1. educator’s
WORLD
Thoughts and experiences of educators related to quality and change
Using Deming’s Principles to Create the Next Generation
of Healthcare Leaders
Kyle Bird, Anjali Kundu, and Graciela de Lujan Perez
“The growing demand for healthcare services is not equipping students to solve complex problems
always met by providers; quality and operations manage- when they enter the workforce. The healthcare
ment techniques are needed to reduce waste from the system faces a hostile environment where con-
healthcare system and streamline processes to bolster stant changes in policy mandate a steep learning
supply”.1 In 2008, the PricewaterhouseCoopers’ curve and a life-long learning commitment from
Health Research Institute noted that of the $2.2 the next generation of leaders. Traditional opera-
trillion spent on national healthcare, $1.2 trillion tions management courses and teaching material
was attributed to wasteful spending.2 The onus to that could not be applied immediately to health-
cut the associated costs is being shifted to the next care systems produced sub-optimally prepared
generation of healthcare administrators, the ones graduates.
who will lead teams to identify and reduce waste The University addressed these concerns by
in the incoming healthcare system. establishing a new healthcare operations and
This article describes a successful partnership quality management (HO&QM) course with a
in the spring of 2009 between the master’s level goal to produce patient-centered leaders while
health administration class at the University of teaching the most up-to-date process-improve-
Pittsburgh and the Veterans Affairs Pittsburgh ment techniques. This emerging field integrates
Healthcare System (VAPHS). This partnership operations research and quality principles within
played a key role in the city’s bid to acquire one the healthcare system to ensure efficient delivery
of four new veterans engineering resource cen- of services. The program was designed to con-
ters built across the nation. The project utilized sider significant healthcare-sector issues and teach
Deming’s 14 Points,3 which are available as a future leaders new skills to cope with them, mod-
framework in the online supplement to this article eling the new operational role of the healthcare
at www.asq.org/pub/jqp/. leader (see Table 1).
Furthermore, the Department of Health Policy
Addressing Concerns Management at the University also decided to put
Pittsburgh is a national and global leader theory into practice by establishing a pilot immer-
in healthcare excellence, a city where approxi- sion program and finding a hospital partner.
mately 25 percent of the labor force works in the Ultimately, the Office of Systems Redesign (OSR)
healthcare sector.4 Clinical and administrative of the Veterans Affairs Pittsburgh Healthcare
healthcare alumni from local universities are System (VAPHS), which is comprised of three
scattered throughout the world in myriad roles urban facilities and five community-based out-
and responsibilities: small outpatient clinics, patient clinics, signed on to participate. The OSR
large academically-affiliated hospitals, long-term was created in June 2008 to improve patient care
care facilities, private and group practices, health delivery systems and business processes to provide
insurance, and government agencies. These early exceptional veteran-centered healthcare. The pilot
careerists have provided their alma maters with project offered an opportunity for a mutually
a unified concern: the need to enhance graduate beneficial partnership between VAPHS and the
curriculum in the healthcare administration field University’s MHA program.
to include process improvement.
University-level faculty recognized the need to New Curriculum
address process improvement while continuing A series of small changes were put in place to
to deliver a comprehensive graduate education, improve the HO&QM course, as follows:
www.asq.org/pub/jqp 15

2. Table 1: Program Design Considerations
Issues Primary New Skills
• Rising healthcare costs • Aligning clinicians with organizational strategy
• Crowded emergency department and other • Modeling data for executive decision support
healthcare facilities tools and problem solving
• Pay-for-performance • Analyzing processes and performing root-cause
• Increasingly strict payer reimbursement analyses
• Changes in Medicare and Medicaid policies • Diminishing unassignable service variability
• A recessed economy and incidence of bottlenecks
• Competition • Improving patient throughput
• The challenge of managing/coordinating • Streamlining processes through resource
increasing and future changes while facing one allocation optimization and waste elimination
of the most demanding set of stakeholders, the
chronically and acutely ill
• The traditional operations management syllabus team cooperation, allowing each group to
was replaced with a project-process approach. work through the lean process, apply project
The course was revised to include principles management methods, and test classroom
and techniques associated with strategic align- theory before applying their newly acquired
ment, kaizen events, lean, Six Sigma, simulation, knowledge at VAPHS.
scheduling, inventory, and facility management.
