Tuesday, May 8, 2012

Quality in Government

Is this an oxymoron?  Well, it kind of depends on how you define “quality” and who your customers are.  I work in the Office of Medical Services of the Department of State (DOS).  One customer group we deal with is DOS employees who want to serve overseas.  Our other customer group consists of job applicants with some medical condition that may prevent them from being hired. 

Those in the employee group have little clout as individuals, but as a group they are potent.  If enough of them become unhappy with our services, a directive comes down from above to “FIX THIS PROBLEM!!”  Once we understand what excites senior management, we fix that problem.  And then we fix it again, until it is so slick, we get kudos from customers. 

The applicant group is less powerful.  Some write their Congressman, and that gets attention tho not usually the desired result.  Some hire lawyers.  Again, attention but not usually the desired result. 

And then, a funny thing happened.  Five years ago, we adopted ISO 9001 as a management system.  Now, each of the 30+ sub-processes in MED has a written procedure about how they do what they do.  They know who their customers are and actively solicit input.  The most common metric is clock time, and “stuff happens faster now.” (A quote from an employee survey.)  One process in my office that routinely took 60 to 90 days now gets done routinely in 2 to 4 hours.  A few years ago, it took, on average, 11 months to hire a new employee.  Last month, we interviewed an applicant who applied only two months ago. 

If this still seems long to you, you’ve never dealt with OPM or applied for a Federal job.  If you do so, the person who wants to hire you may never see your application.  Some clerk in HR, who knows nothing about the job will decide how well qualified you are.  The office that has the opening will only see the top three names on her list.  For the rest, it’s a coin toss.

Are we truly worse that the civilian healthcare industry, as Paul Borawski suggests?  No.  We’re better, and I can prove it.  We collect HEDIS data every month from each of our 180 primary care offices around the world.  (Now there’s a challenge!)  Three times a year, we compare our data to the best US healthcare system results and discuss improvement strategies at the senior management level.  In general, we do well, although there are some special challenges in our system.  (Like getting a frozen vaccine to Ulaanbaatar.)  One thing we have that makes all this work is a culture of quality—the universal desire to do a good job coupled with the knowledge that senior management shares that goal.  Each quarter, we discuss errors, deaths, and complaints with those providers stationed in Washington.  I once received this email from a medical officer overseas: “Bob, we made the following mistake in our health unit this week.  Please discuss it at your next meeting.  I’d like to see what the group thinks.” 

How do you get there?  It takes leadership, consistency, and credibility.  It can be done in government


  1. hi Robert
    good to hear from someone who has skin in the game to use your expression

    I had been more involved in Quality in Manufacturing environments however recently have begun participating in consultations on delivery of Emergency Dept facilities - so I'm finding posts from bloggers such as yourself & others in ASQHealthcare very informative


  2. Sadly health care provides one of the worst recent examples of politics messing up government quality. Don Berwick has done as much as anyone to move forward the use of quality management tools to improve health care systems. The government had him running and helping deal with huge issues. But politics got in the way and he was thrown out. The authority he had required legislative approval and for political reasons (certainly not because he wasn't about the most qualified person ever in his position). It was a very sad case of the government again falling short due to bad political decisions leaving those trying to improve worse off.

    1. Sorry. Don't blame Berwick's problems on "the government." This was the Republicans in Congress. Other parts of government function very well--or at least can do so.