A primer on leading the improvement of systems

• Published in: BMJ Vol. 312; no. 7031; pp. 619 - 622
• Main Author: Berwick, Donald M
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 09.03.1996; British Medical Association; BMJ Publishing Group LTD; BMJ Publishing Group; BMJ Group
• Edition: International edition
• Subjects: Asthma; Biological and medical sciences; Changes; Continuous production; Education & Debate; Health and social institutions; Health care; Health care organizations; Health Care Reform; Health participants; Homes; Laboratory equipment; Leadership; Learning; Medical equipment; Medical sciences; Mortality; Nebulizers; Nurses; Organizational Innovation; Planning; Public health. Hygiene; Public health. Hygiene-occupational medicine; Quality Assurance, Health Care - organization & administration; Quality control; State Medicine - standards; United Kingdom; Workforce; Learning; Human; Health system; Professional experience; Improvement; Review; Change; Decision criterion
• ISSN: 0959-8138; 0959-8146; 1468-5833; 1756-1833
• DOI: 10.1136/bmj.312.7031.619

Learning points Not all change is improvement, but all improvement is change Real improvement comes from changing systems, not changing within systems To make improvements we must be clear about what we are trying to accomplish, how we will know that a change has led to improvement, and what change we can make that will result in an improvement The more specific the aim, the more likely the improvement; armies do not take all hills at once Concentrate on meeting the needs of patients rather than the needs of organisations Measurement is best used for learning rather than for selection, reward, or punishment Measurement helps to know whether innovations should be kept, changed, or rejected; to understand causes; and to clarify aims Effective leaders challenge the status quo both by insisting that the current system cannot remain and by offering clear ideas about superior alternatives Educating people and providing incentives are familiar but not very effective ways of achieving improvement Most work systems leave too little time for reflection on work You win the Tour de France not by planning for years for the perfect first bicycle ride but by constantly making small improvements Saying that performance is a system characteristic does not imply that performance never varies. According to the central law of improvement, the results everyone wants to change are properties inherent in the system.