Dr. Don Berwick is “Stunned” By How Few Organizations Study Deming


Yesterday, I shared some more notes from Part 3 of the 1980 NBC documentary “If Japan Can, Why Can't We?” that featured W. Edwards Deming.

Next week, I'll release Episode 238 of my podcast series, which is a discussion with Kevin Cahill, one of Dr. Deming's grandsons. I think you'll really enjoy his memories and reflections on Deming's work

One of the first people in healthcare to be influenced by Deming's work is Dr. Don Berwick, founder of the Institute for Healthcare Improvement (at right in that picture).

Berwick wrote about Deming's ideas back in 1989, in the New England Journal of Medicine, as I blogged about here: “Dr. Donald Berwick – Ahead of his Time on Kaizen in 1989.”

Hear Mark read this post (as part of the “Lean Blog Audio” podcast):

This article, from December, was floating around social media the other day (hat tip to Paul Levy):

Don Berwick Offers Health Care 9 Steps to End Era of ‘Complex Incentives' and ‘Excessive Measurement'

Among the points that Berwick makes, here is the one most directly related to Deming, Lean, and continuous improvement:

5. Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I'm trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming's work, no one recognizes a process control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel's Method or the route to the top. You can see the proof of concept. This is beyond theory now.

I share Berwick's view that most healthcare organizations today don't really practice any of Deming's methods or teachings. And this is too often true in organizations that would say they are “implementing Lean.” People remember Dr. Deming and they know of PDSA, but very few really get an opportunity to practice PDSA — being encouraged to do it or being coached well by leaders who understand it. There's lip service.

I see lots of charts posted on the walls of Lean organizations, but there's very little understanding of SPC or control chart thinking. I've blogged about this many times before. Instead of Deming's approach, we see arbitrary targets, slogans and admonishments to do better, and a lack of distinction between special cause and common cause variation in organizations.

Back to Berwick's paragraph, I'll have to claim ignorance about “Nathaniel's Method” and I haven't been able to figure that out via Google searches. Can somebody help with that by posting a comment?

Whether we call it Deming, PDSA, Lean, or “improvement science,” Dr. Berwick is right that we have many “proofs of concept.” It's beyond theory that Lean can make a big difference in healthcare.

It frustrates me that we have such powerful proofs of concept that aren't leading to everybody fully embracing Lean. Part of the problem is that organizations THINK they are embracing Lean, but they won't get the results of ThedaCare or Virginia Mason or others if they don't follow the process of those organizations. Training a few green belts or using a few Lean tools here or there won't bring the same results as the widespread culture change and management systems do at the best Lean health systems.

I recently talked to somebody at a health system who lamented that they had a “lack of energy around Lean.” They had originally trained about a dozen green belts who were supposed to then get 20% of their time dedicated to improvement work.

This didn't happen. There was “no real effort” to give them time to do improvement work. Lean became “the lowest priority” within the organization. That's not the fault of green belts. That's a leadership problem. If your executives don't have enthusiasm for Lean, nobody else in the organization will either.

One of my resolutions for 2016 is to fret and complain less about organizations who aren't making progress or who seem to “not get it.”

If people don't “get it,” whose fault is that? In the Training Within Industry method, they say, “If the student hasn't learned, the teacher hasn't taught.”

Of course, if people aren't even trying to be students, maybe that's not the teacher's fault. How many executives would claim to be “leading a Lean transformation” without studying Lean or reading a book themselves?

Paul Levy wrote a few interesting tweets about this, as somebody who is trying to teach and influence others too:


Why don't more organizations embrace Deming, Lean, and improvement science? Why do many who say they embrace it do so half-heartedly?

What do you think?

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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. > Why do many who say they embrace it do so half-heartedly?

    They stick to old mental models and just pick and chose how to adjust a bit if those old models (pleasing the boss etc.) require they at least spin what they do as lean or whatever else they are expected to do. Also often the existing culture fights against really adopting management improvement ideas so only those willing to challenge convention will push through those barriers (which is a small number of people).

