of measurable behaviors when their objective is to create win-win outcomes. How these behavioral tools are put together varies. Car dealers would put them together differently from care dealers, but they tap the same pool of behavioral choices.

The BQA process would begin with patients selecting the concrete behaviors that their direct providers must exhibit in order for them--as customers-to conclude they are being healed, that is, being treated with loving care and respect. A simple card-sorting process could be used. Market research could identify the subset of behaviors from the generic pool that patients are likely to associate with respect and TLC.

Before admission, or shortly thereafter, Charlie would identify the five specific behaviors that would show him that he was being cared for as a human being. These would become a part of this treatment plan. He might choose "You explain the bases for your decisions," and 'You ask me for my ideas and thoughts." Charlie's needs are now concrete. For instance, if he wants a sleeping pill, he wants to ask for it or have it offered with an explanation while he's awake. When he makes a future appointment, his medical, insurance, and demographic information could appear on the computer screen, along with his BQA choices. The same information can be prominently displayed on his medical record and updated according to changing needs.

Airlines and hotels have adopted minor aspects of this process. Make a reservation at any Ritz Carlton Hotel in the world, and if you've been a customer, information about your preferences will appear on the computer screen. Your personal definition of that subjective term being cared for will guide your treatment there.

What are the practical implications for the health care organization that chooses to implement BQA? For patients to believe that care givers really care for them as human beings, all employees in the organization must participate in creating a healing culture. They must care not only for patients, but for each other. Providers must learn to treat one another with TLC. No delivery organization can expect to sustain its ability to export this high-touch quality without regenerating it from within.

The awareness component of BQA radiates from the patient throughout the entire organization. The bottom line of this awareness phase would be the creation of BQA contracts between pairs of individuals or groups or among the members of a group whose meetings set the tone for others. Selecting from the same generic pool, staff would define the behaviors that others must exhibit in order for them to conclude that they are being treated with loving care and respect.


When there is a lack of win-win behaviors in car dealerships, financial bottom lines suffer. When there is a lack of win-win behaviors in care dealerships, humans suffer. The behavioral skills needed to continually forge and fine tune win-win relationships (healing relationships) can, and must, be learned. To develop the specific behaviors within and among key organizational levels requires different but related developmental programs.(9) The overriding objective --high-quality care and healing-- would be common to all programs, as would the generic behavioral pool.

Active listening, for example, is an essential skill for all human encounters. What an individual might be actively listening for as content would vary--that is, a provider would seek certain information from a patient; a clinic nurse would seek different information from a laboratory technician. The day-to-day work situations confronting those who operate in the board room are qualitatively different from those confronting providers who work in the operating room. While the new skills focus on behaviors related to treating people with loving care and respect, the core structure of the learning process remains the same.

In most provider organizations, three to four program interventions will be required: one for those with direct patient contact, one for middle managers and support personnel, and one for senior managers and executives. Because the behavioral pool is common to all the interventions, when everyone has been trained, a common frame of reference a common language system-will have been implanted. A common way of doing things--a common way of relating to one another-- forms the core of every organizational culture. BQA provides people with the tools for creating a culture where everyone is treated with loving care and respect.

While the awareness phase radiates from the patient up, the behavior-change process cascades from the top down. The behavior of those who operate in the board room affects the behavior of those who function in the O.R. This does not mean that the seeding of a healing culture cannot begin anywhere along the line. But staffers want to know that the new BQA values apply to everyone. They'll be inspired by senior executives who are practicing what they preach. Otherwise, there will be stress and burnout.

Let's look at an example of a senior executive group's role in implementing BQA. Senior executives wanted to create a win-win culture focused on customer service, so the CEO and those reporting directly to him committed to a BQA contract that guides all their meetings. The result was the sample Meeting Behaviors Monitor Sheet shown in the figure below. The specific behaviors referred to are those that bubbled up as a clear consensus from the awareness phase described earlier.

At the end of each weekly meeting, each member records his or her evaluation, from excellent to poor, of the extent to which the group reflects each behavior. The meeting secretary records the weekly and meeting-todate information. The first item on each weekly agenda is a review of the Monitor Sheet to heighten awareness. Like others facing external forces beyond their control (government regulations and increasing competition), members of the senior executive group had found it easy to ignore ideal behaviors. In the heat of battle, they often forgot to acknowledge another's contribution by saying "thank you," and by "gracefully accepting feedback."(10)

As an outgrowth of the BQA contracting process, a new TQM team was formed, chaired by the CEO. This team's only responsibility is to ensure that employees are caring for each other in the same way that the organization needs to care for its customers. Customers had also reported feeling that they were not given the "time and attention needed to get their points across."

What differences can be expected as a result of these efforts? The mission statement of this organization, a simple but powerful formula, reads:

Self-Esteem + Quality Improvement

= Customer Satisfaction

Employees who value themselves and each other will put their hearts and souls into improving quality. Early quantitative results are encouraging and are strongly confirmed by a growing body of research on the role of patient-generated data in improving quality care.(11) An anecdotal example of the power of caring for internal customers speaks poignantly to the difference between car dealers and care dealers.

