Abstract

Traditional quality control methods identify “variation” as the enemy. However, the control of variation by itself can never achieve the remarkably low non-conformance rates of world class quality leaders. Because the control of variation does not achieve the highest levels of quality, an inordinate focus on these techniques obscures key quality improvement opportunities and results in unnecessary pain and suffering for patients, and embarrassment, litigation, and loss of revenue for healthcare providers. Recent experience has shown that mistakes are the most common cause of problems in health care as well as in other industrial environments. Excessive product and process complexity contributes to both excessive variation and unnecessary mistakes. The best methods for controlling variation, mistakes, and complexity are each a form of mistake proofing. Using these mistake proofing techniques, virtually every mistake and non-conformance can be controlled at a fraction of the cost of traditional quality control methods.