Managing your way to better addiction treatment outcomes

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 https://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.

In Deming's time, supervision was often predicated on mistrust. Supervisors ensured that no employees got a “free pass” or garnered a paycheck without earning it. This approach is out of line with reality: most employees really want to do a good job and few people start a job with the intent of doing otherwise. So-called “problem” employees generally develop cynicism over time in organizations with poor cultures. Put the same employee in an organization with a positive, client-focused culture, and you will likely see different results.

8. Drive out fear, so that everyone may work effectively for the company.

Employees are naturally fearful in the face of uncertainty. It is the job of management to create and communicate a transparent organizational purpose of customer service. Employees will be fearful and mistrustful if they do not understand key objectives and are likely to misunderstand when leadership fails to communicate frequently and clearly with them.

9. Break down barriers between departments. People in research, design, sales, and production must work as a team, to foresee problems of production and use that may be encountered with the product or service.

It is critical that functional roles in addiction treatment (management, clinical, clerical, etc.) work in concert to effectively serve clients. Every handoff of a client between people or departments presents a potential system breakdown. When departments “silo” themselves, nobody takes ultimate responsibility for the client. Leadership needs to make client service the goal, and charge each department with the responsibility to work together to achieve that goal.

10. Eliminate slogans, exhortations, and targets for the workforce asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.

Have you ever been asked to “do more with less?” Or has someone ever asked to “help me help you?” Do you need to “work smarter, not harder?” Pat phrases such as this are patronizing and sap morale. Asking employees to do better without changing the fundamental organizational processes that govern their actions leads only to mistrust and dystopia.

11a. Eliminate quotas. Substitute leadership.

11b. Eliminate management by objective, numbers, or numerical goals.

This may be one of Deming's most controversial viewpoints, which seemingly flies in the face of currently en vogue management practices that emphasize accountability. Deming was notoriously hard on managers, and believed that management was fully accountable for an organization's performance or lack thereof; he refused to let managers cop-out to excuses that they had bad employees who just wouldn't work hard enough. Remember that 85% of customer problems are due to bad organizational processes.

To hold individual employees accountable for performance measures over which they have no control is nonsense (see point 10). Individual performance measures tend to undermine organizational purpose because they fail to recognize the contribution that each employee makes to the larger system of care. Worse yet, employees often find ways to “game the system” to maintain levels of production that keep them out of trouble. Quotas are dangerous because they force employees to focus on meeting “numbers,” rather than serving clients.

12a. Remove barriers that rob the hourly paid worker of his right to pride in workmanship. The responsibility of supervisors must be changed from sheer numbers to quality.

12b. Remove barriers that rob people in management and engineering of their right to pride in workmanship. This means,inter alia, abolishment of the annual or merit rating and management by objective.

Pride must be cultivated in the workforce. It is the antithesis of cynicism, and cynicism runs rampant in organizations that do not work the way they should. It is important to recognize that often, life and death are at stake in our work. Employees can and really do take pride when they work in organizations that effectively provide life-saving support to clients in need.

Small touches can make a big difference. Clean, tidy facilities increase employee pride, while dingy, disorganized, and unpleasant working environments drain morale. Making the work environment more pleasant can be an easy and powerful first step in building organizational pride. Spend a Saturday painting the waiting room or plant some flowers outside the front door.

13. Institute a vigorous program of education and self-improvement.

Employee development should be continuous and incremental, just as organizational improvement is. Management must take the initiative to provide opportunities for professional growth. An organization cannot hope to continuously improve without investing in the talents and skills of its employees.

14. Put everybody in the company to work to accomplish the transformation. The transformation is everybody's job.

While management is responsible for creating organizational vision, success is never achieved by management alone. Every member of the organization plays a role in fulfilling its purpose. While top-down, adversarial management often seems the only way to get everyone into line, organizations that live the 14 points find that employees are eager to step up when they are engaged and entrusted with responsibility for fulfilling a vital purpose.

Andrew Quanbeck, MS is a researcher at NIATx, centered in the Department of Industrial & Systems Engineering at the University of Wisconsin- Madison. He thanks Lynn Madden, Tom Mosgaller, Kim Johnson, Amy McIlvaine and the many NIATx providers who contributed to the article. For more information, contact andrew.quanbeck@chess.wisc.edu or visit https://www.niatx.net. Behavioral Healthcare 2009 October;29(9):34-35