Quality is something we all hear a great deal about. But when asked the question 'how do you define quality?' many stop, pause and think, and a period of silence is followed by a variety of responses.

How do we define quality? What is a quality service? Who is responsible for it? When do we consider quality? How do we measure quality?

In lean terms quality is defined as "doing the right thing, right first time, every time, on time at a price the customer can afford":

  • doing the right thing (meeting the demand as defined by the patient);

  • right first time (no defects, no errors, no waste);

  • every time (a standard way of working);

  • on time (predictable);

  • at a price the customer can afford (cost-effective).

On a recent visit to a lean manufacturing organisation in the Midlands we learned that quality was their byword. It was the second measure for daily working, the first one being safety. Safety and quality were on all the daily measurement charts, and top of the agenda for all business meetings. Delivery, cost, morale and environment followed.

Bill, the team leader from the shop floor, described how over the past five years their way of working has been transformed. Every member of staff is an expert in his or her field and no one knows their part of the process better. They all understand the impact of their actions and that if they have a fault it will have a major impact on everyone else in the process. All staff are empowered to record and remove any defect, even the smallest blemish, from the flow.

Bill explained that by using lean principles the workforce had more than doubled the throughput, with zero defects, and with fewer staff. He described how since the 7,000 workers were all responsible for quality, they now had 7,000 quality managers. "How many staff do you have in the NHS?" he asked, "Over 1 million" was the response, "Wow" he said, "Imagine 1 million quality managers."

Do we all see ourselves as a quality manager? Do we record and remove the defects at every stage of the process? Can every member of staff stop the process if there is a defect, no matter how small?

In the NHS we work around some of the defects, even passing them on to someone else, including inappropriate referrals, information omitted from requests, repeated appointments or procedures, staff trained in different ways, and unquantifiable waits.

The reality is often one where staff feel they do not have time to stop for every minor defect, as it would make the waiting longer.

Using the 80:20 rule to look at the defects that occur most frequently we could get a 50 per cent improvement in quality by addressing 5 per cent of the errors. Can we get a million quality managers in the NHS?