Don Berwick:
I often wish in English, we had a word that combined three ideas: improving (getting better), changing and learning, because whatever that word would be, that’s the word we’re looking for.

Alec Patton:
This is High Tech High Unboxed. I’m Alec Patton. I’m here today with Stacey Caillier, the director of the Center for Research on Equity and Innovation at the High Tech High Graduate School of Education.

Stacey Caillier:
Yes.

Alec Patton:
Stacey, you brought us our interview today. Tell us about who you talk to and why you want to talk to him.

Stacey Caillier:
So, I have been a big Don Berwick fan for years, pretty much ever since I learned about improvement. Earlier this year, I was at a virtual convening and I was put into a breakout room. When I entered the breakout room, the first face that I saw on the video screen was Don Berwick’s. I knew it was him because I literally had a screenshot of his image on my desktop because I had recently used it for a slide I was presenting for a grad class. I saw him and I was like, “What? Don Berwick is in this breakout room with me!” I ended up private chatting him during the session, basically, just to say how much of a fan I was of his work and the impact he’s had on healthcare.

He, being the beautiful person that he is, wrote right back to me and was like, “Oh, I’d love to chat more and hear about High Tech High and what you guys are all doing, and so excited this is taking root in education.” And so, I asked him, “Great. I would love to talk with you.” He gave me his email and then it went from there. We set up a conversation with him and our team, and got to ask him all of these great questions, just spend an hour learning from him. At the end of it, I just thought, “I wish I would have recorded that entire conversation.” All of us were talking about it for weeks afterwards, thus, the podcast.

Alec Patton:
You got to take another shot.

Stacey Caillier:
Yeah, exactly.

Alec Patton:
People outside the continuous improvement fan community may wonder why you were so excited, but your introduction to Don, I think very, very briefly encapsulates how impressive his resume is. So, let’s just play it.

Stacey Caillier:
You were a career pediatrician, who then went on to be president of the Institute for Healthcare Improvement. You’ve launched the 100,000 Lives Campaign. You became part of the Obama administration. You ran for governor of Massachusetts. If you don’t mind, can we just start at the beginning with when you know you wanted to be a doctor?

Don Berwick:
Oh, from the moment of birth. I mean, I grew up in a really small town in Connecticut, a very rural town. My father was the only doctor there for many, many years, general practitioner. Made house calls. He rounded at the hospital every day. He was an old style GP. And so, I don’t know. My image was always of that lifestyle and that commitment to community. Of course, he was pretty honored in the community. Everyone respected him. And so, I guess that must’ve attracted me because I always intended to be doctor. My mother was a pretty active member of the community and a school committee and other public services, and that informed the other side of my intentions, but I don’t ever remember not wanting to be a doctor.

Stacey Caillier:
So what brought you to improvements and why did you become such a champion for it in healthcare?

Don Berwick:
When I was in medical school, I got a joint degree in public policy that happened to be Harvard Medical School. I had this opportunity. It was very attractive to me. So I entered medical career with a lot of background and ammunition on statistics and operations research, political science, economics. I was interested in organizations, and that led me, when I finally began my career after training, to be drawn into the Harvard Community Health Plan, which was a health maintenance organization. I was in charge of research there, but also told to take a look at quality of care, which I did for several years. It was boring. It was stable. Nothing was ever changing. We certainly had evidence of lots of problems, but nothing ever changed. The only that had changed was that people got angrier and angrier because we got lots of measurements and we told them that the waiting times are too long or that the complication rates are too high.

They’d say, “Yeah, we know it. We’re trying as hard as we can.” It was pretty bleak. And that led me to accidental journey encouraged by the chief executive at HMO to go look at other industries. That began stuff for me. Quality issues has been a sideline for me. But once I started seeing what was happening at NASA or Bell Laboratories or globally competitive manufacturing companies or hotel chains, there was a very, very systematic approach to improvement and healthcare hadn’t learned it. And so, with a number of friends, we had a group of seven or eight people that were doing the same thing together and the support of the John A. Hartford Foundation, we founded first a demonstration project to see if modern approaches to improving systems could work in healthcare. And then, eventually, when the answer was “Yes, for sure,” the foundation agreed to anchor the founding of a nonprofit, the Institute for Healthcare Improvement, IHI, which I then ended up running for 19 years before I went into the Obama administration. That’s the short story. There’s a lot of details in there.

