Dr. Donald Berwick – Ahead of his Time on Kaizen in 1989


I've blogged before about Dr. Donald M. (Don) Berwick, the founder of the Institute for Healthcare Improvement and the former administrator of the Centers for Medicare and Medicaid Services (CMS). I was fortunate to meet him briefly at the 2010 IHI National Forum, where he spoke a lot about Lean in his keynote remarks.

When Joe and I were doing research for our book  Healthcare Kaizen, I wasn't really that surprised to discover that Dr. Berwick had written about  kaizen and continuous improvement, in 1989, in the famed New England Journal of Medicine.

The article was titled “Continuous Improvement as an Ideal in Health Care,” published in NEJM just three years about the publication of Masaaki Imai's seminal work Kaizen: The Key To Japan's Competitive Success. Dr. Berwick cited Imai's book, along with the work of Juran, Deming, and other quality legends.

I can't share much except the briefest of excerpts from Dr. Berwick's article, but I'll summarize some key points here. Hopefully many of you have access to the NEJM archives through your health system.

Update: Somebody posted a link to the article text in a comment to this post.

Joe and I did write this about Dr. Berwick's work in Chapter 2 of our book:

Dr. Donald M. Berwick's Call for Kaizen (1989)

During this wave of the West's initial interest in Kaizen, a small number of healthcare leaders took notice. Dr. Donald M. Berwick is legendary in healthcare quality and patient safety improvement circles, thanks to his advocacy and education work done as the founder and chairman of the Institute for Healthcare Improvement and as the former administrator of the U.S. Centers for Medicare and Medicaid Services. In 1989, Berwick published a piece called “Continuous Improvement as an Ideal in Health Care” in the New England Journal of Medicine, where he wrote that contin- uous improvement “holds some badly needed answers for American health care.”

Berwick cited Imai with the definition that Kaizen is “the continuous search for opportunities for all processes to get better” and emphasizing that the self- development and the pursuit of completeness are “familiar themes in medical instruction and history.” In highlighting what is different with Kaizen, Berwick criticized disciplinarian-style leaders who look to punish “bad apples” instead of improving processes. He also argued that a leader cannot be “a mere observer of problems,” but instead needs to lead others toward solutions.

Berwick highlighted a number of themes, including:

  • Leaders must take the lead in continuous quality improvement, replacing blame and finger-pointing with shared goals.
  • Organizations must invest managerial time, capital, and technical expertise into quality improvement.
  • Respect for healthcare professionals must be reestablished, highlighting that they are assumed to be trying hard, acting in good faith; “people cannot be frightened into doing better” in complex healthcare systems.

While he mentioned technical quality improvement tools in the article, Berwick's summary of continuous improvement emphasized the culture change required to have everybody work together—removing fear, shame, and finger-pointing from the healthcare system.

Dr. Berwick started his piece (and, again, this was in the NEJM — for healthcare people) with a tale of two assembly lines with two different foreman.

Bad Factories / Bad Leadership

Foreman 1 (my summary):

  • Hounds employees – by watching and measuring
  • Assumes people who don't meet his goals are “unprepared or unwilling” (blames the workers)
  • Threatens to fire and replace individuals who don't measure up
  • “Relies on inspection to improve quality”
  • Subscribes to the “theory of bad apples” – managers need to find them and move them out

Under Foreman 1, workers “are afraid, angry, and sullen, but they play nonetheless.” The workers “play defense” through one of three tactics:

  1. Kill the messenger (the foreman or inspector)
  2. Distort the data
  3. Blame the other guy (worker)

Berwick says “any good foreman knows how clever a frightened work force can be,” adding “practically no system of measurement – at least none that measures people's performance – is robust enough to survive the fear of those being measured.”

That's straight out of the philosophy of Dr. W. Edwards Deming and it reminds me of the work of Brian Joiner (a student of Deming) who said people can do one of three things:

  1. Distort the data
  2. Distort the system
  3. Improve the system

It's far easier to do #1 and #2. “Foreman 1” (and those who manage that way in factories or hospitals) are not going to achieve quality. Dr. Berwick said “The signs of this game are everywhere in health care” (and I've seen it too).

Better Factories / Better Leadership

What about Foreman 2? The good foreman:

  • Asks how we can help
  • Is in partnership with the workers for “the long haul” and has a common interest in a job well done
  • Realizes most people are trying hard
  • Their job is to find opportunities for improvement – learning, sharing, and experimenting
  • Gives people the means to do their jobs better

Berwick elaborated that the “Japanese” approach (now practiced around the world) says “every defect is a treasure” because it is an opportunity to improve.

He added that kaizen (using the word) and “The Theory of Continuous Improvement proved better in Japan; it is proving itself again in American industries willing to embrace it, and it holds some badly needed answers for healthcare.”

I'll continue in my summary of his article in another post later this week. Dr. Berwick provided some tips for leaders – how to achieve a culture of continuous improvement – or kaizen!

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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. Great post! Back in the olden days of Deming method of C.I. foreman’s and employees would talk in length about the predictions and results of the bead game experiment. Each in a group would take turn counting all the letter “E”‘s on the back of a Camel Cigarette pack to prove inspection doesn’t guarantee quality. Practically no one can get the correct count first try. This was genuine learning, sharing and experimenting as referred in your post. That spirit of TQM is too often lost in today’s environment.


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