Revisiting Don Berwick circa 1989

Well, it has been over 20 years since Dr. Don Berwick, newly appointed administrator of the Centers for Medicare and Medicaid Services and well known as CEO of the Institute for Healthcare Improvement, called for a change in American health care to a systems-based culture of continuous quality improvement (CQI). His seminal 1989 article "Continuous improvement as an ideal in health care" highlighted the then 'new' [to us] Japanese concept of total quality control or total quality management (TQM) that has been idealized as a model of culture, management and efficiency since the early 1990s here in the USA.

The world's most successful implementation of CQI is Toyota's Production System, now popularly referred to as LEAN or LEAN management. What we know of LEAN are professors' descriptions over the past 20 years of Toyota's culture, production system principles, work rules and process improvement tools. The LEAN philosophy at its heart is a culture underlying a core business strategy founded in the ideal of continuous improvement (kaizen) that is based on the knowledge of process variation. It is founded in the management system proposed by W. Edwards Deming, a management guru to the Japanese since the early 1950s, who was discovered late by Western businesses. Looking at the recent decline of American automotive manufacturing, some would say too late. LEAN is a scientifically based approach to quality improvement predicated on the data-driven Plan-Do-Check-Act (PDCA) analytic, also known as the Shewhart or Deming Cycle, that was fairly ineffective 20 years ago in this country when practiced as TQM.

Application of PDCA problem solving appears to be in resurgence, but successful application for change is highly variable, especially in healthcare. Toyota's success over the past 50 years, rarely reproduced, derives from a leadership-driven management culture of continuous improvement that over many decades perfected the principles of Deming and innovated aspects of efficient production design with worker empowerment to produce thousands of process improvements, many at the level of the worker, year in and year out. Toyota's organizational structure and cultural expectations empower organized teams of employees to drive a daily examination of continuous improvement opportunities and learning, thereby allowing them to be accountable, in charge of their own jobs and allowed to design their standardized work. The result is continuous quality improvement bread into the DNA of Toyota's culture.

This cultural transformation of work is what will be required in healthcare for the true power of LEAN to be leveraged. We failed to change our culture when attempting TQM 20 years ago and the fate of LEAN will be no different if we don't change our culture this time around. Transforming the culture of work, or more correctly the employees' incentives to relate to each other and work differently, is a requirement to obtain success in a LEAN enterprise that is continuously learning and improving. This requires leadership, as only leaders can make this kind of significant change and support realignment of incentives so that workers in connected workstations are encouraged to work collaboratively and horizontally along the path of workflow. This is the only way to obtain the strengths of Toyota's culture- namely 1) Employees in charge of their own jobs; 2) Employees designing standardized work; 3) Employees working to continually improve the work at their own level, with changes made and effectiveness assessed by the customer focused PDCA cycle.

LEAN success does not result from merely training in the process improvement tools; it is founded in culture and the empowered worker! We need more than a handful of foot soldiers trained in 'bootcamps'. Success will require effective battalions and brigades supported by impassioned generals. Success starts and ends with leadership. The current challenge for businesses of any type, and especially healthcare, is how to adopt the Deming-style of management rather than merely how to apply the principles and use the tools of Toyota's efficient production system.

The key lesson from the TQM history in healthcare is that what is really required for success is a change in culture- that is, the behavioral incentives that derive from the norms, values, belief systems, decision making processes, and political power bases that make an organization function. Anything less comes up short when the goal is to effect continuous process improvement.