Stacey Caillier:
Ah, that’s so great. One of the things that I’ve been really intrigued by in the talks that you’ve given is I think in education, people often talk there’s this tension between improvement and innovation as if you’re either in one camp or the other and I don’t sense that same tension in healthcare. I’m curious if you could talk a little bit about how do you see the relationship between improvement and innovation.

Don Berwick:
Firstly, there is that tension in healthcare. I often hear that debate. It’s sort of a silly debate if you asked me. So improving is doing better for whatever your mission is, doing better for the people you serve, and it’s always about learning. It’s about doing something new. It could be something small that’s new, like discovering that in the sequence of work that you have to , in healthcare, take an electrocardiogram from a patient or maybe in education would be the sequence of work you do to assure that adequate supplies are in the classroom. Maybe you find steps that aren’t needed. So why don’t we do that? We keep a record, but nobody uses it, or we buy this, but nobody uses it. So, that’s a little micro-improvement and it’s a change. You take that step out of process.

There are bigger changes, like learning that the way you approach a kid struggling with algebra is different from the way I do it and you get better results. So, I’d like to learn how you do it, Stacey. What’s your way of doing that? That’s a little bigger. Maybe we have different classrooms and they’re really, really different. I can learn how to reconfigure architectural space. So, improvement is like this nested idea. Maybe at some point the change gets bold enough or big enough or unfamiliar enough that we would call it innovation. But to me, it’s a continuum. It’s all about learning and trying new things in a way that is informative. So, I don’t see that boundary. I mean, obviously, we can get hooked on our current processes and say, “Well, you could never teach over the internet.” And then when someone says, “Oh yes, you can, and it’s a big surprise,” we call that an innovation. But no, it’s all part of a continuum to me. The heart of it is learning, learning a new system.

Stacey Caillier:
I like that a lot. One of the things that we’ve talked about was the importance of co-design. Could you talk about how co-design emerged for you is so important?

Don Berwick:
I often wish in English, we had a word that combined three ideas, improving, (getting better), changing and learning, because whatever that word would be, that’s the word we’re looking for. We want doing better, learning and changing. Those are the nexus. So, in the search for change and for a learning how to do something new, the question is what’s the position of the person we’re trying to help? In my case, a patient. In the case of the classroom, I suppose not only, but including the kid. It turns out, to a level I never ever understood at first, when you get the beneficiary, the person you’re trying to help, in the room, all the time and always reinvent together, it’s a much, much more effective way to change, so that the resultant product or service is co-design. Actually, we’ve done it together.

That’s important in product design because when you’re making a car or a pencil, the person using it can really contribute an awful lot, and by the way, can save you a lot of money because usually you’re doing stuff that doesn’t help them at all and they say, “Why do you bother with that? I don’t care about that.” In services, like healthcare or education, it’s much more important. Services, they’re going to be co-produced. A teacher doesn’t produce education and a child consume it. The teacher and child together are producing learning. So you’re always doing that whether you like it or not. Co-designing means you’d figure out how to do that better together all the time. It’s a shift of power actually in healthcare, it is any way, where when properly done, patients and communities, they feel much more powerful in helping determine the processes that are helping them stay healthy or get healthy.

I’m intrigued at what could happen in a classroom. I have eight grandchildren, but my eldest is an 11-year-old boy and he’s pretty smart. He’s pretty observant. I would imagine a teacher would be really smart to say to Nathaniel, “How’s it going? Am I doing okay? What would you like to be different about the way we’re approaching this?” and working together. That’s co-production or co-design.

Stacey Caillier:
Can you say a little bit more about what that looks like in healthcare?

Don Berwick:
I can start with a little story that I tell. I have four kids in my own, four kids, and when the second one, my wife was pregnant with my second child, I remember one time we went into the obstetrician’s office together, Paul Goldstein was his name, and he examined my wife and did what he had to do to assure everything was okay. Then he said, “I know you’re very busy, but would the two of you just spend another couple of minutes with me?” I said, “Sure.” He said, “Today, in my office, in what happened in the way you were greeted, in the way I examined you, the whole thing, was there anything that could have been better?” We said, “No, it was fine.” He said, “No, no, no. Tell me something that could have been better.” That’s all it is. It’s this micro-interaction of, “How is this going?”

