W. Edwards Deming's ideas about systems thinking, measurement, psychology, and leadership remain highly relevant for healthcare improvement today, even decades after they were first articulated.
Why Deming Still Matters in Healthcare Today
Healthcare leaders continue to struggle with quality improvement efforts that feel expensive, exhausting, and difficult to sustain. Decades ago, W. Edwards Deming warned that these outcomes were predictable when organizations focused on tools instead of systems, targets instead of learning, and incentives instead of motivation. His thinking remains strikingly relevant for healthcare today.
An article in the Stanford Social Innovation Review, co-authored by Maureen Bisognano and colleagues from the Institute for Healthcare Improvement, reflects many of Deming's core ideas about quality, systems, and leadership in healthcare.
10 Lessons From Health Care on Quality Improvement
Pitfalls and promising practices drawn from experimentation with quality-improvement methods and performance management in health care.
They write:
“While results have been decidedly mixed [with Lean, Six Sigma, and Continuous Quality Improvement], the field has made some advances while learning a great deal about the best use of these approaches.”
For every health system that gets great results with these methods, there is one (or likely more) that struggles and, at some point, gives up on the method instead of figuring out how to do it better.
Deming would argue that these failures are rarely about the method itself, but about how leaders apply it within the system they manage.
Seeing the System — Not Just Departments
They cite Dr. Deming first in talking about the need to understand broader systems:
“With respect to the first pillar–seeing the system–health care has long been guilty of myopia, focusing on improvement in hospitals and specialty areas, while failing to understand the larger societal factors responsible for unequal outcomes and skyrocketing costs…”
In some recent work that I did with an outpatient surgery group, one of our key strategies was to break down silos — helping people from areas like registration, pre-op, the family waiting room, and the recovery room see how their individual work fit into a broader system or value stream. This system also includes other locations, such as the individual surgeons' offices.
I'm still amazed (but not surprised) to see what happens when cross-functional teams map out processes or value streams that they are a part of. When communication, visibility, and transparency is added to that improved understanding, great things start to happen.
Adapting Best Practices Instead of Copying Them
The authors also write about the need to adapt best practices, rather than rigidly copying:
“Much of the work of improvement in health care involves taking ideas and innovations already established in the evidence base, and adapting them to different care settings. Seeking strict adherence to implementation protocols is thus often counterproductive. In most cases, after communicating which components of an intervention are clinically sacrosanct, leaders must trust professionals to make it work within their own context, culture, and operating constraints.”
Deming repeatedly warned that copying without understanding variation and context leads to disappointment, not improvement.
I've written before about learning from others, but not just blindly adopting what they did:
Measurement for Learning, Not Punishment
The authors then write about measurement systems (an important topic to me). To me, it's not just measurement that matters, but connecting measures to our improvement efforts.
“In health care, measurement systems too often serve the needs of regulators, administrators, academics, and other third parties who use data for research and inspection. Care providers do the arduous work of entering data into forms and spreadsheets, never to see it again unless leaders use it to rank or admonish them.”
Deming repeatedly warned that copying without understanding variation and context leads to disappointment, not improvement.
“The first design principle of any effective measurement system is this: Put timely, easy-to-interpret data in the hands of those who can make day-to-day change, including doctors, nurses, patients, and families.”
Deming was clear: when measures are used to judge or rank people, they stop reflecting reality.
Using Process Behavior Charts to Avoid Overreaction
I've seen “Process Behavior Charts” be very helpful as a method for accomplishing that aim. PBCs help people better understand the cause-and-effect relationships between changes they make and their results.
In that surgery center's work, the main aim was to increase patient experience scores. In the past, they had a tendency to overreact to every up and down in the metric (as happens at most every organization). Without sharing the exact data, the previous 18 months' scores were just fluctuating around an average. It was a “predictable” metric… there was no reason or root cause for any small up or down within the upper and lower limits that were calculated for the chart.
One key principle, as an improvement team, was that we were NOT going to declare victory over one or two above-average data points. We weren't going to try to fool anybody with a simplistic before-and-after comparison of two data points. We were going to look for statistical signals that showed performance had changed enough that it couldn't be the result of fluctuation and randomness.
We had a hypothesis:
If we made these changes to the system, then the scores would increase. Even if they just increase a few points, we'll look for eight consecutive data points above the old average and proof of a sustained increase. We also started looking at the scores in WEEKLY buckets, which might show a signal more quickly than monthly numbers.
This is exactly what Deming meant by “seeing the system” — helping people understand how their work connects to outcomes instead of optimizing isolated departments.
For leaders, this changed the conversation from “Why did the score drop?” to a more useful question: “Has the system actually changed?”
Psychology, Motivation, and Change
The authors also encourage us to understand the psychology of change, as Dr. Deming emphasized. Again, on the topic of the psychology of change, I hosted a webinar that I highly recommend: “From Ambivalence to Action: Leadership Lessons from Motivational Interviewing.”
“… technical work that fails to connect with the reasons people are called to their professions soon becomes drudgery.”
Pascal Dennis, a sensei of mine, always talked about the need to focus on hearts AND minds in our improvement work.
Why Incentives Often Undermine Healthcare Improvement
The authors also warn us, as Deming did, about incentive systems:
“Doctors and nurses are endlessly ranked and rated, and compensated accordingly, but there is very little evidence to suggest that this leads to better outcomes for patients. Possible reasons for the failure of pay-for-performance programs include the fact that they make faulty comparisons between dissimilar organizations, induce groups to misreport their performance, and belittle and discourage care providers, resting on the problematic assumption that financial incentives are what drive their behavior. The social sector should approach payment incentives with caution, and invest more time in cultivating the intrinsic motivations we described in the previous lesson.”
I agree. “Motivational Interviewing” is a method that helps us draw out intrinsic motivations that already exist.
Deming warned that ranking, rating, and rewarding individuals for outcomes driven by the system would reliably damage trust and performance.
A Better Question for Healthcare Leaders
If Deming were visiting your organization today, where might he see people being blamed for system failures — and what conversation would that invite?
Instead of telling leaders to do those ten things, can we use a Motivational Interviewing approach to have a conversation about needed change?
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.
I have a link to your blog in my latest LinkedIn article.
Thanks for linking to my post on Quality Circles.
I added a link to your article in your comment, too.