The video above shows Don Berwick’s presentation at the IHI/BMJ International Forum on Quality and Safety in Health Care, 13 April 2016. He starts the presentation with the Red Bead Game (see related posts on our blog: Lessons From the Red Bead Experiment with Dr. Deming, The Red Bead Experiment with Dr. W. Edwards Deming).

Quoting Shewhart, Berwick said:

When you inspect you are conceding the to the system.

This is a nice short quote to emphasis the weakness of relying on inspection. What we want to do is improve the system to reduce the instance of poor results, not to inspect our unreliable process to remove bad results. This is even more true in services where often you can’t inspect to catch errors before the customer is disappointed (think of call centers for example). If the customer service representative gives a poor response you can’t inspect it before it reaches the customer. You need to improve the system to avoid producing poor results. (See: Inspection does not improve the quality, nor guarantee quality. Inspection is too late.)

Tampering is responding to random variation as if it were informative.

This is very common. When you don’t understand variation you react to data points as if they mean something other than what they do mean. See our posts of understanding variation. Evidence-based decision making is good, but just because you use data doesn’t mean it is effective (for example, the read bead experiment). You must know how to understand what data is telling you.

Deming’s proposal was this. He said, you used to think, before Stewart, before Deming, before Juran, that if you want to get better at something you needed to understand the subject. You want to get better at surgery study surgery, if you want to get better at nursing study nursing, if you want to be better at pharmacy study medicines. Thats right, thats subject matter knowledge, you better know it. I don’t want a surgeon to operate on me that doesn’t know anatomy. And that he says will produce traditional improvement. But, he said we are not after traditional improvement, we are after total system transformation. He said there is another set of knowledge we need, in fact he said there are really four kinds of knowledge.

Those 4 areas are appreciation for a system, knowledge of variation, theory of knowledge (in the talk Dr. Berwick sometimes lists this as PDSA) and psychology.

If you are a CEO or leader you want to have a portfolio of this kind of constant learning (multiple PDSAs being carried out on several aspects of systems concurrently) going on in the non linear world of systems… fail, in order to learn.

I accept the “fail, in order to learn” concept but I think it is better to see it as accepting the risk of failure (that you try to minimize the costs of) when you experiment to learn and improve.

I also think we need to focus on learning from success and failure. You often hear people say you can only learn from failure; that is just not true. There are aspects of things working well that you knew (or believed) which is why you acted in the way that resulted in success but there are often things to learn from success and that potential learning is often ignored.

By the way, he says no-one has learned to ride a bike without falling. Well, I did. My Mom liked to tell me I sat in my front yard watching the older kids ride their bikes for several days. Then I saw a bike not being used and I got on and started to ride. It is true that mainly you have to accept the possibility of failure but don’t discount the value of some thought and study before you act as a way to reduce the instance of failure. Don’t be so cautious that you miss out on opportunities. But don’t just think failure is just the result of trying. How you try will greatly impact the proportion and size of failure.

Dr. Berwick provides an excellent reading list of 6 books: The Design of Everyday Things by Don Norman; The Fifth Discipline by Peter Senge; The Improvement Guide by Langley, Nolan and Nolan; Overcoming Organizational Defenses by Chris Argyis; Managing the Unexpected by Karl Weick and Kathleen Sutcliffe; and Human Error by James Reason. The last 2 I haven’t read, but the first 4 are great, I am sure the last 2 are also.

Don Berwick’s penultimate illustration was discussing his experience at Deming’s 4 day seminar:

In 1986 when I went to Deming’s course and I saw the bead game I was in charge of quality. I was Frederick Winslow Taylor’s best friend. I was in an HMO and my job was to do everything I just did the red bead game, I just didn’t know I was doing it. And then I went to Deming’s Course and he began to lay out just what I am laying out to you. And here’s what happened. It was a four day course. On day 1 and a half, noon on day two, I left. I hated it. I was so angry at this pontificating drone – Deming. And I said “this is crap” and I left. It was in Washington DC. I left the hotel, went to the airport, got on the plane and I flew home to my family. And my wife said “what are you doing?” I said, what I am doing is not wasting my time, that was crap. And that night I went to bed and I could not sleep. I tossed and turned and I tossed and I turned. I was sweating, I remember it, my wife said “what’s going on here?” And I didn’t know. Until 6 AM. And then I just remember saying, “oh my God, he’s right.” He’s right, I was seeing for the first time in my experience in systems leadership a way to think that I could identify with as a science. When I went back and inspected my “bead game” I said “that’s not science, where did all that come from?” And that moment for me was a moment of realization. I got back on a plane. My wife still thinks I was crazy. 6 AM I drove to Logan Airport, got back on a plane and attended day 3 and day 4. Its a true story. My point is this isn’t easy, it’s hard. It’s hard intellectually, It’s hard because you have to give up beliefs you have and hold very dear and beliefs that are appearing and reinforced in every issue of every morning paper. Only transformation will work: transformation of the way we think.

Related: We Need to Understand Variation to Manage Effectively – Riding a Bike and the Theory of Knowledge – The History and Evolution of the PDSA Cycle – Application of Deming’s System of Profound Knowledge in Healthcare