Cincinnati Children’s Hospital Medical Center has brought it to full scale. So, patients and families are on the board. They’re in every improvement meeting. They’re in the design work of the organization. They really don’t take many steps without patients, kids, and families in the room doing it together because they know they get better results. The designs are going to be smarter. The waste will be lower and the work more targeted at needs. In the Institute for Healthcare Improvement, IHI, thanks to my successor, CEO Maureen Bisognano, and two other researchers, Michael Barry and Susan Edgman-Levitan, there’s a particular form this takes. Maureen teaches it as, “What matters to you, medicine?” The concept in healthcare we say to the patient, “What’s the matter with you? And then I’ll fix you up.” The idea is change the question, not what’s the matter with you, but what matters to you. Just start there. And that redirects the work in a profound way.

There’s now an international “What Matters to You?” Day every year. Millions of healthcare workers are encouraged to ask that question and use it. I don’t mean once. I mean, all the time. I don’t know how that would work in a classroom. I guess you could say to a kid, “What matters to you today?” And think about learning as moving towards that need. You would bring stuff right down to this. I think my two oldest children are boys, Ben and Dan, oh, maybe they were probably 10 and eight or 11 and nine. We were driving in the car, and I don’t know, I guess I was studying improvement or something. I said them, “Hey, Ben and Dan, I’d like to be a better parent. What would be some ideas about how to be a better parent?” They took me seriously. They had a little meeting in the backseat of the car, and then they said, “Okay, dad, here’s something. When we ever asked you for money, you get angry.”

They said, “You could change that. You could say no. That’s fine. I mean, we understand we won’t always get what we asked for, but you don’t have to get angry.” What they were tuning into was my own background. I think I mentioned to you, my father grew up in the Great Depression. Money was very charged, but they were co-designing parenting with me and they were just right. That was just waste and I could change it. And then the most profound thing is what happened in about a minute later, as we were driving along after that transaction, they were chatting. And then they said, “We have a question, which is how could we be better children?” I mean, it’s this beautiful dynamic of let’s help each other and I think that’s what we’re after. You’re after it at every level, from that little individual transaction all the way up to what a school is, for example, or what a hospital is.

Stacey Caillier:
And what did you say to your children?

Don Berwick:
I don’t remember. However, they were still great. I must have told them something, but I don’t know. It probably about making their beds or something, but it was the dynamic that I noticed.

Stacey Caillier:
Yeah. Yeah. I remember you told a story during our last conversation too, about a hospital team that was meeting and they had come up with some idea or something, and there was a patient who was in the room that chime in.

Don Berwick:
Oh, yeah. Yeah.

Stacey Caillier:
Do you mind retelling that story?

Don Berwick:
Yeah, this is a vert powerful story and it really has a point to it. So one of the severe chronic illnesses in kids is cystic fibrosis, a genetic disease. I mean, when I began my training, kids died. They never got to the teenage years or rarely did. But luckily, there are cystic fibrosis centers all over the country, 160 of them at the time of this story, and they’ve been working away with research for years and years and years, and they’ve done a lot. Now, it’s not at all uncommon for people with CF to live into adulthood or even late adulthood. It’s been real progress. It’s all done with a database that the 160 centers have contributed to through the Cystic Fibrosis Foundation.

They pour data into this database and then they can do research with the data. However, it’s a secret database, that is if you have a child that has CF, I presume you might want to go there and say, “Okay, I could go to any CF center in this area. Who’s the best? Who’s got the longest survival? Who preserves lung function the best? Where are the kids gaining weight the most?” The foundation knows, but they wouldn’t tell you. It was a research database. This has been controversial for a long time and consumer rights advocates have been saying, “Oh no, no, you have to release the data.” And they’d say, “Well, if we released the data, no one will give us the data because they’ll use it for competitive advantage. Stacey’s hospital will be afraid that Don’s hospitals better and they’ll lose patients.” So it was not shared, but they were worried about this.

