Do doctors need Deming?

Amongst the relatively new group of health professionals concerned with evaluating the quality of care there is confusion with regard to the terminology of programs for assessing that care. The new terminologies of Total Quality Management (TQM) and Continuous Quality Improvement (CQI) certainly imply a greater involvement by "managers" of health care facilities. If this leads to the provision of more resources within a facility for evaluation of care, the change in terminology is a positive step for quality assurance programs etc. Quality assurance programs as we have been conducting them will fail if there is no commitment from the "top" to provide resources for the conduct of review programs. In 1987 a review conducted by the Australian Institute of Health (AIH) [1] revealed that only 65% of Australian hospitals had a budget item for quality assurance, and from my observations of such hospitals in none of them (with one exception) did it reach a figure of 0.1% of a hospital's budget. It has also been my experience, in hospitals both in Australia and the United States, that unless there is a commitment from the heads of the clinical departments quality assurance programs will be ineffective as there is limited action taken when problems are revealed. The call has thus come for a change in "culture" in a health facility towards the adoption of TQM and the CQI as suggested by Berwick [2]. I certainly agree that there is a greater need for commitment in the search for quality from administrative groups but I would argue that clinicians are constantly striving, admittedly with varying degrees of success, for continuous improvement. Of the fourteen points outlined by W. Edwards Deming [3], who revolutionized industrial output in postwar Japan, some already exist within a clinician's philosophy and some are not particularly appropriate (see Table 1). Deming's first point is the need for a constancy of purpose. This already exists (for the vast majority of clinicians), namely the desire to heal sick people, and there is no need therefore for his second point, the adoption of a new philosophy. Deming's third point is a recommendation to cease mass inspection. Such an inspection is not done and cannot be done in our health facilities. A large industrial firm such as General Motors concentrates upon the production of a limited number of items which are all expected to be identical at the end of the production line. A health facility on the other hand deals with an infinitesimal number of "products" and the outcome will vary, not only according to problems with the system of care or with the people providing the care, but also with the "raw materials" provided. These will vary according to the state of the patients at presentation, their age, anatomy, physiology and particularly their psychology, in other words their case-mix and illness severity. Deming highlights the importance of ensuring uniformity and quality in the raw materials prior to the processing of the product but such an advantage is not available to clinicians. The fourth point is that price is not the best goal to success. However, the health care dollar, in Australia as in most countries, is limited and any particular health care facility is therefore limited in the control of its product price. Deming's fifth point is to improve production and service. Certainly with regard to the latter health care facilities and their providers may be found wanting with regard to good communication and "hotel" services offered to patients, and production can be improved in