Walking the talk requires dealing with severance issues--the organizational equivalent of informing a patient of a terminal illness--in the most caring manner. A manager reported the following experience with a group of his employees who had to be terminated: "Eight were area managers, and one was a manager at the same level as me. It wasn't easy, but I used the BQA skills and felt that company objectives were met and that the people were happy with the explanations and procedures used. They left the Company with dignity and no ill feeling. One even wrote a note thanking me' for the way I handled the situation."

Writing a thank-you note to a person who told you that you were no longer employed is, to me, very atypical. Care dealers must ensure that employees and patients who leave, regardless of the circumstances, do so with their dignity and self-esteem intact.


Progress, not perfection, is our lot in life. The behavioral training interventions provide needed tools. But effective, long-term use of these tools requires attention to three highly user-friendly areas of consequence management:

* An individual information feedback system. High-quality care must begin at home. The organization's existing internal computer network (and even its telephone system) can be programmed to provide comparable BQA information when one colleague contacts another for a consult. In addition to identifying the caller, business as usual in many organizations, the computer could remind both parties of their BQA contract. The technology is nearly here.

* All of the organization's formal policies and procedures. Selection and orientation procedures must ensure that new hires are aligned attitudinally with the organization's commitment to treating everyone with loving care and respect. Baum has suggested, "It would be nice if everyone who left our offices and hospitals had the same feeling of a good experience" as does nearly everyone who visits a Disney theme park.(12) Although health care organizations deal in life and death, not fun and games, engendering this "feeling of a good experience" in health care is not just a matter of good guest relations: it is the core of healing.

Performance appraisal systems and procedures similarly must be aligned with the behaviors individuals have acquired. The fulfillment of BQA contracts and the general manifestation of win-win behaviors need to be visibly tied to formal organizational rewards that support the creation of healing cultures. Career planning procedures must allow for the possibility that there will be organizational casualties. Those who cannot, or choose not to, embrace the need for loving care and respect will require the most humane treatment. Their lives in the organization have come to an end.

* Creation and regular use of an information feedback system. A systematic survey of the health of the organization's human assets-- a climate survey(13)--will ensure that senior management has the information to guide the creation of an organizational culture focused on caring and healing.

Awareness of behavior and consequences is the key to feedback, and feedback is the key to learning how to better care for others and for ourselves. Without feedback, no learning can take place. Without learning, the healing process becomes stymied.

The Bottom Line

Friedman warns us, "The resource we are not money; it is political courage. It is leadership.''14 We need leaders who are committed to the ABCs of behavioral quality assurance, leaders who will add TLC to the culture of our health care organizations.|5 Without BQA, quality management in health care cannot be total. Human beings who are in need of repair deserve a better deal than their cars get.


1. Faltermayer, E. "Let's Really Cure the Health System." Fortune 125(6):46,47,4950,54,58, March 23, 1992.

2. Curry, W. "Looking Ahead." Physician Executive 16(1):4, Jan.-Feb. 1990.

3. Skelly, F. "Extending the Boundaries of Healing." American Medical News 35(8):29-33, Feb. 24, 1992.

4. Personal communication, Robert H. Hodge Jr., MD, FACPE.

5. Revans, R. Standards for Morale: Cause and Effect in Hospitals. London: Oxford University Press, 1964. Two recent studies confirm this common-sense idea: "Heart Update: Coronary Patients Recover Faster When Pampered." USA Today, Nov. 12, 1991, 1D; and "Doctors Need Better Conversation Skills." Austin American Statesman, Nov. 15, 1991, 11A.

6. Brent, R. "Medical-Legal Survival: A Risk Management Guide for Physicians." JAMA 267(9):1273-4, Mar. 4, 1992.

7. Rubin, I., and Fernandez, C. My Pulse Is Not What 1t Used to Be: The Leadership Challenge in Health Care. Honolulu, Hawaii: Temenos Foundation, 1991.

8. Bezold, C. "Five Futures." Healthcare Forum Journal 35(3):29-35,37,39-42, MayJune 1992.

9. For more detail on this concept, see Rubin, I., and Inguagiato, R. "Behavioral Quality Assurance: A Transforming Experience." Physician Executive 16(5)30-3, Sept.-Oct. 1990. See also, Rubin, I., and Inguagiato, R. "Changing the Work Culture." Training and Development 45(7):57-60, July 1991.

10. Rubin, I. "Management by Walking Our Talk." Physician Executive 17(5):44-6, Sept.-Oct. 1991.

11. Epstein, K. "Utilizing Patient's Perceptions to Assess Quality of Care." Health Policy Newsletter 5(2):2-3, May 1992.

12. Baum, N. "Doctors Can Learn Much from Disney about Patient Visits." American Medical News 35(7):32-3, Feb. 17, 1992.

13. For more on the role of a climate survey in the healing of a health care organization, see Rubin, I., and Fernandez, C. My Pulse Is Not What It Used to Be. The Leadership Crisis in Health Care. Honolulu, Hawaii: Temenos Foundation, 1991, pp. 25-44.

14. Friedman, E. "Rationing Health Care: Crisis and Courage." Healthcare Forum Journal 34(6):12-5, Nov.-Dec. 1991.

15. Rubin, I. "Extended Coverage or Coverup?" Los Angeles Daily News, June 26, 1992.
COPYRIGHT 1992 American College of Physician Executives
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Title Annotation:Medical Quality Management
Author:Rubin, Irwin M.
Publication:Physician Executive
Date:Sep 1, 1992
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