    I have written more on this (this links has links to more related posts)


  2. Thanks for sharing this Mark,

    Dr. Berwick might be stunned, but I am not. Every time I talk about improvement I mention Dr. Deming. I always ask “how many people have heard of him?” The number of hands that are raised is about 5% and is getting to be fewer and fewer. I don’t think it’s only the younger age of the audience (that’s one factor).

    I think there are 3 main factors:
    1) Theres a lot of noise and nonsense in the world that is competing for attention. Most of what you read is the promise of new tools and methods, but it still comes from the prevailing thinking and prevailing style of management. Executives go after the latest “quick fix.” Most will not read “Out of the Crisis” or “The New Economics” claiming they are “too theoretical” “out-dated” or just too many pages. Most seem to want something they can read on the airplane and then delegate to a subordinate when upon landing.
    2) Dr. Deming was “placed in a container” – people think he was all about statistics, or manufacturing, or TQM (don’t get me started on how much he hated this TLA) or mistakenly associated with 6 sigma. So, people put him into a category in history and he’s been mislabeled and largely forgotten.

    Many people have latched onto “lean” as the promise for improvement and survival. They don’t realize that much of what was noticed in 1987 with the MIT study about Toyota and other companies can be traced back to the 1950s when Deming went to Japan. He brought new knowledge (not the prevailing style of management). He taught leaders and engineers about the quality chain reaction, how to view their organizations as systems and how to react to variation.

    In 1980 (in the NBC program “If Japan Can, Why Can’t We?”) he stated, “people think they can go to Japan and copy, but they don’t know what to copy.” They see and copy the surface things, but they don’t know the principles behind them.


    Edit by Mark Graban: Here is the link to the NBC video.


    Many people are making the same mistake now. They copy lean tools and methods from others without understanding the principles behind the tools. Lean is often used as a tool for efficiency or a weapon for reducing headcount.

    Lean was misnamed. Simon Sinek had some useful comments on this in a recent commentary: http://bit.ly/sinekcouragelead

    “Lean has nothing to do with efficiency. Lean has everything to do with people. The biggest mistake Americans made bringing Toyota process to America was calling it Lean. Americans turned it into a tool for efficiency, but that’s never what it was supposed to be. There are zero, zero examples of an American company successfully implementing Lean when they do it as a tool for efficiency. Zero. How good can a process be if there are zero examples of success? It’s about cooperation, not efficiency. Efficiency may come out of the cooperation, as will profit and innovation, but the motivation is human. It’s not a metric. If you had social scientists and anthropologist down the research, the would have named it something else. They they would have called it teaming, or they would have called it cooperation, or they would have called it trust, or they would have called it community, because that’s how Japanese companies operate.”

    Dr. Deming was about joy in work and joy in learning for everyone. He was about cooperation and “win-win.” He was about the individual and bringing back their intrinsic motivation that has been crushed by the prevailing style (system) of management.

    I’m not stunned. I’m saddened.


    • All good points Mike.

      Especially #2. Deming often used statistics to illustrate his arguments, for example with the red bead experiment. Sadly, this approach seems to have led to people conflating the bulk of his ideas with statistical control of quality.

      With regards to the article, there are are many challenges for getting traction with Deming’s ideas:

      * As was pointed out, many leaders “think” they they are already doing it (e.g. most companies will have a “process improvement team” or some such)

      * It is much, much easier to justify replicating what other companies do (i.e. “the prevailing style of management”). The term for this is “Mimetic Isomorphism”, and I feel it is a central element of why Deming’s ideas have not been widely adopted.

      • Marcin – Thanks for commenting.

        It’s far to common for hospital leaders to hear a bit about Lean and then say “that’s easy” or “we’ve already been doing that, we just don’t call it Lean.”

        New Lean tools added into the “prevailing style of management” won’t really help much. As the Toyota people say today, TPS is a holistic system. You can’t copy just a piece or part here and there.

  3. I completely agree, Mark. I don’t see how anyone can advise on or lead the transformation toward lean thinking without understanding Deming’s Theory of Profound Knowledge. Unfortunately, I see people and companies attempt it every day, resulting in weak or unsustainable gains.

    Great post!


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