The syllabus was built around patient needs
Immersion Program
When meeting with VAPHS OSR personnel to
and stressed critical thinking and quality service
plan the program, University faculty agreed that
delivery at VAPHS.
the critical component would be involving the
• An agreement was reached with the students
students in ongoing projects and facilitating inter-
who participated in the immersion project,
action with clinical and administrative staff and
shifting the focus of the class from grades to
veterans. This was ultimately the most beneficial
discussions and optimizing their experiential
aspect of the program to the students’ success.
learning. For the students this was a consid-
The educational model was based on expe-
erable change from the traditional teaching
riential and problem-based learning. Students
paradigm.
analyzed their projects and developed alternative
• During the first five weeks of the course, stu- processes for improvement, receiving feedback
dents followed the learning process in class almost exclusively from the OSR staff.
through lectures, current case studies with The OSR provided students with brief descrip-
presentations of successful operations applica- tions, status information, and goals for each available
tions, customized assignments, and structured project. University faculty pre-approved those goals,
processes to lead and complete small kaizen which were designed to complement the curriculum
projects. Discussions related to managing road- and associated learning objectives. Students divided
blocks, such as healthcare’s strong political into small groups and selected projects aligned
groups, were underscored as a common opera- with their learning objectives and potential career
tions issue in class. paths. OSR project facilitators established flexible
• Finally, students integrated their learnings meeting times to accommodate and coordinate
in a simulation of a nurses’ station that used project plans with student schedules, and these
LEGOS®, stopwatches, whiteboards, and mea- facilitators also served as mentors.
suring tapes to demonstrate the value of lean Key performance indicators included the fol-
process development. This activity fortified lowing metrics:
16 The Journal for QualiTy & ParTiciPaTion July 2010

3. • Perform a 5S process.
• Create a high order value-stream map. On the Road to Baldrige in
• Produce a detailed flow map of a specific segment. Education
• Generate recommendations for improvement. The Keller Independent School District
Students not only applied techniques learned (KISD) in Texas has adopted the Baldrige
in the classroom but also discussed the topics framework to guide its systems and improve-
they encountered at VAPHS in their subsequent ment efforts. KISD provides progress updates
classes. Students were expected to work with in each issue. Check the October 2009 issue for
stakeholders without contradicting or imposing the information that launched this multi-part
their newfound knowledge on VAPHS person- series, and go to http://www.asq.org/pub/jqp
nel. When differences occurred between what to see the archived updates and videos, as
students learned in the classroom and what they well as to view a webinar that addresses the
experienced in their projects, they were instructed following areas:
to ask questions to determine the root cause of • Keller ISD superintendent James
the problem. To minimize discord, students were Veitenheimer details the district’s reor-
encouraged to focus on learning the process and ganization plan, which includes a direct
developing positive relationships with the stake- alignment of administrators to the strategic
holders before recommending modification and priorities and goals reflected in the 2011-
improvements. 2015 KISD strategic plan. Veitenheimer
Students initiated action plans more quickly lays out the functional organizational
than the professional VAPHS staff assigned to the alignment around the district’s eight
teams. After four weeks at VAPHS, the instructor key functions. It is an intentional pro-
asked students to critique the work they were per- cess to align the district’s most valuable
forming by considering five tenuous situations they resources—its people—to its most essen-
had faced. Students completed a force-field analy- tial areas of need.
