Longwoods Online

Longwoods Online November 2013

A Different Way of Thinking

Ted Ball and Hugh MacLeod

When we listen to the conversations taking place on the “balcony of personal reflection” they are personal and human interest stories. The conversations stem from personal experiences as patients, family members, care providers and managers in healthcare. Our exposure to healthcare, in this capacity, proves a key learning experience for all. Healthcare is a touch business, and care is all about relationships between and among care providers and patients. Hugh asks: “Do we fall into a trap of forcing from the top a blueprint, a plan, a process, a tool, without truly allowing for the generation of a new way of thinking and doing business?” I reflect on a 1989 “Event at Harvard” that I attended with a group of healthcare reform radicals led by an unknown professor/physician named Don Berwick – who went on to become the acknowledged healthcare quality guru on our planet.

At the time, Berwick and his team were breaking new ground. They were equipped with dozens of “tools,” “frameworks” and “quality processes” which were all borrowed from Deming’s work with Japanese manufacturers. Unfortunately, the first generation of healthcare quality learners felt inclined to seek out existing frameworks, and began consulting with firms that sold fancy TQM Workshops with CQI Tool Boxes. They had misinterpreted the essence of what Berwick was trying to teach, embracing and advancing “a different way of thinking.”

Sadly, the idea of education and skill development for the front line care providers became another fad due to the misunderstanding of what Berwick, Deming and Juran were attempting to communicate. The quality improvement movement was about a different way of thinking, it wasn’t about the tools.

These inadequate practices have continued to spread over the past 10 years and have now become central to current quality improvement curriculums. Curriculums which are targeted to middle managers, who in turn are responsible for engaging their front line workers with these specific tools.

The Ghost of Healthcare Consciousness appears and says:

“Many consultants and organizations have cashed in on the lucrative ‘bums-in-seats’ educational workshop industry. Most of the training packages available today provide ‘old-school’ quality tool training. These training programs are prone to heavy academic attendance and, therefore, leave front line staff at arm’s-length. Why? Because left-brain manufacturing processes that promise to ‘save money’ do not really motivate care providers.”

Today, Berwick admits that when the TQM/CQI movement commenced, he (believe it or not) did not even consider the one diagnostic tool that fundamentally changes the whole equation: the patient! It’s extraordinary that the “old-school quality” didn’t recognize the patient as a potential source for solutions, or even as a meaningful measurement. In addition, Berwick noted, “We also didn’t understand ‘systems’ back then … we didn’t understand hospitals as systems, or local community services as a ‘system of services’ that somehow ought to fit synergistically together.”

Were Deming and Juran cognizant of the needs of workers, such as pride and joy in work, breaking down barriers, driving out fear, eliminating slogans, and initiating programs for education and improvement of all? I believe they were, but somehow it was neglected when healthcare leaders began to jump on the TQM/CQI bandwagon. It was the rare manager/leader who took the time to really understand what Deming and Juran were saying before leaping on the “I think we can improve the process, improve outcomes, save money and reduce workers with this way of doing business,” bandwagon.

We are ingrained in fragmentation and automatically break off the various pieces from the whole, placing them into isolated and incomplete piles. Instead of examining the experience silo by silo, participants should be asked to address the “whole picture,” rather than the “sum of the individual parts.”

Peter Senge explains that “from a very early age we are taught to break apart problems, to fragment the world. This apparently transforms complex tasks and subjects into more manageable details, but we pay a hidden and enormous price. We become blind to the consequences of our actions; we lose our intrinsic sense of connection to a larger whole.” When we try to “see the big picture,” we try to reassemble the fragments in our minds, to list and organize all the pieces. 

Giving up on the illusion that the world consists of separate and unrelated forces, we are able to build “Learning Organizations,” organizations where “people continually expand their capacity to achieve the results they truly desire; where new and expansive patterns of thinking are nurtured; where collective aspiration is set free; and, where people are continually learning how to learn together.”

In such organizations, people no longer compete with one another and the traditional silo wars between departments or factions dissipate. People are working cooperatively and collaboratively in order to fuse the component parts into a coordinated whole. Integration is the opposite of fragmentation. Learning how to think in an integrated, holistic way involves a struggle to overcome our traditional, fragmented ways of thinking.  Systems-thinking shows that small, well-focused actions in the right place can produce significant, enduring improvements. By contrast, traditional fragmented thinking focuses on symptomatic fixes – not underlying causes.

Let’s be clear: we are not suggesting Quality Tool Training is bad. We’ve learned a lot since then. We actually know the limitations of last generation’s tool-based QI training programs. They tend to be more about teaching than about learning. They tend to be more top-down than bottom-up, and more didactic than participative. Often they are more expert-led than collective intelligence and more about politics/optics than about fundamental transformational change. Lastly, they focus on the process rather than on achieving results. Unless we change how we think, we will always produce the “same/old” results. To repeatedly perform an identical action, with the expectation of arriving at a different outcome, is completely absurd.

To help instigate a change in thinking, we suggest reflecting on these three recommendations:

  1. Your organization has a quality and patient safety accountability framework in place with a set of indicators and it is credible among and relevant to care providers.
  2. Measuring and reporting on quality and patient safety is a core expectation of all leaders and managers and care providers, and part of their continuing education agenda.
  3. There is an organizational mentorship and professional development program that highlights quality and patient safety improvement theory and practice.

We close with a passage from the essay, “Accountability for Performance”:

“If the healthcare system is to improve its performance over the long term, it must shift from a paradigm where no one – or only a few – are accountable for achieving a particular set of results, to one where a wide range of players is accountable for achieving a broad range of results. To paraphrase Barber, when there is a problem in the system, the answers cannot come only from government, because it has the money, or from provider organization boards and management, because they are ‘in charge.’ Rather, the answers will come when we ask, collectively, how we are going to solve the problem. Accountability for achieving results must go beyond boards and management – and beyond a vague concept of shared responsibility – to include physicians, other healthcare providers, professional associations, regulatory bodies, government, regional networks and the public.”

Let’s continue with the conversations. Join next week’s conversation titled: “Three Care Provider Voices: Let Compassion Be a Guide to Unleash Professional Potential, Social Determinants – We Have Work to Do and Why Are We Still Looking the Other Way?”

About the Author(s)

Ted Ball, Patient, Consultant.
Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Husband, Father, Brother, Grandfather … Concerned Citizen.


The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute – with partners – has tools and resources, please contact www.patientsafetyinstitute.ca


Berwick, D.M., A.B. Godfrey A.B. and J. Ruessner.1990. Curing Healthcare. San Francisco, Jossey-Bass.
Deming, W. 1966. Some Theory of Sampling. Dover Publication.
Juran, J.M. 1980. Quality Planning and Analysis. New York – McGraw-Hill.
Senge, P. 2006. The Fifth Discipline. Doubleday, New York.
MacLeod, H. and T. Closson. 2013. “Accountability for Performance.” Longwoods Ghost Busting Essays.

Barber, M. 2007. Instructions to Deliver. Methuen & Co. Ltd. 


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