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Science of Improvement


W. Edwards Deming, a statistics professor and physicist, is often considered the father of quality improvement. In the 1950s, Deming helped the Japanese manufacturing industry redefine quality control. His beliefs of cooperation, mistakes as opportunities for improvement, and striving for continual improvement helped the Japanese improve their production process and product quality while reducing costs. Recognizing the success of the Japanese manufacturing industry, in the 1970s, American industries began adopting his theories of management and quality. Finally, during the 1990s, his theories trickled into healthcare improvement efforts. Utilizing these quality improvement methods, healthcare industry leaders, such as Intermountain Healthcare and Geisinger Health System, have now demonstrated improved efficiencies and effectiveness of healthcare processes and outcomes.


Poor outcomes or poor quality are often not the result of bad people. Instead, as Paul Batalden notes, “every system is perfectly designed to achieve exactly the results that it achieves.” Critical to improvement is introducing change to a process or system. Often, subject matter knowledge gathered through training and experience will help develop the ideas for change that can then be tested and implemented. For example, to improve care, a team may develop disease-based care guidelines to be instituted on the basis of literature and practical experience. However, for successful adoption, a broader understanding of knowledge and change is required.


Deming described another form of knowledge, called a “system of profound knowledge,” that is instrumental in developing effective change and thereby improvement. His theory is composed of four components. The first is an appreciation of a system. The healthcare industry is a complex system of interactions. To accurately assess the impact of changes on the system, an understanding is needed of the interdependencies and relationships among all of the components of the system—doctors, nurses, ancillary staff, patients, treatments, diagnostic tests, and location of care, to name a few. The second component is an understanding of variation. Variation is inherent in every system. A lack of appreciation of variation and its causes will lead to mistakes in dealing with the variation. Individuals may see trends where there are no trends or may try to explain natural or random variation as special events. A fundamental understanding of variation is needed to develop appropriate actions for processes. Building knowledge is the third component to Deming’s theory of profound knowledge. In quality improvement, a change represents a prediction. It is predicted that if the change is made, an improvement will result. The more knowledge one has about the current system, the more “accurate” the prediction will be and result in improvement. If the changes do not lead to improvement, the process can be reviewed and the theory modified with new ideas for changes. These iterative cycles of learning by making changes and observing or measuring the results form the foundation of improvement. The final component of profound knowledge is the understanding of the human side of ...

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