J.M. Juran observed many workplaces over several decades in the 20th century, looking at the circumstances in which individuals committed errors—mismatches between the service or product supposed to be produced and the service or product actually produced.
He concluded that most of the time the responsibility for error was failure of the managers and their management system rather than poor individual motivation, lack of skill or deliberate mischief.
We need to review Juran’s concept of “self-control” to buy his argument. Self-control enables organizations to have each individual provide a foundation for quality control.
According to Juran, self-control for an individual has three requirements:
1. Means for knowing what the individual is supposed to do.
2. Means for knowing whether the individual is actually doing matches what is supposed to be done.
3. Means for changing if what is actually done doesn’t match what is supposed to be done.
(J.M. Juran (1968), “Operator Errors—Time for a New Look”, Quality Progress, 1 (2), 9-11, 54, available at http://www.juran.com/elifeline/elifefiles/2009/11/Operator-Errors-Time-for-a-New-Look_JMJuran-94.pdf).
Juran reasonably asserted that managers and their management system are responsible for providing each individual with these means—vital tools to produce and control the quality of the product or service, day after day.
Here’s the logic behind Juran’s conclusion: When Juran observed individuals and their errors, about 80% of the time management had failed to provide all of the three vital tools—so, most of the time the responsibility for the errors rested with the managers.
(Juran’s Quality Handbook, 5th Edition, 1999, McGraw-Hill: New York, p. 4.19, available at http://www.pqm-online.com/assets/files/lib/books/juran.pdf).
Application to a Team Setting
Ambulatory surgical centers participating in the AHRQ HRET safety program have worked to sustain reliable use of surgical checklists and associated communication behaviors by operating room teams.
For instance, a “time out” before the initial incision typically includes audible checks of key items on a checklist and explicit statement by each member that he or she is “Ready”.
To develop consistent adherence to the time out standard, each team needs to know (1) what they are supposed to do; (2) whether their actual practice matches the standard, agreed-to work; and (3) how to change their behavior if actual practice differs from the standard.
Juran’s self-control language has useful implications for OR teams. And the management concept holds for teams, too: if each OR team does not have the three self-control “means”, it is management’s responsibility to equip the OR teams with those means to build a foundation for quality control.
OR team self-control is tough in large part because operating room team behavior depends critically on behavior of the surgeon, who is not subordinate to the OR supervisor and may have formal ownership in the center.
Nonetheless, based on our work this spring, it looks like centers can start by tackling parts (1) and (2) of self-control for all team members, including the surgeons.
Daily huddles and direct observation of time-outs are useful tools if the center is serious about reliable use of time-outs, part of a larger management system described in my last post (link here).
Discussion of time-out behavior in daily huddles by OR staff helps to reinforce knowledge of what to do and to flag specific issues in time-out practice. Regular observation of time-outs by both the OR supervisor and center senior leaders identifies gaps between actual practice and standard. The observations, summarized in tables or charts, have a place on a unit visual management board, to show current performance, trends, and the effects of specific improvement interventions.
Shigeo Shingo’s innovation of source inspection and error-proofing is a logical extension of Juran’s self-control. S. Shingo (1986), Zero Quality Control: Source Inspection and the Poka-yoke System, Productivity Press: Stamford, CT).