Dr. Don Berwick on Kaizen in Healthcare: Ahead of His Time (1989)

TL;DR: Long before Lean and Kaizen became common language in healthcare, Don Berwick argued in a 1989 New England Journal of Medicine article that improvement requires leaders to stop blaming “bad apples” and start fixing systems. His message–replace fear with learning, inspection with improvement, and punishment with partnership–remains a powerful reminder of what Kaizen in healthcare was always meant to be.

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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.

This systems-first perspective later became a central theme in my book Lean Hospitals. Lean in healthcare was never meant to be about isolated tools or efficiency for its own sake–it's about leadership responsibility for designing systems that reduce harm, improve flow, and support clinicians in doing the right thing. Berwick's 1989 argument anticipated that framing long before “Lean healthcare” became common language.

I can't share much beyond brief 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.

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.

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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

(Blame, Fear, and Inspection)

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

This is exactly the kind of environment where mistakes get hidden rather than learned from.

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.”

This is an early–and remarkably clear–statement of what we now describe as psychological safety.

That dynamic–fear distorting data and driving problems underground–is something I explored much more deeply in The Mistakes That Make Us. Berwick's warning makes clear that mistakes don't become organizational failures because people err; they become failures when leaders respond with blame instead of curiosity, punishment instead of learning.

That's also 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

(Learning, Partnership, and Kaizen)

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 explained that the “Japanese” approach (now practiced around the world) holds that “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!

Dr. Don Berwick's Timeless Blueprint for Continuous Improvement in Healthcare

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Key Leadership Lessons from Berwick (1989):

• Blame blocks learning
• Fear distorts data
• Inspection doesn't create quality
• Leaders must participate in improvement, not observe it

Why This Still Matters for Healthcare Leaders Today

More than three decades later, Berwick's message remains uncomfortable–and necessary. Many healthcare organizations still default to inspection, performance metrics, and blame when things go wrong, even as they claim to pursue Lean or continuous improvement. Kaizen fails not because the ideas are flawed, but because leadership behaviors haven't caught up to the philosophy. Berwick's 1989 warning reminds us that improvement begins when leaders replace fear with learning and take responsibility for fixing systems, not people.

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If you’re working to build a culture where people feel safe to speak up, solve problems, and improve every day, I’d be glad to help. Let’s talk about how to strengthen Psychological Safety and Continuous Improvement in your organization.