One time they called the board meeting and asked me to come because they knew I worked on improvement. In the room, they had the mother of a CF patient. We were talking in the room and I knew on our page from my work with Cincinnati Children’s, so that the board of the foundation was saying, “Should we make these data public or not?” I remember turning to Mrs. Paige. And I said, “Well, Mrs. Paige, what would you advise?” She said, “I would advise you that for my daughter, the clock is ticking.” And you could just almost hear the shift. How could they not share this information? And they faced it. They came up with it.

That’s a happy story in its own, but the happier part of it is that from then on, they continue, of course, to track cystic fibrosis outcomes in the 160 centers. The slope of improvement doubled that year and kept going at that new rate. Just sharing the information allowed them to enter a whole new phase of learning and exchange. So now they could find out that the such and such center and wherever in Minnesota was having the best lung function preservation, and everyone could then say, “Hey, how do you do that?” And the worst one could say, “Excuse me, we got a problem. Can someone come over here and help us?” It changes the dynamic.

Stacey Caillier:
I’m so glad you brought that up. I think we’re seeing that in education right now, too. There’s so much fear around like, “No, we can’t actually highlight who’s doing great work or who’s really struggling, because then they’ll be afraid.”

Don Berwick:
Yeah. Well, the education system is managed or incented with winners and losers. So there’s the good schools and the bad ones. The good ones get praised and the bad ones get blamed. I mean, that’s not a learning dynamic. You know that with kids. I don’t imagine you’re a very successful teacher if you set up a classroom, which every kid wants to beat every other kid, in which someone’s gain is someone else’s loss. That’s fear. That’s not learning. I mean, in IHI, we have many slogans. One of them is “All teach, all learn.” You may think that hospital is not doing too well, but I’ll tell you, they know something other hospitals need to know. It doesn’t matter where they are in that league table. Same is true in human development. Everybody can help.

Stacey Caillier:
Well, staying with that, what does that culture look and feel like? What are the characteristics of it?

Don Berwick:
I don’t want to be glib about it, but I might ask a teacher that and say like, “Okay. If you have a classroom or a kid and you want to create an ideal environment for those kids in that classroom to learn or the kid to learn, what would be some of the words that would occur to you?” I’ll guarantee you, almost everything you think of applies to improvement in an organizational level. So you have to begin with the absence of fear. Fear and improvement are not compatible. Fear and learning are not compatible. As a father of four and a grandfather of eight, I know that. When a kid is scared, they’re too busy being scared to learn. The same is true in organizations.

So there’s this enormous weight on the shoulders of leaders to create an environment in which people are not afraid of each other, and that is subtle because the minute you sit as a leader in judgment or in the minute you’re the distributor of rewards and punishments as a leader, you lost the game. You lost at the start because you’re creating an atmosphere in which people are scared of you, of change, of failure, of each other, and that’s not compatible with improvement. There has to be a set of other supports as well. For example, learning takes some time. You don’t get it for free. It’s like a front-end investment. So creating processes in a workplace where there’s time to reflect to stop, pause, “Everybody, stop. How are we doing? What did you just learn? We tried this. Did anyone notice anything?” That reflective moment we call the PDSA cycle, plan-do-study-act, but that’s just jargon. It just means reflect, act and reflect.

What I noticed in very busy healthcare systems is there’s no time for reflection. Nobody has the time to stop and say, “What just happened? How are we doing?” In a workplace that can improve, that’s embedded in the workflow. You have in the workflow the very processes of reflection. Another related to the fear issue is the encouragement to take risks. Again, I always use child metaphors, but like kids learned to ride a bicycle, that’s an improvement. They never learned to ride a bicycle without falling. You try and then you fall and then you learn. And so, then some environments treat a failure as a bad thing as opposed to a lesson. I do think back to the discussion of co-design, I think in environment which invites, I’ll say, the customer in the room, in your case it’s a student, the family is going to learn faster because they’re going to have a much more intimate and immediate sensing capacity so they can really assess what they do.

