In his seminal book, “Out of the Crisis,” W. Edwards Deming famously posited that 85% of customer problems can be attributed to poor processes. In a field plagued by long waiting times, high-no show rates, and early dropouts, what are the implications of this statement for leaders in addiction treatment?
Conventional thinking would hold that client motivation is the problem. However, agencies that practice the NIATx process improvement model (based on understanding and involving the client) have demonstrated time and again that waiting lists can be eliminated, with higher show rates, better continuation, and greater admissions as a result. Streamlining processes to better serve clients ultimately leads to greater cost efficiency and enhanced organizational effectiveness.
In “Out of the Crisis,” Deming laid out “14 points” essential to transformational leadership. While they may seem challenging, even confrontational, these principles have been proven for decades by world class companies like Honda and Toyota. (American auto makers Ford and GM largely rejected Deming, and we see how well that worked out.)
Deming's 14 Points are laid out below, verbatim. While they were originally written for manufacturing organizations, they can apply (with minor adjustments) to any organization that serves customers. Following each is a brief discussion of how they might be used to improve addiction treatment.
Deming's 14 Points
1. Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business, and to provide jobs.
Remaining competitive and staying in business are critical issues as the field faces funding challenges. Employees are worried about keeping their jobs. Management is responsible for creating and articulating an organizational purpose of client service, and engaging staff in supporting the mission. With organizational survival at stake, every employee must believe in the criticality of customer service.
2. Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.
Though the “new economic age” Deming spoke of was actually the 1970s, the statement is timeless. Change is the one constant force in economics, and leaders need to recognize the constancy of change to be effective. The “new philosophy” required is to understand and involve the customer in the design of services. All successful service organizations share one common trait: a commitment to customer service. Organizations that do not respond to customer needs are unlikely to survive.
3. Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place.
Deming railed against achievement of quality through inspection because it hides, rather than examines, the underlying processes that delivered the defect or quality problem. A common process “defect” in the addiction treatment field involves client no-shows. Rather than planning for and accepting no-show rates of 50 percent or more (all too common in the field), agency leaders should examine how agency processes impede access to treatment and cause no-shows. Should we really be surprised, for example, when clients told to wait a month (or more) for an assessment fail to show for their appointments?
4. End the practice of awarding business on the basis of price tag. Instead, minimize total cost. Move toward a single supplier for any one item, on a long-term relationship of loyalty and trust.
Payers increasingly demand services that achieve long-term treatment outcomes (i.e., employment, crime avoidance, etc.) Such outcomes put a premium on agency engagement with its clients. Yet, conventional treatment approaches do not. Agencies need to design services that treat the “whole person” across the continuum of care, from the first request for service through aftercare and wraparound services. Many successful agencies now help connect clients with housing and employment during the course of treatment. Providers need to take an empathetic, holistic view of clients and help them address all life problems that hinder successful treatment.
5. Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs.
Designing efficient processes aimed at optimizing the customer experience are the key to decreasing costs. Processes that impede access increase wait times, drive up no-shows, and reduce staff productivity. In a field where labor costs are a predominant factor, no-shows and dropouts are extremely costly. Process improvement tools such as the walkthrough exercise, flowcharting, and the nominal group technique (available at http://www.niatx.net) can help agencies fix disruptive and costly process problems.
6. Institute training on the job.
The operative phrase here is “on the job.” Employees need to be trained in all appropriate skills required for their jobs. Adult learning research shows that experiential learning is preferred to didactic learning. In other words, training manuals are insufficient; employees learn best how to deliver excellent service by doing it, not by reading about it, listening to it, or watching it.
7. Institute leadership. The aim of supervision should be to help people and machines and gadgets to do a better job. Supervision of management is in need of an overhaul, as well as supervision of production workers.