Dr. Berwick’s 1989 Advice on Making Kaizen Happen in Healthcare

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Last week, I blogged about the 1989 New England Journal of Medicine article by Dr. Donald M. Berwick, “Continuous Improvement as an Ideal in Health Care.”

Dr. Berwick wrote that kaizen (as continuous improvement) is not alien to healthcare, as “self development, continuous learning, the pursuit of completeness are all familiar themes in medical instruction in history.” However, Dr. Berwick said, “today we find ourselves almost devoid of such thinking when we enter the debate over quality.”

So what advice did Dr. Berwick have for creating a kaizen culture?

Dr. Berwick was arguing against the “disciplinarians” finding “bad apples” as the route to quality, saying:

“It would be naive to counsel the total abandonment of surveillance and discipline. Even in Japan, there are police. Politically, at least, it is absolutely necessary for regulators to continue to ferret out the truly avaricious and the truly incompetent. But what about the rest of us? How can we best be helped to try a little kaizen in our medical back yards? What follows are a few small steps.”

His tips for leaders (as Dr. Deming said “quality starts at the top” )… but I think these ideas apply to leaders at all levels.

I will paraphrase and quote with my comments in italics.

Leaders must take the lead in quality improvement… establish and hold to a shared vision of a health care system undergoing continuous improvement. Berwick said to replace blaming and accusation with goalsl that are shared by payers and “producers” (providers of care)

Investments in quality must be substantial. Berwick didn't mean money, he said “managerial time, capital, and technical expertise” along with a “long-term vision… education and study… we must understand [processes] before we can improve them.” The beauty of kaizen, however, is that it improvement requires more time and leadership than spending and capital… “mind before money,” as is said.

Respect for the health care worker must be reestablished. Berwick said that all participants “must be assumed to be trying hard, acting in good faith, and not willfully failing to do what they know to be correct.” He pointed out that people make unintentional mistakes and they “cannot be frightened into doing better.” The influence of Dr. W. Edwards Deming is very strong here. Berwick says when people are afraid, they “will be wasting their time in self defense instead of learning.” Deming said we need to “drive out fear” from the workplace (as does Facebook's Mark Zuckerberg).

Dialogue between customers and suppliers of healthcare must be open and carefully maintained. Berwick was advocating long-term relationships instead of threatening to take one's business elsewhere, another key Deming point.

Modern, technical, theoretically grounded tools for improving processes must be put to use in healthcare settings. Berwick cited Shewhart, Dodge, Juran, Deming, and Taguchi. Berwick said there are cultural barriers, such as “physicians seem to have difficulty seeing themselves as participants in processes, rather than as lone agents of success or failure.” Berwick said even the work of an individual doctor is a process… processes are everywhere in scheduling patients, giving instructions to patients, etc.

Healthcare institutions must “organize for quality.” Berwick said “other types of companies have invested in quality improvement” and management techniques… but not healthcare. Hospitals need quality engineers, flexible project teams, and more training so “all staff members must become partners in the central mission of quality improvement.”

Health regulators must become more sensitive to the cost and ineffectiveness of relying on inspection to improve quality. This is a key Deming and Toyota (lean) point. Berwick said we need to measure quality, but there is also an “orgy of measurement involved in healthcare regulation, that the assessment and publication of performance data will somehow induce otherwise indolent care givers to improve the level of their care and efficiency.” Berwick said measurements should be used “by the producers themselves.” This reminds me of factory workers ideally making (and understanding) their own control charts instead of being terrorized by engineers or managers over statistical measures or data that just pressures you to do better (instead of focusing on the system).

Professionals must take part in specifying preferred methods of care, but must avoid minimalist “standards” of care. He adds “quality control engineers know that such floors rapidly become ceilings, and that a company that seeks merely to meet standards cannot achieve excellence.” Berwick said that “specifications of process” are “widely lacking” in healthcare. This is the same point as made in the lean approach to “standardized work.” People must create and improve their own standardized work, as opposed to something being forced on them. Berwick also emphasized that “our current best” method should be assessed and revised over time (kaizen).

Individual physicians must join in the effort for continuous improvement. Berwick wrote that it might seem that CQI methods that come from manufacturing might be of little relevance to physicians… but the opposite is true. He said few health systems “can improve without the help of the medical staff.”

Again, it's not surprising that Dr. Berwick was ahead of the curve on the acceptance of kaizen and continuous improvement.

Do you think his assessment holds true 23 years later?


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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.

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