Notes from Dr. Brent James Teaching at the Shingo Prize Conference – The MD / Administration Split


At last week's Shingo Prize conference, I was very excited to meet Dr. Stephen Covey (my podcast is here), but I was just as excited, if not more so, to meet Dr. Brent James, the noted healthcare quality expert from the Intermountain Healthcare system. Dr. James was on the cover of the New York Times Sunday magazine in November 2009 with the cover headline: “If healthcare care is going to change, his ideas will change it.”

Almost every healthcare quality leader I've met in the Lean world has gone through Dr. James' famous quality improvement class in Utah, as described in the book The Best Practice: How the New Quality Movement is Transforming Medicine.

I'll share some notes I took during his breakfast talk last Thursday.

One thing I did not realize is that Dr. James worked alongside Dr. W. Edwards Deming in the late 1980s. That's the root, thankfully, of his views on quality and process. You can't have a better start than that. Since then, Dr. James said he has been through “TQM, re-engineering, Motorola six sigma, Alcoa-type TPS, GE six sigma, and now a more Toyota-style lean approach.” It's often, he said, “consultants repackaging the same things as something new to sell.”   He did give credit to Womack, Jones and Roos for their book The Machine That Changed the World as adding some new ideas, mainly that of “mass customization.”

One of the first things that Dr. James said was the question:

For healthcare, what's your core business?

That's basically the same question that Shigeo Shingo always asked, according to Bruce Henderson. Before you try to improve, do you understand your purpose?

The purpose is the patient. So how do healthcare organizations get to the point where they are doing things that aren't patient centered? From the outside, you might ask how it's possible to NOT have patient-centered care. How do organizations get to be inwardly focused?

Dr. James points to the famous Johns Hopkins, which in 1895 first separated management from clinical practice. Dr. James said this helped avoid a conflict of interest for the doctors AND it freed up time for patient care.

But, this separation created a “chasm” — it divided the goals for those two groups. The business people focused exclusively on money and facilities, while the clinical side focused on patient outcomes. Doctors didn't dare talk about what something cost. Then again, healthcare administrative leaders would say that they're not responsible for clinical outcomes. That's classic bureaucratic behavior, only worrying about and taking responsibility for your silo.

Dr. James said:

You can't be bureaucratic and focus on your silo's rules and regulations and say ‘safety's not my problem'.

Why did that system spread? “Because it worked,” said Dr. James. But we end up with some fairly systemic dysfunctions.

One thing that Dr. James has studied is variation in care delivery (a lesson learned from Dr. Deming, that variation harms quality). Dr. James described many types of variation:

  • Variation across the country (as documented by Dr. Atul Gawande)
  • Variation in the same hospital with different MDs and RNs (what Dr. James called “massive variation”)
  • Variation with the same doctor in the morning or the afternoon (Dr. James asked, “Did the medical science change since this morning?)

Dr. James sees how standardization can be beneficial, but not to an extreme. That's actually the same view as textbook Toyota Production System (see the book Toyota Talent for a discussion on how you don't take standardization too far, even in a factory setting). Dr. James likes the application of “mass customization” as a principle in healthcare, because it means you might need flexibility around a standard process that serves most patients.

Now even with the quality problems in healthcare, Dr. James was disappointed that, during the health insurance reform debate that:

People had a great fund time criticizing healthcare delivery.

Even with all of the preventable errors and infections – Dr. James said “care delivery fails against its theoretical potential” — we should care careful about criticizing the system, as that's the key to engaging physicians, realizing that “nobody has perfect execution anywhere in the world.” Dr. James said that “doctors don't appreciate being disrespected” over quality because “healthcare today routinely delivers miracles.” Is that a reason to be overly sensitive? What do you think? Dr. James said, of quality problems:

In any other industry, that would be an opportunity.

Dr. James says we should treat these problems as an “opportunity” not a “failure.” I don't think it's inherently disrespectful to criticize systemic problems in healthcare – I'm not blaming doctors as individuals.

He recalled a Dr. Deming teaching that better quality costs less, adding:

That idea was just crazy in the late 1980s.

Is that idea still crazy in some circles today?

Come back on Tuesday, June 1 for Part 2 of my notes about Dr. James' talk where he shared a pretty fair criticism of the Lean world.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I am of the impression that organized healthcare began with the military. The patient was not a customer, he was a human resource. The purpose was to serve the army by getting injured soldiers back into action. Even that purpose should have made speedy, quality health care a focus, but the position of the surgeon as an office and the patient as an enlisted man, coupled with the military hierarchy, probably went a long way toward setting the tone for future thinking.

    I don’t know this, but it is what I speculate. Maybe you could write a future blog around this.

  2. Great insight, thanks for sharing what you heard. Engaging doctors with Lean can sometimes be a challenge.

    I find insurance denials for diagnosics to be one point of contention between clinical staff and administration. Providers do not seem overly engaged in fixing this sometimes because they are paid for their portion of care and feel insurance contraints should not limit their ability to order what they feel is needed for the patient.

    Granted, the insurance organizations may be the problem but it a fascinating schism between the doctors and the administration needs. Maybe because hospitals write off denials instead of passing the charge onto the patient is why the problem is not high on the list to fix. There is a lot of complexity to this issue!

  3. Mark-
    Congratulations on these excellent notes and those of part 2. I am delighted that you were able to attend the Shingo Conference, and that you had the opportunity to interview our new colleague, Dr. Stephen Covey. I am equally delighted that you attended the breakfast meeting with Dr. Brent James, the eminent pioneer of quality improvement in health care. Unfortunately, we had a smaller audience for Brent than I would have hoped, but thanks to your careful notes, his message will be heard by others.
    All the best,
    Doug Anderson,
    Dean and Professor
    Jon M. Huntsman School of Business
    Utah State University


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