sis for each situation to evaluate and mitigate any • Keller ISD’s teacher trainer Leah Beard
negative consequences from unexpected project then outlines the district’s deployment
roadblocks, instilling continuous improvement timeline, reviewing the first year’s goal in
thought processes. Finally, students presented which a pilot group learned the funda-
their recommendations and achievements to mentals of continuous improvement and
VAPHS executive leadership. implemented quality tools in the class-
Conclusion room. In addition, Beard details the goals
The immersion program was a great suc- for years two through five. She explains
cess, mutually benefiting University students how the pilot group will develop support
and VAPHS. Students gained the opportunity to skills to train campus staff during the sec-
test their knowledge and acquire unparalleled ond year of the plan. Finally, Beard shares
hands-on experience in a nationally recognized examples of the quality tools currently
healthcare organization; VAPHS was able to par- used in the classrooms.
ticipate in the development, recruitment, and
deployment of experts in healthcare operations
improvement. Additionally, students received summer residencies as leaders of newly formed
professional letters of recommendation from the groups, rather than apprentices. Students esca-
VAPHS project leaders who attended the final lated their careers because this collaborative effort
presentations at the University to show their provided them with exposure to the changing
appreciation. environment in healthcare administration.
Although common in teaching hospitals, the As a direct result of this partnership, the
“from class to the bench” concept is still new for University and VAPHS were awarded one of the
training healthcare administrators. This program four newly commissioned Veterans Engineering
made it possible for MHA students to start their Resource Centers (VERC) in June 2009. The
www.asq.org/pub/jqp 17

4. Veterans Health Administration strongly believes
that through education, such as provided in this
program, its hospital system will reach and better
serve a broader population of veterans with the
same scarce resources. The work of all nine MHA
students shed light on the high-quality progress Kyle Bird
that is possible when graduate students and
Kyle Bird is a quality improvement specialist at the University
healthcare institutions collaborate.
of Pittsburgh Medical Center’s NCI-designated Hillman
Currently, four out of the nine MHA candidates
Cancer Center. He holds an MHA from the University of
are working with the Pittsburgh VERC to address
Pittsburgh’s Graduate School of Public Health, Health Policy
local and national priority projects and continue
and Management Department. Bird has research interests
developing their skills. The remaining five stu-
in healthcare quality, health systems simulation, and lean
dents are working with other local hospitals and
processes. He can be contacted at birdke@upmc.edu.
also are applying the same approach they used at
VAPHS.
Acknowledgment: The faculty and MHA candi-
dates express their gratitude to VAPHS personnel
who participated in this pilot: Robert Monte, Dr.
Jeffrey Peters, Jason Leuice, Rachel Crofutt, Julie Anjali L. Kundu
Warren, Danielle Terrel, Tina Howell, Amy Jones,
Bill Shaughnessy, Vicky Phillips, Jana Budde, Anjali L. Kundu received her MHA degree from the University
Laura Perdices, and Kim Toland. of Pittsburgh in 2010. She currently works at the physician
services division of the University of Pittsburgh Medical
References Center (UPMC). Kundu’s interests involve integrating
1. ASQ, No Boundaries, ASQ Future of Quality Study, strategic planning, operations, and service quality tools
2008, p. 6. in everyday tasks to improve the healthcare processes.
2. PricewaterhouseCoopers Health Research Institute, Her e-mail address is kundual@upmc.com.
The Price of Excess, Identifying Waste in Healthcare
Spending, 2008.
3. W.E. Deming, Out of the Crisis, MIT Press, 1986.
4. Pittsburgh Regional Alliance, http://www.allegheny
conference.org/PRA/RegionalData.asp#Regional.
Graciela de Lujan Perez
Graciela de Lujan Perez is adjunct faculty of operations
More Online
To learn more about how “Deming’s 14 Points” were used as
and quality management for the Graduate School of Public
a framework for this program and to review descriptions of Health, University of Pittsburgh. She is a Senior member
the projects, go to www.asq.org/pub/jqp/. of ASQ and is ASQ certified as both a Manager of Quality/
Organizational Excellence and as a Quality Engineer.
During her 20-year career, Perez has applied statistical
and operations research models in engineering, education,
business, genetics, and medicine and has presented and
published her findings in U.S. and EU front-line journals.
