Paul Batalden has worked his magic yet again. He invited fourteen pilgrims - leaders in healthcare improvement - to share stories about their pilgrimage – their experiences trying to improve healthcare and the lessons they have learned on the journey. They were invited to lecture at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire – a lecture series held between the fall of 2008 and the spring of 2009 – and then to submit a chapter for this book: Lessons in Changing Healthcare…and how we learned them. The reflections harvested by these labors represent leadership actions across a broad cross section of contexts: local, large system and national and constitute a useful and very readable guide for fellow pilgrims. Chaucer’s pilgrims were headed toward Canterbury to honor Thomas Beckett; Batalden’s pilgrims seek a more elusive goal – safer, less costly, more humane and more effective healthcare for patients and populations. Further, they want to teach others how to lead improvement in healthcare.

As with Chaucer’s pilgrims the importance of community emerges as a common theme of the work. Each of the authors has by hook or by crook learned the tools of improvement work (necessarily by hook and by crook because the formal education system has not incorporated these skills as part of the trade until recently). Learning the techniques and rules of improvement work is important and necessary, but what comes across in this book is the importance of intelligent improvisation, improvisation grounded in values as well as rules. Truth telling, transparency, good data, humility, and a willingness to share credit for progress and accountability for failures emerge as helpful, if not essential, traits for good healthcare leaders. To paraphrase several of the authors: Learning quality improvement requires doing quality improvement. It is understood by all that good healthcare requires two tasks: doing the work and improving the work, it is not sufficient to simply do the work and go home.

Honing the skill, however, is not enough. Greg Meyer reminds us of the story about Louis Pasteur on his deathbed. When his colleagues told him that the infection he had was usually not fatal he replied: “You have learned nothing. It is not the seed but the soil,” i.e. not the germ but the context in which the germ functions. Several of the pilgrims confirm the truth in this story – it is the communal context and not simply the introduction of quality improvement techniques that determines if the intervention succeeds. Communal context, in turn, is determined by the quality of the people in the community and the quality of the relationships they have with one another. Quality improvement requires thinking deeply about community, about people and the glue that holds them together as a community and the forces that divide them. Leaders need to know when to invite and attract the goodness in people, and when to use command and control to get over a bump in the road. They need to know how to acknowledge and manipulate drivers and barriers to change, how to manage conflict, how to detoxify the communal environment and create a place in which a person’s inherent intelligence and goodness is invited to participate wholly. It is the task of leadership to create an ecology that can support life. These approaches can be applied as skillfully as the surgeon uses a scalpel, or can be used incompetently with destructive effect. Quality improvement is not for the faint of heart – and paradoxically it is also everyone’s work. It is another task of leadership to manage this paradox.

On the cover of Lessons is a simple drawing of a thread. At the conclusion of the book Batalden quotes William Stafford’s poem on the thread: The Way It Is. He invites us to think of each pilgrim as holding onto a thread: “There’s a thread you follow, it goes among things that change but it doesn’t change….You never let go of the thread.” Lessons gives us a glimpse at the threads these pilgrims hold, threads that are usually “hard for others to see.” He invites us further to think of these fourteen threads as forming a tapestry, a tapestry that permits a larger viewing of healthcare change and change efforts. He invites us also to contribute our thread. Such efforts will ultimately constitute healthcare in the United States – we need a more beautiful tapestry.

Gary Kaplan says: “Leaders are dealers in hope.” Lessons is dedicated to the “next in line.” The pilgrims have recorded their tales and there is cause for hope, but much work remains to be done. This book provides a framework robust enough to support the next in line and beyond.