What Is Quality?
August 2015 Issue
I was having a conversation with a friend the other day about the quality of a particular technician's work, and even though we roughly agreed on the "goodness" of the work, we couldn't really agree on the "quality" of his work. Yes, the work was passable. But was it the kind of work we felt good about? This made me think about what "quality" means and why we use the word even though we don't seem to understand it in a finite way. How do we know when a product is a quality product?
Everything we make is a quality product right? Of course it is! If it wasn't good enough, we would have kept going until it was. So by definition, even the worst thing you've ever delivered was, at some point, good enough. Even if it took some rationalization, even if we had to convince ourselves that Mrs. Jones won't mind that little blemish, or Mr. Smith will never see that second stitch, at some point we look at the product and think, "Good job!" The question is, how do others perceive our quality? Do people look at your finished devices and think they are as high quality as you do, or do your competitors pick your stuff apart when it comes into their fabrication facility, the same way you pick theirs apart?
The most critical factor in our notion of a "quality orthosis" should be fit. But how do you know what fit means? Everything we do has to fit somebody, and specifically, the somebody we are making it for, but the clinician makes the final decision about whether or not it fits based largely on his or her own prejudices. Here is an example. When I started my company, one of my earliest customers was a great guy who lived about 40 miles away. He had several offices and would also regularly visit the nursing homes in the area. At the end of a day, he would call me and give me the information I needed to fabricate metal and leather AFOs, which he would attach to a shoe later. The information he gave me consisted of three measurements: calf circumference, fibula head to floor, and ankle diameter. He would also tell me if it was a left or a right, and whether it was for a male or female (men always got black leather and women always got white). With this basic information, we would start to build the devices and usually had them completed by the time he arrived to pick them up. Now, the concerned technician in me was always a bit distrustful of the outcome, but I asked him once how they generally fitted, and his reply was, "I have two pairs of bending irons in the car."
Some people expect a more intimate fit in the devices we deliver, and that's good, but others don't, and there is no set standard for the expected outcome. Everyone seems to believe there is a right way and a wrong way, but really there is just "my way" and "the wrong way." Even if a device doesn't meet your idea of "fit," it can still meet the patient's idea of function.
For years, I've heard the adage about giving patients with post-polio syndrome exactly what they came in with. I guess it is supposed to mean that these patients have been wearing a certain type of device for so long that they won't be able to become accustomed to anything else. I've always thought that was a bit shortsighted.
Most of the patients with postpolio symptoms who I have known were regular, hardworking, thinking people who should, from all appearances, be able to adapt to change like the rest of the population. I remember a fellow who came to a facility where I worked, and because of his diagnosis, my boss told me to just map out what the patient had and duplicate the orthosis exactly. After seeing him walk into the fitting room, I knew I couldn't do that. He was "happy" with the function of his orthosis, but he had been walking terribly for all these years and just didn't know how bad his current orthosis was. I casted him for a modern thermoplastic KAFO and promised him that if he didn't like the new style, I would not charge him for it, and I would then duplicate his old one. He instantly exhibited a strong desire to move more smoothly and expend less energy, and that was all I needed to do my best for him. We worked really hard to help him adapt to the more efficient device. It only took a few fittings, and he was walking better than he had since he was a kid. His function was so much better with the new orthosis he was barely able to transition back to his old device after each fitting. In the end, he was so pleased that he actually offered to put up the capital for me to start my own facility because no one had ever tried to help him move forward. That patient, like most do, walked in with what he thought was a highly functional orthosis and walked out with a better understanding of what a functional orthosis really is.
For most of us, the most obvious element of quality is the cosmetic value. Is it attractive? Are the lines clean? Is the surface smooth and free of blemishes? Those things are the immediate aspects of a device that we can judge, but all too often those are the factors that fall short. Over the years, I have had to train quite a few technicians for our company as well as others, and we always start with the same ideal: It has to be pretty.
In my first few months in the industry, I was fortunate to have been taken under the wing of one of the meanest, most disagreeable fellows I've ever met. He had a background in fine woodworking and was very talented, and like the main character in Truman Capote's book, In Cold Blood, he constantly chewed aspirin. Aside from being mean, he was also a bit of a perfectionist. That's a bad combination. He expected everything anyone handed him to be absolutely perfect and would frequently throw the things that did not meet his standards at that person from across the room. He didn't like me (or anybody, as far as I could tell), so he would never take the time to explain to me or other new technicians how to do things properly. He would just call the person an idiot and walk away. Once I realized what I was up against, I took the tactic of just watching him as he worked. I would study how he stood, where he held his hands when grinding, whether he was moving his elbows or his shoulders, and so on. After a while, my work started to improve. My lines became smooth. My work became pretty in spite of him. I understood his philosophy; he wanted everything we made to be a quality item, and in his eyes, that meant clean lines, smooth edges, and perfection. I bought into that philosophy and agreed that just because the devices were handmade, didn't mean they should look crude. They should look like they came out of a machine.
One of the best things about my job is that I get to work with a lot of technicians from all over the country, and even some from around the world. I frequently have to explain to them that even though they have certain skills, there are things I am going to demand that they do in my lab that might get them fired in your lab-and there are things I will fire them for doing in my lab that are demanded of them in your lab. The reason for this is simple: We all have slightly different ideas about what quality means. We all have our own myths and prejudices about what is good and what is bad, and we all know exactly what a quality device is. Mostly.
Tony Wickman, CTPO, is the CEO of Freedom Fabrication, Havana, Florida. He can be reached at .