She is a senior consultant in healthcare quality delivery
systems and has served as judge for the ASQ International
Team Excellence Award since 2008. For more information,
contact her at glphci@gmail.com.
18 The Journal for QualiTy & ParTiciPaTion July 2010

5. online-only content
educator’s
WORLD
Thoughts and experiences of educators related to quality and change
Improving Students’ Learning Experiences
As described in the article, “Educators World: Results: Reduced processing time for capital
Creating the Next Generation of Healthcare goods orders for purchases between $3,000 and
Leaders,” the master’s level health administra- $25,000.
tion (MHA) class at the University of Pittsburgh Comments: “This pioneering immersion program
was restructured to improve the relevance of its between the University of Pittsburgh and VAPHS
curriculum. At the same time, the program incor- has provided us with the unique opportunity
porated a pilot immersion program with the to familiarize ourselves with the application of
Office of Systems Redesign (OSR) of the Veterans techniques we are learning in class. While our
Affairs Pittsburgh Healthcare System (VAPHS). coursework at the GSPH is essential to our careers
The project utilized “Deming’s 14 Points” as in healthcare administration, learning experiences
a framework for enhancing students’ learning such as these differentiate our skill set from those
experiences and better preparing them for careers in similar programs. We now feel prepared to
in healthcare management. It also helped the city identify real-life problems and suggest solutions
of Pittsburgh, PA, secure one of the four, newly grounded in quantitative management theories
commissioned Veterans Engineering Resource used in various industries. Our group experience
Centers (VERC) in June 2009. at the VAPHS has not only allowed each of us an
Table 1 describes the approaches incorporated exceptional opportunity to apply quantitative and
into the program aligned with Deming’s points. qualitative management skills from conception to
By using these points as a framework for the completion, but it has further enabled us to take
design, the pilot program achieved great suc- operations theory out of the ivory tower to the
cess in its first year of operation. Not only did patient’s bedside.”
students’ practical understanding of the field
increase significantly, but also their leadership Project: Medical Trainee Processing
competencies were honed through hands-on MHA Candidates Project Team: Sara Demmler
experience. Furthermore, VAPHS benefitted by and Neha Singla
improving its processes, and the city of Pittsburgh VAPHS Department: Education
also acquired new jobs when it was selected as a
Primary Tools and Techniques Used: Flowchart,
site for the VERC.
value-stream map, analysis of process constraints,
Project Summaries 5S analysis, and brainstorming.
The four projects managed by the MIHA stu- Results: Streamlined processes and initiated formal
dents are described below along with comments data collection for process cycle time data.
from students regarding their experiences. Comments: “During our time at VAPHS we used
a number of tools toward improving the com-
Project: Process for Acquisitions and Contract up
puter access request process for trainees. A most
to $25,000
significant portion of our project was using the
MHA Candidates Project Team: Anjali Kundu and flow map, the value-stream map, and applying
Kyle Bird concepts of the Theory of the Constraints. We
VAPHS Department: Acquisition and Contracts understood the real life constraints when we
Primary Tools and Techniques Used: Flowchart, fish- recognized that many policies and mandatory
bone diagram, value-stream map, student’s t-test, process requirements could not be eliminated.
supplier-input-process-output-customer (SIPOC) We also undertook the employment of 5S meth-
diagram, and force-field analysis. odology to create a more efficient workspace
www.asq.org/pub/jqp 1

6. Table 1: Deming’s 14 Points Applied to Program Design
Point Program Design Approach
1: Create constancy of purpose Established a long-term goal of better equipping students to
address the complex problems facing the healthcare sector
and implement a process for continuously improving the pilot
program.
2: Adopt the new philosophy Developed a new healthcare operations and quality management
curriculum that integrates operations research and quality
principles within the healthcare system to ensure efficient
delivery of services.
3: Cease inspection, require evidence Provided simultaneous instruction and practical experience on
tools and techniques for analyzing and improving processes.
4: Improve the quality of supplies Worked with a local hospital, a local supplier of healthcare
services, to expose students to the real-world conditions they
would encounter after graduation.
