Dr. Donald Berwick – Trouble in the Making for Health Care

Reading through the Wall Street Journal this morning I ran across the “Letters to the Editor” and the one written by Keith R. Jackson, MD titled “Standardized Medicine Doesn’t Mean Better Medicine.”  Dr. Jackson should be worried, the WSJ article he was writing  about has to do with implementing manufacturing ideas into service.

The article in question from the Wall Street Journal is titled Berwick: Better than Kagan written by Daniel Henninger of the Journal.  In this article Dr. Berwick says some alarming things.

It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded. 

I have often written about the damage of targets and though well-intentioned are arbitrary in nature and drive dysfunctional behavior (search “targets” on this blog for further reading).  The issue here is method and we will need experimentation with method to achieve results, not setting new targets.

I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.

Here is the “lean” connection something that I have found fundamentally wrong with taking a lean manufacturing approach.  Service is different from manufacturing in that variety is greater.  All of this standardization for care leads to a one-size fits all – ever hear of a weight reduction plan that works for some and not others?  Variety is great in health care and standardization will lead to the wrong care.  Dr. Jackson (in his letter to the editor) rightly that “best care” can only come from the “right diagnosis.”  If the variety of patient is great (and it is) than standardization will lead to cheaper services, but more expensive care.

Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can’t standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection.

I have pointed this out often as a problem.  Dr. Berwick accepts the existing work design of Frederick Taylor – this functional separation of work is part of the problem with health care, service, manufacturing and government.  We optimize the pieces (functions) with standardized work and sub-optimize the entire system.  Costs are seen reducing by function but total costs rise as the pieces don’t synthesize.  Lean too many times misses the opportunity to design for effectiveness to achieve functional efficiency.

Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy

Berwick advocates best practice as well as standardization a notion of the one best way.  He does not in any way account for the variety patients bring and ask the questions important to avoiding systems that can not absorb this variety (who invented the standard? what problem were they trying to solve? Do I have that problem?).  Inability to absorb variety will cause failure demand (demand caused by a failure to do something or do something right for a customer) and costs will rise . . . a lot.

Unfortunately, Dr. Berwick learned the wrong way by going to other industries (for best practices) and he often quotes trying to be like manufacturing.  Not a good example as the US has so little manufacturing left.  Further, this approach leads to copying and copying rarely ends well.

Some will see this as lean-bashing, but Jim Womack of lean.org has touted his friendship and influence of Dr. Berwick.  This is troublesome as I have often pointed out that lean manufacturing is not for service.  To learn more about why see Redux:  Rethinking Lean (Six Sigma) Service from IQPC’s website.

There is much to learn and improve in health care, but in order to begin we need to start with customer purpose and demand.  This will tell us if standards are needed and if the workers (in the form of physicians, techs and nurses) can pull them.  We can redesign these systems based on purpose and build systems that absorb variety.  They should never be pushed for the sake of best practice, standardization or saving money and if they are . . . look for skyrocketing health care costs even worse than now.

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Make the new decade a profitable and rewarding one, start a new path here.  Download free from www.newsystemsthinking.com “Understanding Your Organization as a System” and gain knowledge of systems thinking or contact us about how to get started at [email protected].  Reach him on Twitter at www.twitter.com/TriBabbittor LinkedIn at www.linkedin.com/in/trippbabbitt.

Tripp Babbitt is a columist (Quality Digest and IQPC), speaker, and consultant to private and public service industry.

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