The Next Cultural Transformation in Medicine, Part I

To understand the next cultural transformation in medicine, we first need to understand the last one -- the cultural transformation around quality.

Picture Track Coach Jones.  His team practices daily.  Every week, every member of the team runs a timed 100 meter sprint.  Anyone turning in a time of under 12.5 seconds is placed under heightened scrutiny for a week, and if a second subpar performance is turned in, he is booted from the team.  At the end of six weeks, Coach Jones feels his team is fast because no one runs the 100-meter at an unacceptably slow pace.  The speed distribution of the Jones team looks like this -- he cut the runners in the "red zone":

Track Coach Smith is in a school in the same town.  In practice, he measures everyone's 100-meter time.  An individualized training regimen is developed for every athlete, and personal improvement goals established.  Improvements made by all individuals are celebrated, even that of the slowest member of the team.  The speed distribution of the Smith team looks like this:

Against which team would you rather compete?  For which team would you rather run?  Which team will have the most long-term success?

Obviously, this is an extreme example to make the point.  We would all want to be part of the organization that takes the skills and talents people bring with them, and actively works to make everyone better.  The worst improve (and still, at times, need to be cut); the average improve, and some will excel;  the stars come closer to realizing their full potential, and set a new aspirational standard for others.

You do not have to roll the clock too far back in the history of health care quality to find a time we were virtually all playing for Coach Jones.  Quality improvement was a process of identifying the lowest performers—those with clear and unequivocal poor quality —remediating them, and failing remediation, getting them out of practice.  We actively cut our slowest runners, but did nothing to challenge or develop the rest of the team.  We assured ourselves our quality was high, because we actively policed our problems.

Dr. Don Berwick is an icon in quality improvement, at least in part due to his tremendous work with the Institute for HealthCare Improvement (IHI).  Back in 1989 he wrote an editorial for the New England Journal of Medicine encouraging the adoption of Deming-inspired, Japanese-operationalized principles of continuous process improvement.¹  He observed:

“…Not that the idea of continuous improvement is alien to medicine; self-development, continuous learning, the pursuit of completeness are all familiar themes in medical instruction and history.  Yet today, we find ourselves almost devoid of such thinking when we enter the debate over quality.  The disciplinarians seek out Bad Apples; the profession and its institutions by and large try and justify themselves as satisfactory.”

Over the past 25 years, we have fired Coach Jones, and hired Coach Smith.  Although we still have far to go, the culture of quality has palpably shifted.  We measure, compare, challenge and try and develop all our colleagues.  Those with major problems are supported to improve (but still, and hopefully rarely, “cut”); the average improve and some excel; the stars come closer to reaching their full potential, and set a new aspirational standard for others.  Most importantly, I do not believe this change is cosmetic or superficial — it reflects a great cultural transformation.  Most physicians believe in the power of continuous process improvement.  We want to play for Coach Smith.

Next:  The Next Great Cultural Transformation

¹Berwick D. Continuous Improvement as an Ideal in Health Care. N Engl J Med 1989; 320:53-56.