Health Care Quality as a Scientific Endeavor

by Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement

Excerpted from from the Foreword of Quality Health Care: A Guide to Developing and Using Indicators, Second Edition, by Robert C. Lloyd. (Available Sept. 1, 2017)

In the now 30-year history of bringing modern quality methods into the control, improvement, and planning of health care, skeptics sometimes comment on the “religious” tone of that movement.  Leaders and others in the workforce who get the quality “bug,” seem to buzz with their enthusiasm.  They adopt phrases like “joy in work,” “pursuing perfection,” and a “never-ending journey,” and sprinkle their vocabulary with unfamiliar technical expressions, like “PDSA cycles,” “high reliability organizations,” and “statistical process control.”  And, they seem to think they are right, lamenting together that too many others so not see what they, at last, see.

So it does, indeed, seem to newcomers as if a religion, or at least a cult, has arrived in town.  The “immune reaction” can be strong.

If you are of that mind, think again.  Imagine, maybe, that what these newfound enthusiasts are evincing is, not religiosity, but intellectual excitement.  To overstate, what might Galileo have felt when, for the first time in human history, he saw those moons of Jupiter, and realized that they must be orbiting a sphere?  Or, more mundane, what did my 5-year-old grandson, Caleb, feel last weekend, when all of a sudden at a Sunday lunch he “got” the idea of letters’ spelling a word. (It was the word, “bark.”)  Like Galileo, maybe, he laughed out loud.

I do not know why for so many decades health care called itself “modern,” which it technically became in the era of bioscience, but remained distinctly “unmodern” in its understanding of its work as a system – complex, interdependent, and improvable.  My teachers in medicine taught me to be a heroic individual problem-solver.  My mentors in organizational management taught me to use incentives, hierarchy, and accountability to extract excellence. The language and tools of improvement revealed the underlying theory that “trying harder” was the route to success, and that metrics somehow – magically – led to results.

Ideas like that now seem to me to be a pervasive form of system illiteracy.  They are not scientific.  I simply did not know that for much of my early career, since it was, before I studied systemic quality sciences, as evident to me that effort is the root of results as it was to most people before Newton that apples fell because they just moved toward the center of the universe.

It took breakthrough in a number of sciences to reach today’s level of understanding of how things get better, or worse, in complex systems.  That understanding – call it “quality sciences” if you need a name for it – came through eventually intersecting lines of progress in statistics, general systems theory, cognitive and behavioral psychology, epistemology, and more.  It also continues to be dynamic.  Like all sciences, quality sciences are in continual evolution and increasingly powerful.

Happenstance introduced me to these sciences in my mid-forties, and I have never looked back.  By understanding systems better, by relearning how to interpret and learn from variation, by realizing how informative very small scale, local tests of change can be, by rethinking my theories of human motivation and communication, I was able to see more clearly where defects were coming from and how to find and change their causes.  Those subjects, mastered over time, gave me lenses and tools far more persuasive and helpful than the atheoretical approaches of the first part of my career.

Maybe it was an epiphany of sorts.  But there was nothing at all “religious” about it.  I just learned things I had not previously known – new guides to effective action.  Someone showed me Jupiter’s moons.

That’s not comfortable, at least at first.  It is not easy to let go of theories closely held, even when shown logically to be wrong.  Galileo paid a huge price for that in a public that found misconception less disruptive than changed perception.  And so, the jargon and excitement of the quality sciences are easy prey to those whose beliefs are time-honored, though wrong.

To accept the change in understanding depends in part on teachers – people with the patience to meet learners where they are and walk them down the path of new perception.  Like religion this takes empathy and compassion. But, far from faith-based change, this job also takes rigor and commitment to science.  I love the quotation from Albert Einstein at the entrance to the Keck Building headquarters of the National Academies of Sciences, Engineering, and Medicine: “The right to search for truth implies also a duty; one must not conceal any part of what one has recognized to be true.”  If that be a religion, sign me up.

Available Sept. 1, 2017

And that brings us to this book, Quality Health Care: A Guide to Developing and Using Indicators, and to its author, my longtime friend, mentor, and colleague, Bob Lloyd.   No topic is more thoroughly a battleground between the older, and unscientific, methods of improvement, and to the newer, more theoretically grounded methods that I call “modern” than is the topic of measurement. And few topics generate more controversy at first.

The prior, hegemonic, view of measurement is that it causes improvement, and is therefore a powerful tool for implementing a theory of exhortation, accountability, and incentive.  Not so.  Get in touch with the workforce and ask them how it is going with the metrics in their work-lives, and they will tell you how scrutinized they feel, and how demoralized, threatened, and misunderstood they feel by that scrutiny.  They will equate measurement with waste and risk, not growth and learning.

The scientific approach to improvement also values measurement, but it is measurement for learning, not measurement for judgment.  It knows, in the words of an African proverb, that “weighing a pig does not make the pig fatter.”  But it also knows that careful, respectful metrics, linked with sound interpretation of variation, trust in the workforce, methods for local trials and tests, celebration, and supports for innovation, can be invaluable in continual improvement. And that all of this matters in the search for knowledge, put to use.

Bob Lloyd is the best teacher I have ever met in those vineyards of measurement-for-improvement.  He is stunning in the classroom.  I have teased him often about how relentlessly at the top his ratings are in the many Institute for Healthcare Improvement conferences where he is an instructor.  It’s very hard for the rest of us, like watching a gymnast do what is for normal people impossible.  We watch him in awe as he takes novices by the hand, and in days shapes them into expert interpreters of variation, and therefore far more helpful quality champions in their home organizations.

This book is a resource for that change, written by a master.  Bob has been able to skillfully blend the quantitative aspects of the science of improvement with the more qualitative and strategic aspects that allow organizational transformation to flourish.  In the final chapter he provides clear guidance on how to “connect the dots” by linking measurement efforts to improvement.  As he points out, “Data without a context for improvement are useless!”  We have a long way to go yet in grafting quality science into the core of our health care systems, but those who really want to do it, to help our patients, their families, and our communities, have no better place to turn for their development than to this book and this teacher.

It’s not a religion.  It’s intellectual progress, personal and cultural.  So, welcome it, and read on.


Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, is also former Administrator of the Centers for Medicare & Medicaid Services.

A pediatrician by background, Dr. Berwick has served on the faculty of the Harvard Medical School and Harvard School of Public Health, and on the staffs of Boston’s Children’s Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women’s Hospital. He has also served as Vice Chair of the US Preventive Services Task Force, the first “Independent Member” of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality. He served two terms on the Institute of Medicine’s (IOM’s) Governing Council, was a member of the IOM’s Global Health Board, and served on President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.

Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions. In 2005, he was appointed “Honorary Knight Commander of the British Empire” by Her Majesty, Queen Elizabeth II in recognition of his work with the British National Health Service. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as Lecturer in the Department of Health Care Policy at Harvard Medical School.

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