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Revisiting the Scientific Foundations: “The Classics” DonaldM.Berwick,MD,MPP,PresidentEmeritusandSeniorFellow,InstituteforHealthcareImprovement

This presenter has nothing to disclose

April30,2013

Objectives

Describe the components of W. Edwards Deming's “profound knowledge.”

Describe the intellectual pedigree of each of the components of “profound knowledge.”

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Getting Started…

THE RED BEAD GAME

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Intellectual Foundations

Improvement sciences have deep roots in intellectual history.

These intellectual foundations are not static; they develop over time, as all sound science does.

“Fads” come and go as the sciences are packaged for action, but underneath the fads are unifying scientific principles…the “classics” of improvement.

W. Edwards Deming’s categories – which he called “profound knowledge” – offer an efficient framework for sorting the scientific foundations.

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The “Classics” We Shall Review

W. Edward Deming – “Profound Knowledge”Historical Roots for the Profound Knowledge CategoriesWalter A. Shewhart – “Statistical Process Control”Douglas McGregor – “The Human Side of Enterprise”W. Edwards Deming – “14 Points for Top Leaders”Joseph M. Juran – “The Juran Trilogy”Avedis Donabedian – “Structure-Process-Outcome”Kaoru Ishikawa – “Seven Tools”IHI Mainstays…– Associates in Process Improvement – “Model for Improvement”– Leadership for Improvement Model– Breakthrough Series Model

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Appreciation of a system

Understanding Variation

Theory of Knowledge Psychology

Deming’s System of Profound Knowledge

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Categories of “Profound Knowledge”(with examples)

Knowledge of a System– Non-linear Dynamics– Flow and Interdependency

Knowledge of Variation– Measurement– Enumerative and Analytic Statistics– Common Cause and Special Cause

Knowledge of Psychology– Group Processes, Conflict, and Cooperation– Adult Learning and Creativity– Theory of Motivation

Theory of Knowledge– Plan-Do-Study-Act

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Development of Deming’s System of Profound Knowledge

Variation

Systems

Psychology

Knowledge

1900 1920 1940 1950 1960 1970 1980 1990 2000

ShewhartControlChart 1924

Design ofExperimentsSir RonaldFisher, 1925

SamplingmethodsDeveloped,H. F. Dodge

Use of statisticalmethods tosupport the wareffort 1941 - 1945

Enumerative vs AnalyticStudies in Statistics, Deming

Shewhart’s 1931 and 1939Books on Quality Control*

Principles of SystemsJay Forrester, 1968 Holistic Management, Stafford Beer, 1959

General Systems TheoryLugwig vonBertalanffy,1949

5th DisciplinePeter Senge1990

Theory of ConstraintsE. Goldratt, 1990

The Goal1984

F. Taylor, Frank & Lillian Gilbreth, Scientific Management

B - f(p,e)Kurt Lewin1920

AnthropologyExpertsapply theoryto business

OrganizationDevelopmentD. McGregor

Tavistockinstitute 1951Eric TristSoclotechnicalSystem

Open SystemsFred Emery

Maslow – Hierarchy of Needs1962

Participatory ManagementMary Parker Follett, 1925

Human Side of EnterpriseD. McGregor, 1960

Motivation TheoryHerzberg,1968

Hawthorne ExperimentsPlant, EltonMayo, 1927

Mind & The World Order, C.I. Lewis1929*

Double LoopLearning in OrganizationsChris Argyris,1977

Lectures atThe USDA,1938, organizedBy Deming*

John DeweyRealism ofPragmatism, 1905

How We ThinkDewey, 1933

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Improvement as a System - Deming 9

Walter A. Shewhart (1891-1967)10

Statistical Process Control

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Douglas McGregor: Theory X and Theory Y11

Deming’s 14 Points for Leaders1) Create constancy of

purpose toward improvement

2) Adopt the new philosophy

3) Cease dependency on inspection

4) End the practice of awarding business on the basis of price tags

5) Improve constantly and forever

6) Institute training on the job

7) Institute leadership 8) Drive out fear

9) Break down barriers between staff areas

10) Eliminate slogans, exhortations, and targets for the workforce

11) Eliminate management by objectives

12) Remove barriers to pride of workmanship

13) Institute education and self-improvement

14) Transformation is everyone’s job

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Dr. Joseph M. Juran’s “Trilogy” 13

QUALITY PLANNING

QUALITY IMPROVEMENT 

QUALITY CONTROL

What does it mean?