5: Continuously improve production Engaged students in projects that changed performance in high-
priority hospital operational processes.
6: Train and educate all employees Combined the new classroom curriculum with the pilot immersion
program to create a comprehensive learning experience for
students.
7: Supervisors must help people Had instructors and hospital personnel mentor students’ projects
together, guiding, rather than directing, activities and decisions.
8: Drive out fear Created an open forum for discussion among students, instructors,
and facilitators that focused on translating project experiences
into career strategies and that eliminated judgmental evaluations.
9: Eliminate boundaries Involved students in real-life projects at the hospital that included
clinical and administrative staff and veterans and worked with
students to use force-field analysis to evaluate and resolve
roadblocks.
10: Eliminate use of slogans Demonstrated application of quality improvement principles
through real-life structured projects, rather than depending on
conceptual lectures.
11: Eliminate numerical standards Eliminated traditional grading, shifting to discussions and
experiential learning.
12: Let people be proud of their work Provided opportunities for students to share learnings and
experiences, recognizing progress and accomplishments.
13: Encourage self improvement Fostered life-long learning as a means of keeping abreast of and
being qualified to respond to constantly changing healthcare
policy mandates.
14: Commit to ever improve quality Debriefed student experiences in a way that built a long-term
commitment to quality improvement in the healthcare system.
From W.E. Deming, Out of the Crisis, MIT Press, 1986.
2 The Journal for QualiTy & ParTiciPaTion July 2010

7. for nursing educators. By using 5S concepts, we transition of moving behavioral health into the
helped eliminate waste, improve workflow, and customer support center.”
reduce process unevenness. Through the imple- Note: This project won the “Best in Content” prize
mentation across service lines it will enable at the VAPHS OSR showcase on March 31, 2009.
employees to operate more efficiently in their
own work environment.” Project: Document Tracking (a paperless solution)
MHA Candidates Project Team: Kelly Butler and
Project: Customer Support Center/Developing Christina Kratz
Metrics for Improvement
VAPHS Department: Education
MHA Candidates Project Team: Rachel Goffman,
Primary Tools and Techniques Used: Value-stream
Angela Karloski, and Kate Wilson
map, flowchart, analysis of process constraints,
VAPHS Department: Behavioral Health and queuing models.
Primary Tools and Techniques Used: Scorecards, Results: Shortened request waiting time by devel-
flowchart, value-stream map, action plan, and oping a paperless system.
prioritization matrix.
Comments: “Our group was charged with the task
Results: Determined key performance indica- of improving the document tracking procedures
tors (KPI): no-show rate (percent), number of for the education department of VAPHS. While
days from contact to appointment schedule, and we took all of the tools and procedures learned in
amount of triage time. class and applied them to a real-world situation,
Comments: “We had the task of working with the one of the tools that deemed itself most effective in
behavioral health department at the VAPHS, try- exposing the real issues surrounding the tracking of
ing to streamline the patient scheduling process training requests by the education department was
before implementing a new customer support the value-stream map (VSM). The VSM indicated
center. One of the most rewarding parts of our that out of the total process, value-added ratio
assigned project was the application of the tools was almost 0 percent; the process was extremely
we learned throughout our class and witnessing inefficient due to extended approval queues and
the impact they had on our assigned project. very few value-added steps. The VSM aided our
Our favorite tool was the performance score- emergency department (ED) that will diminish
card, where we developed quantifiable metrics waiting times for both the ED and the employees
to measure the current process. These metrics requesting training permission and funding. We
allowed our group to determine appropriate are confident that the new comprehensive paper-
standards to continuously measure the impact of less form will eliminate employee confusion and
our improvement recommendations. The project frustration as well as condense the tasks required
allowed us to clearly define roles of the stake- in monitoring the approval process.”
holders in the process and help differentiate the Note: This project was selected to have its findings
avenues of entry and exit into the system. We and recommendations presented at the VAPHS
hope that our recommendations will aid in the OSR Showcase.
www.asq.org/pub/jqp 3