When I first worked in health promotion, workplace-based services such as free screenings or health coaching were only available to executives, smoking policies were a radical idea, school lunches were uniformly abominable, and community bike paths and gardens were a rarity. Mid-career, I worked in Africa where HIV/AIDS was rampant, and in the USA, our Surgeon General, Dr. C. Everett Koop, was vilified by many for delivering AIDS education. Now employee wellness initiatives are commonplace; highly trained health educators and grassroots champions are co-creating workplace initiatives that strive to meet the needs of all employees and are built on an impressive and growing evidence base of best practices. What’s more, health and well-being improvement efforts are getting broader and more ambitious every year. Everyone from the C-Suite to the shop floor is leading ever more fulsome workplace, school and community initiatives intent on moving bold metrics like engagement, culture and the built environment, as well as health, happiness and enjoying a more purposeful life. I could go on interminably about how far we’ve come. I’m proud to work in a profession that has matured well beyond what I imagined it could become in effectiveness, impact and stature.
That’s why we need to change. Best practices are best when they’re used far and wide, and our profession’s reach, relative to the magnitude of the health and well-being needs of those we serve, is dramatically undersized. For an incisive and detailed description of the therapeutic dose needed to achieve a broader impact in our field read Dr. Michael O’Donnell’s White Paper on “Universal Access to Health Promotion.”
The story of one of the most extraordinary social and economic transformations in the world is a story of a professional field that was doing great, but that really needed to change. The automobile was invented in the late 1800’s and was perfected in Germany and France. The design and performance of cars was fundamentally sound, but given the cost to produce a car, driving was out of reach for all but the very wealthy. Henry Ford designed the Model T based on best practices at that time, but it was his passion for improving production processes that led to nearly universal access to driving. In 1899, it took nearly 500 companies to produce 2,500 cars. First came the “standardization” of materials and parts in the United States, and by 1913, America produced 485,000 of the 606,000 produced worldwide. Ford’s mass production plant was built that year and his mass assembly line came on in 1913 reducing the price of cars from $575 in 1912 to $290 by 1927. More astoundingly, Ford sold 15 million Model T’s before it was replaced in production.
As Ford and his CQI quality guru successors like W. Edwards Deming have taught us, the very essence of quality starts with a process that enables a product or service to be delivered the same way, hopefully, a great way, with everyone doing it that way every time. The audacious idea that launches each process improvement event is “what do we need to do differently to improve this process by 50%?” That is, how can I produce the same result in half the time, or how can I increase the value of this service by 50% without increasing the cost? Ford’s amazing achievement was that of vastly increasing production while at the same time dramatically reducing costs such that cars became a commodity for the masses.
Working on your work
Only by stepping back and examining our processes can we see the time and motion required to make what’s working now work better and be more accessible to more people next time. Where should we start? Pick a product or service you think you do best and ask “what is our process?” For example, health coaching has become “standard work” for many organizations. Can you show that you deliver this service with every coach using established principles every time? If you can’t show me your process, preferably visibly, I wouldn’t expect quality. Deming believed such processes flow from, and support, a theory of knowledge and a book he often recommended to convey the changes in thought processes needed to improve quality was Lewis’s “Mind and the World Order.” Caution, it’s not a casual read.
Early in my career, I managed a hypertension management clinic, and our team was deeply ensconced in training clinical providers the right way to take a valid and reliable blood pressure. This includes common sense steps such as rolling up sleeves, allowing for a minute of rest, uncrossing legs, and taking two measurements. I know this training is commonplace which makes me all the more bemused that the evidence, and my thirty years of personal observations, tells me that getting a good quality blood pressure reading is totally hit-and-miss. (For data on this: Levy, J., Gerber, L., Wu, X., Mann, S., “Nonadherence to Recommended Guidelines for Blood Pressure Measurement.” J. Clinical Hypertension, Vol. 18, No. 11. Pg. 1157-1161, Nov. 2016.) I routinely commend those clinicians who have taken my blood pressure correctly, but I seldom criticize those who don’t. Why? My experience tells me that absent a commitment by themselves or their organization to assess, measure and intentionally work on their processes, transient complaining is a waste of time. And wasting time is antithetical to quality.
Soaring with our Strengths
Why do I favor starting with improving processes that are already great rather than beginning with a process fraught with errors? One of the CQI tenets I’ve subscribed to as an organizational leader is that there are no “bad apple” employees, only bad processes. If you truly embrace this philosophy, you live with the sobering reality that quality ultimately resides with leaders and their capacity to motivate and support continuous change. You simply can’t do this with admonitions. Change, by nature, is already hard. Starting with “let’s soar with our strengths” simply seems more inspiring to me than “let’s stop screwing up.” Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion professionals as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners. Conversely, and to paraphrase Bill Clinton, there is nothing about what’s wrong with health promotion that can’t be fixed by what’s right in health promotion.
Every organization with a health promotion mission will likely have a different quality improvement agenda when it comes to improving their processes. After all, the health and well-being aims of each organization will vary so their metrics for success will vary as will their processes for achieving their goals. It behooves those of us interested in continuous good change to press our profession’s leaders to be generous about sharing processes that work best and transparent about processes that aren’t achieving intended results. Our profession has extraordinary expertise in supporting good change. Now is the right time for us put to these skills to work in changing the health promotion field for the greater good. To read this full editorial go to “Why Health Promotion Needs to Change” at the American Journal of Health Promotion.
Paul E. Terry is Editor in Chief, American Journal of Health Promotion and President and CEO, Health Enhancement Research Organization (HERO)