Quality Planning: You develop a new process using the principles of reliability from the beginning.

Quality Control: You monitor the process to be certain that it is working as designed. Does it continue to deliver the outcome you want?

Quality Improvement: The process is not delivering the outcomes as designed so it must be improved.

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Juran Trilogy 15

QUALITY CONTROL (DURING OPERATIONS)

00

40

20

CO

ST

OF

PO

OR

QU

ALI

TY

Op

era

tions

Be

gin

Chronic Waste (an opportunity for improvement)

TIME

LESSONS LEARNED

Sporadic Spike

Original Zone of Quality Control

New Zone of Quality Control

QUALITY IMPROVEMENT

Examples of Tools and Techniques

Quality Planning: – Quality Function Deployment– Failure Mode and Effect Analysis– Off-Line Design and Modeling

Quality Improvement: – Plan-Do-Study-Act Cycles– Process Mapping and Value Stream Analysis– Quality Improvement Teams

Quality Control: – Statistical Process Control Charts– CUSUM Graphs– Checklists

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Dr. Avedis Donabedian17

S + P = OStructure + Process = 

OutcomesSource: Donabedian, A. Explorations in Quality Assessment and 

Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI, Health Administration Press, 1980.

Seven tools of Kaoru Ishikawa

Cause and effect diagram

Check sheet

Control charts

Histogram

Pareto chart

Scatter diagram

Stratification

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What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

The Model for Improvement

Act Plan

Study Do

When you combine

the 3 questions with the…

…the Model for

Improvement.PDSA cycle,

you get…A Model

for Learning and Change Source: The Improvement Guide p. 10

Changing the old

Making the future attractive

Framework: Leadership for Improvement

WillIdeas

Execution

Establish the Foundation

Setting Direction: Mission, Vision and Strategy

PULL

PUSH

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PULL

PUSH

1. Set Direction: 100% or Zero

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Involve patients and families • Understand the gap between

your current performance, the best in class and the theoretical ideal

• Use stories and data• Go transparent• Show courage

5. Execute Change• Establish accountability for

results• Establish good oversight

process on “are we achieving our aims?”

•Watch your own dots•Weekly or monthly data•25% Board time on quality

4. Generate Ideas• Read and Scan Widely, Learn

from other Industries & Disciplines

• Benchmark to Find Ideas• Listen to Customers• Invest in Research &

Development• Manage Knowledge• Understand Organization as a

System

2. Establish the Foundation

• Quality education standards for board

• Build a board culture of healthy conversations with MEC and administration

• Establish Quality Committee• Bring knowledgeable quality

leaders onto the board

Framework: Leadership for Improvement

Breakthrough Series(6-18 months)

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Select Topic (Develop Mission)

Planning Group

Develop Framework & Changes

Participants (10‐100 Teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 2

Supports

Email (listserv) Phone Conferences 

Visits                      Assessments 

Sponsors           Monthly Team Reports

Expert Meeting

AP1 AP2

LS – Learning Session

AP – Action Period

*AP3 –continue reporting data as needed to document success

LS 3

Dissemination

Publications, Congress. etc.A D

P

S

AP3*Holding the Gains

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Intellectual Foundations

Improvement sciences have deep roots in intellectual history.

These intellectual foundations are not static; they develop over time, as all sound science does.

“Fads” come and go as the sciences are packaged for action, but underneath the fads are unifying scientific principles… the “classics” of improvement.

W. Edwards Deming’s categories – which he called “profound knowledge” – offer an efficient framework for sorting the scientific foundations.

A Durable List of Elements… (from Paul Batalden – circa 1991

Quality-Mindedness

Customer-Mindedness

Process-Mindedness

Employee-Mindedness

Supplier-Mindedness

Statistical-Mindedness

Continual Learning (PDSA)

Leadership

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