In a rush? Download this post as a PDF to read it later

‘And what is good, Phaedrus, and what is not good – need we ask anyone to tell us these things? (Robert M. Pirsig, Zen and the Art of Motorcycle Maintenance, 1974)

Quality and value, like beauty, are in the eye of the beholder.

Armand Feigenbaum in Total Quality Control (1961) defines quality as the “total composite characteristics through which the product or service in use will meet the expectations of the customer” (Feigenbaum, 1961).

Disciplines like Statistical Process Control (SPC), Total Quality Management (TQM), Lean and Six Sigma plus derivatives (collectively LSS) are predicated on the assumption that value is what customers/clients value and that quality precedes value.

Activities that customers don’t value are classified as “non value-adding”. This isn’t necessarily true of course. Many activities (possibly even most activities) have little or no direct impact on the ‘value’ received and/or perceived by the customer.

It may be necessary to drill down several layers to find the connection between what happens inside, beside or before a process and what the customer gets. But that’s a rabbit hole for another day…

Today, let’s look at value and quality from a customer’s perspective. At this stage, almost all organisations claim and promise that quality and value are of paramount importance to them, that customer satisfaction is front of mind, basically that they care. But do they? Really?

Have you ever noticed that the many of the companies with the poorest customer service are in communications or media, e.g telecoms, data, tv and streaming.

And what about airlines? I have had the pleasures and pains of flying with several carriers, into and out of far flung destinations. I’ve flown APEX Economy, Economy, Business and First Class with flaghship carriers like Delta, Emirates, Lufthansa, Etihad and Qatar Airways. I’ve flown with budget and less prestigious airlines like Ryanair and Pakistan International Airlines. What they all have in common is that they care little about quality and value from a customer’s perspective. Why do I claim this?


Simple really – as long as there are different ‘classes’ of ticket there are different levels of quality and value. So when they say your comfort and safety, the value for money you receive, and the quality of your ‘experience’ are important, what they really mean is that within the class of your ticket you can expect such and such – as defined by them.

Which is the antithesis of quality and value.

Now, don’t get me wrong – I’m not having a go at the airline industry. I’m simply pointing out that dedication to quality and value is determined more by what the customer is willing to pay than by what the customer perceives as important. And airlines are not alone – most businesses do it. It’s just more obvious with them.

A more controversial sector is healthcare, or what I like to call the Sickness Industry. Providers prattle on about quality of service, being patient-centric, and use meaningless platitudes like ‘everyone counts’, ‘best care always’, ‘we care’ and so on. But as long as access to services is determined according to ability to pay, race or citizenship and services themselves are configured according to the wishes and demands of the service providers, it cannot be true that quality and value to the patient count most, or even at all.

A high quality/high value service from a patient’s perspective would give access to the necessary services when and where needed. Those services would be delivered by competent and caring personnel in an appropriate setting, without unnecessary waiting or delay. All pertinent investigations would be conducted and the findings conveyed by staff able to empathise and engage on a human level.

Waiting lists would not exist.

Instead, patients are treated poorly, with little regard for their privacy and little sensitivity towards their fears. Before Covid-19 it was ‘normal’ for patients to spend hour after hour in a crowded emergency ward waiting to be seen, then hours more waiting to be admitted. It is not uncommon for patients to sleep overnight on a trolley in an emergency department or on a corridor.

It is routine for a 15 min visit to a family doctor to take several hours. It is routine to wait weeks or months, and in some cases years, to see a specialist – and as long again to receive surgery or treatment if needed.

In most Western countries, private health insurance gives fast track access to services while ‘public’ patients wait and wait. The shame in Ireland is that we have a health system that allows clinicians to mix public and private practice – even in public hospitals.

I’ve no axe to grind with private healthcare – I’ve been CEO of two private hospitals. I’ve nothing against public healthcare either – I’ve spent 14 years working in public health systems in Ireland, Saudi Arabia and Qatar.

What I do have is a very clear view that unless and until the patient becomes the most important part of any system, we are doomed to repeat the failures of the past.

I am at the final stages of my part time PhD with Dublin City University. My thesis examines the uses, successes and failures of Lean Six Sigma in acute hospital systems and I propose a framework for the successful adaptation of LSS to general and specialist hospital environments.

It’s probably easier for the private sector to be honest – patients understand that access and care depend not only on ability to pay but also the need for the provider to make profits. It would be relatively easy for me as a commercial provider to tell my prospective patients that so long as they are willing and able to pay, here is the level of quality and value they can expect.

It will be more difficult for the public sector to do this, not because the public patient’s expectations are too high but because the service is fundamentally unfit for purpose and not capable of meeting even the lowest standards of quality and value acceptable to the patient.

This applies whether you’re looking at the HSE in Ireland, the NHS in the UK, HMC in Qatar or the US health market (I can’t bring myself to say the US health system because unfortunately for the USA, they don’t have one. This has been horrifically demonstrated as the pandemic took more than 450,000 US lives with no sign of relief in sight).

Edward Deming in his 1982 book “Out of the Crisis” set out his prescription for the salvation of American industry. One of the notable exceptions to his work was healthcare because the rising costs of healthcare ‘are beyond the scope of this book’.

In January 2021, we saw the announcement that Haven – a joint venture between Amazon, Berkshire Hathaway and JPMorgan Chase was disbanding after only 3 years. This was anticipated following the departure of Dr. Atul Gawande, Haven’s CEO and the author of “Better: A Surgeon’s Notes on Performance” (2007).

The sad reality is that Haven became irrelevant as the three partners advanced their own plans and efforts individually instead of collectively. Shares in major health stocks rose on the announcement.

So, if the Sickness Industry has defeated Jeff Bezos, Warren Buffet and Jamie Dimon, what hope is there for the ‘little’ man or woman in the street?

Sadly, not much.

So-called healthcare is BIG business. All major systems earn rewards and profits from maximising utilisation and treatment, i.e. the more ‘sick’ patients can be investigated and treated, the better off the providers are. And that’s not just in the private sector. Public hospital systems take the lions’ share of public health funding and have a vested interest in maintaining the status quo.

This preference for short term urgent action is endemic. We pour trillions of dollars/pounds/euros into systems that don’t work while we starve systems that could and would if the investment necessary was made. In Europe (including the UK) 10% of GDP goes into the sickness industry. In the USA, that figure is 17% of GDP. And what return do we get?

The global pandemic has exposed our approach to health as yet another Emperor Without Clothes (at this stage, maybe I should write a book called Naked Emperors in Your Neighbourhood – I’m only half joking!). Unfortunately for us, the virus has exploited our weaknesses. We each bear primary responsibility for our own behaviour. But when you combine social engagement in a population  accustomed to instant gratification with a highly transmittable disease and creaking healthcare, disaster is only around the corner. We are merely lucky that this virus is less lethal than SARS or MERS.

Promoting wellness is a long term strategy, unlikely to show visible results for years, maybe decades. There are few incentives in healthcare to encourage and reward wellness, or even to measure it. Until this changes, our options for treating chronic non-life-threatening illness will continue to be either symptom suppression (medication) or symptom removal (surgery).

This just isn’t good enough.

What have been your experiences dealing with ‘healthcare’ providers? How do you measure the quality and value of your local health services? What do you feel they do well? do excellently? What might be improved?

Looking forward to your comments.

If you like this article, you can join my newsletter here and receive regular updates and content exclusively for my subscribers.