Journal of Sacred Work

Ultimately, the secret of quality is love.
Avedis Donabedian, M.D. (1919-2000)

Without radical loving care, quality management can be an empty exercise.  -Erie Chapman

   Shortly before he passed away, Dr. Donabedian, internationally known for his "Seven Pillars of Quality" did an interview with Health Affairs magazine. My friend and colleague, Rosemary Gibson, who works for the renowned Robert Wood Johnson Foundation, sent me the article just recently. I was overwhelmed with the power of Donabedian’s words and his piercing insight into the motivation which must underlie any effort at quality.
   Dr. Donabedian, considered by many to be the father of quality assurance, spent his career trying to help organizations, especially hospitals, understand the systems and processes necessary to improve quality in caregiving. Yet, in the end, it was not the systems where he placed his biggest emphasis…

   "System awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success."
   His next words are so completely in line with our work in Healing Hospitals and Charities, Radical Loving Care & Sacred Work that I’m surprised I haven’t come across them sooner: "You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system." (italics added)
   Dr. Donebedian spent his life designing systems, but he never lost his understanding that none of that matters unless love is present. Do we hear his words and feel them in our hearts? So many hospitals failed in their efforts to implement what was, in the ’80s and ’90s called Total Quality Management (TQM). Many continue to fail into the 21st century because they chronically underestimate the role of love. There’s nothing ‘Total" about TQM unless love is central. Without radical loving care, quality management can be an empty exercise.
   If I had to select one thing above all others that contributed most to any success I’ve experienced in a quarter century as a hospital CEO, it would be that I love first line caregivers. I have such admiration for their hard commitment to completing difficult tasks, for the fact that they labor for low pay in difficult conditions, for their willingness to speak honestly and without artifice about their work and their opinions.
   In my twelve years working side by side with caregivers (once a month) at the giant Riverside Methodist Hospital in Columbus where I served as CEO, I had many opportunities to catch sight of the grimmest elements involved in first line work. I share one of those moments with you not for its shock value, but for its raw truth. I was working alongside an obstetric nurse helping her guide a new mother through delivery. It is, of course, inspiring to be present at the sacred moment when a new person enters the world. Blocked by a reactionary doctor from being present at the delivery of our son, I did have the honor of witnessing the birth of our daughter. It was also meaningful to help another mother bring her baby into the world.
   After the birth, I was standing in the hallway near the delivery room. The mother had been moved to recovery, the doctor and nurses had moved on to other work. A housekeeper approached me with a wicked smile. "Hey," she said, mop in hand, "now do you want to come see my part in all of this?" She gestured toward the empty delivery room. What remained was the need for someone to clean up all the blood.
   I wish I could tell you I found the courage to join her, but I dodged that part of the experience. I’d watched plenty of surgeries, but I wasn’t up to helping this housekeeper do what she has done thousands of times – clean away the blood and afterbirth.
    The housekeeper just laughed at me, turned away, and pushed her pail into the delivery room. "That’s okay, Mr. Chapman. I’ll take care of all this mess. I wouldn’t want to have your job either." 
   This is one of the reasons I love first line caregivers. As this woman, and every other first line caregiver knows, there is always the dark side of work. Watching television doctors and nurses may create a sense of the romantic around healthcare professions.
   But there are parts never shown on television. That is why caregiving is so much in need of love. It is, as Donabededian says, "the secret of quality." It takes love to make the extra commitment to be sure the right work is done every single time in the midst of exhaustion, blood and sweat. Love is the fuel that drives quality performance, not systems. And it takes love to support caregivers when things don’t always work perfectly.
   And that is why, in the face of so much contemporary cynicism, I remain committed to caregiving as essentially a charitable, not-for-profit mission. The great Dr. Donabedian said it so well, "Health care is a sacred mission. It is a moral enterprise and a scientific enterprise, but not a commercial one."

   A nice surprise. Dr. Donebedian was a poet as well. Here is the final stanza of his poem.

"Daisies in Winter."

Deep under snow
It is dark winter now.
But in your sun
Winter shades into summer,
All seasons one.

   His poetry, like his work, is a metaphor for the oneness of love.

-Erie Chapman