A Primer on Leading the Improvement of Systems

With this issue of The Human Stream we are introducing a new theme - ‘Papers Worth Reading’ , where we look at influential practice-oriented papers (some from years ago, others hot off the press) and draw out key implications for safety and quality. Not all papers will be from healthcare, but most will. The aim is to break up extended runs of topic-centric issues of The Human Stream with other types of content. Love it? Hate it? Let us know what you think!

A Primer on Leading the Improvement of Systems - 1996 (Don Berwick)

Berwick, D. M. (1996). A primer on leading the improvement of systems. BMJ (7031), 619-622.

This week we look at a paper from nearly three decades ago - ‘A Primer on Leading the Improvement of Systems’ by Dr Don Berwick. For those who might be unfamiliar: Berwick, a Boston-based paediatrician and healthcare quality leader, founded the Institute for Healthcare Improvement (IHI) in 1991 and has been a key driving force behind the healthcare quality movement for much of its recent history.

This early paper reflects Berwick’s deep intuition and enthusiasm for systems-based improvement ideas which reflect those of legendary quality scientist Edwards Deming (whose work was a key early influence on Berwick’s own thinking). While this may not the be first reference to PDSA in healthcare, it is certainly one of the earliest papers to unpack how this approach might be used in healthcare. Most of us are familiar with the PDSA cycle but far fewer are aware of the systems-oriented context in which it was presented in this paper. In fact, very little of what is discussed in this paper makes it into basic QI training in healthcare which is a problem in itself.

Print off a copy, and get your highlighters out and let’s dive in - this is an exceptionally rich paper.

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Beginning with a short case study, Berwick puts forward his ‘Central Law of Improvement’ as the key idea of the paper. It says that ‘every system is perfectly designed to achieve the results it achieves.’ This pithy quote has been widely attributed to everyone from Edwards Deming himself to Peter Drucker, Paul Batalden and so many others, on conference stages to signature blocks, but rarely is it spoken of in the context of Plan-Do-Study-Act cycles! If healthcare performance (of any sort) stems from the design attributes of a system, then all planning, doing, studying and actioning must be directed at the system.

Berwick’s learning points from the paper are conveniently summarised into a set of principles that are reproduced below. As a little personal reflection or perhaps something you look at together at your next team quality meeting, you could consider each of these principles against your current perspectives on quality improvement and quickly note your reflections on each.

You could even complete this quick exercise before reading further.