Flicking through some literature on quality improvement recently I came across a quote from quality expert Harold F Dodge – “you cannot inspect quality into a product”. The simple central message made me pause. It has a particular potency in the context of the recent high profile quality of care concerns in the NHS. So much energy has revolved around what the inspectors and regulators are doing that it seems we are missing the point about how to improve quality.
My thoughts turned to Joseph Juran’s Quality Trilogy which still has currency today. The trilogy holds that, in complex social systems, three elements need to be brought together for improvements to be realised – quality planning, quality control and quality improvement. When working well, and in synergy, they can stimulate a dynamic energy to drive improvement.
The over reliance on inspection suggests that we are operating almost entirely in the control domain. More worryingly though is that it implies that the responsibility for quality control sits outside organisational boundaries. Is this really the route we want to go down?
Independent inspection, no matter how much you invest in it, will not in itself improve quality in the long term. Reflecting on my own experience in public services many of the structures of quality planning, improvement and control are in place. It’s just that they are not always brought together and coordinated centrally. The frisson created within a system when the three elements spark off each other is therefore lost.
I suspect that part of the issue is that the activities of control are quicker and easier to implement. They give the comforting impression that ‘something is being done’ and so become the default.
This is not to say that I am against external systems of regulation and scrutiny. They can create a real impetus for improvement and sometimes it is necessary to move with haste, but with good planning this should be the exception. I would just like to see control balanced with effective planning and more investment in ‘enabling’ approaches to quality improvement.
Achieving sustainable change is about charting a course that includes clarity of vision and direction from the top as well as a range of enabling strategies. The need for this roundedness often gets lost in the heat of the burning platform.
It can take real courage to hold steady in the face of criticism or as Oshry puts it, challenge ‘the dance of the blind reflex’. It starts with a willingness to have a different conversation.