Building a healthy Quality culture

For much of this spring, I've written about system and culture failures. I've written the most about Boeing, but I've addressed other companies too (even ones like Toyota and Patagonia, who are mostly pretty good). After a while it can get grim. One reader wrote me to say, "I am too depressed about the Boeing issue."

What if we look at a success story, for once? A company that built on a history of doing good work, and lifted themselves to world-class performance? It could be a refreshing change, if nothing else.

A couple weeks ago Dale Weeks, another reader, called my attention to an ASQ Case Study about the Mayo Clinic. The study, titled "Journey To Perfect: Mayo Clinic And The Path To Quality," was written in July 2012. That means it is more than a decade old, but it is hardly out of date. The Mayo Clinic is still among the best hospitals in the world. This Newsweek website rates them, in fact, #1 in the world. Mayo's own website states, more modestly, that "Mayo Clinic Hospital — Rochester is top-ranked in more specialties than any other hospital and has been recognized as an Honor Roll member by U.S. News & World Report's 2023–2024 'Best Hospitals' rankings." Whatever they are doing, they are doing it right and it seems to be working.

What are they doing? The article describes a history of Quality initiatives at Mayo, so the first thing is that Quality has been a sustained focus over many years. But the heart of the article is about the Quality initiative in the early 2000's, and this had several elements. We have discussed some of them before. 

• Mayo implemented a "Fair and Just Culture," in which "every member of the medical team is encouraged to report anything that does not seem quite right, without fear of reprisal." Even better, the article gives examples which suggest that Mayo really means it. (By contrast, for example, Boeing's culture sounded good on paper, but did not encourage transparent communication in practice.)
• Mayo asked all departments to display their performance data, so that any room for improvement would be visible to everyone. (Back in the first year of this blog we discussed the value of making your performance data visible to everyone.)
• Mayo used this performance data to look for best practices, and then spread those best practices across all their multiple hospitals. Sometimes the data related to patient outcomes: when one hospital had a much-lower patient failure rate than all the others in administering warfarin, Mayo studied that hospital's procedure and made it standard. Other times, the data was frankly economic: when they found that one orthopedic surgeon could do hip replacements more profitably than any of the others (while all of them had the same rates of patient outcomes), his method became the one to use.
• While of course Mayo had to track their financial metrics the same way any business does, those were never the center of attention. Mayo's key metrics focus on "patient and quality outcomes, patient safety, and the patient experience." We've talked before about why it is more valuable to measure problem-resolution than operational activity, and also about why it is essential to see how the problem looks to your customer. These are lessons Mayo has clearly taken to heart.
• Mayo made training available to all employees on Quality methods, including topics like Six Sigma, lean, and reengineering; and encouraged everyone to take them. They even issued pins of different colors that employees could wear, to show how far they had progressed through the curriculum.
• Finally, Mayo implemented an extensive knowledge management infrastructure.

All of these measures are excellent, of course, and it is no surprise that the outcomes have been so good. But I found myself wondering, Why doesn't everybody do this? If the Mayo Clinic can focus on Quality this relentlessly and achieve such glowing results, then it is clearly possible. And if it's possible, why doesn't everyone else do the same thing? Why—not to put too fine a point on it—isn't Boeing following this very same game plan right now?

The article isn't structured around cause-and-effect. It's a case study, and not a root-cause analysis. But as I combed through it, I think I found three fundamental points that made all the others possible.

• First, Mayo had a history of selecting executives from among its practicing physicians. I have sometimes argued that management roles should not be handed out as rewards for the very best physicians or surgeons, because it's better that those experts continue to save lives in the examining room and the surgical theater. At the same time, it clearly makes a difference when the executives understand the work at a deep level. Once upon a time, Boeing's executives were engineers, too.
• Second, Mayo chose to focus on Quality first, not cost; and their metrics for Quality were tied directly to patient outcomes. This is the correct way to define metrics: start by defining what results you want to achieve, and then build metrics to support those results. In modern management, metrics drive so much other activity that it is critical to get this part right up front.
• Third, it is clear that the whole Quality initiative had unflinching management support over the long haul. Without a clear vision of what to do, and an unwavering commitment to doing it, none of this could have been accomplished.

These three points aren't universal. Not every company selects its executives from its working experts; not every company prioritizes Quality over cost; and not every management team is committed to implementing Quality in every aspect of their business. But they could do. If Mayo can keep finding ways to improve, so can we all.