Another infrastructure is measurement. This is a very edgy one because an environment of fear and surveillance, measurement is the tool of abuse. In environment of learning, measurement is the tool of growth. Unfortunately, if the psychology is wrong and measurement gets tainted by the psychology of punishment or reward, and so, part of the attributes of a learning system is that measurement assessment occurs, but it’s always in the service of answering questions people have. So the measurement is the servant, not the master. One thing I’ll say about that, also, just as I watched education get interested in metrics, measurement doesn’t always mean numbers. Reflection is measurement. Stories are measurement. When that obstetrician asked my wife and me, “Could anything have gone better?” he was measuring, but he was doing it narratively. That’s perfectly fine. That’s one of the tools we have, but sometimes numbers help. And if numbers are going to help, you have to have to know how to interpret them. So there are a little bit of statistical side to this.

Stacey Caillier:
I love that. I remember you mentioning on our last call that you felt like narrative measurement was vastly undervalued.

Don Berwick:
Instead of the word measurement, we should learn a word like growing knowledge or a useful reflection. Of course, in our lives, we do that all the time. How did the soup taste? How did that conversation go? How was that movie? Sometimes we go to numbers. How much gas is left in the tank? What’s the temperature outside? But we don’t always go to numbers, and yet we still learn all the time through other methods of hearing, which are crucial.

Stacey Caillier:
I want to go back to this idea of PDSAs and just how it really is just act and reflect, because I think that’s definitely something we see in education too, that teachers just feel so busy. There’s no time to actually reflect on what you’re learning. You’re just doing, doing, doing. I’m curious if you could share anything about how do you build in those moments to be reflective and is there things leaders can do to support building that?

Don Berwick:
First of all, try to take the mystery away. So PDSA, plan-do-study-act, that is just a very helpful in mnemonic to remind you to try something, but don’t just try it, try it under conditions when you’ll learn from the trial. So I’ve mentioned the pea soup. My wife and I are having pea soup tonight. We’re going to take a spoon. We think curry might make it a little better. There’s some curry a bit, but maybe not enough. This is pea soup we made and put in the freezer. So I know what’s going to happen tonight, which is my wife, who’s pretty sure about the curry is going to say, “Taste this.” We’ll taste it while it’s on the stove heating. And then she’ll say, “Enough curry?” “I don’t know. Let’s add a little more.” We’ll put a little more in it and we’ll taste it again. PDSA, plan, do, study and then act. We just need to keep doing that, so you taste.

The issue of energy that you’re talking about is important, but I would say even a teacher, even a busy teacher can try stuff. I think the leader could possibly arrange for contexts in a teacher’s life where he or she could get an idea to test, like the idea to use curry. To do that, you need to be able to sit together with friends with a particular question, “Who’s trying something I haven’t tried?” or, “I have this problem. Has anyone met this problem before? What do you do about it?” You can do that socially with the classroom next door. You can do it in hopefully a teacher’s meeting. You can do it in a development day. You can do it in the pre-COVID era with an airplane ticket or a train ride, or now with the Zoom. I mean, Zoom should make it easy for 15 schools to get together and decide what are they doing about learning loss and is there something they should try differently.

And then PDSA is just putting it. It’s like getting on the bike. You go back to the real world, hopefully with some friends. You say, “Tuesday at 11:00, we’re going to try this.” You try it Tuesday at 11:00. And then at noon you say, “Okay. Everybody, how did that go? What just happened?” Plan-do-study-act, that’s all there is to it. At more complex environments, you may need more complex metrics. You may need to actually measure something and put it on a run chart and graph some dots. You might even want to use some statistical techniques to see if the variation you’re seeing is random or not. There are great techniques for that, and in a one-hour course, you can learn them. There should be no mystery about it. That’s not mysterious.

Stacey Caillier:
We started calling them, try, collect, reflect cycles, because for some reason, PDSA was just tripping people up often, so we said “Just try something, collect some data and reflect. That’s all it is.”

Don Berwick:
One more step, I think you need to keep the A, PDSA, because once you reflect, you got to make it a cycle. You got to put it back into the loop and say you act. You can keep it if it’s the right amount of curry. You can change the change, which is add different curry. Or you can abandon it, which turns out curry doesn’t work at all, but that step after reflection, that’s the momentum to get to the next test.

Stacey Caillier:
Right. Right. One of the other things that you talked about, too, getting at this thing of like, “Let’s just try something,” and having a culture, you also talked about joy. I would love to have you just talk about where does joy fit in with improvement, because I totally think it fits in improvement. It has to be there, but I don’t know that people always go there automatically.

Don Berwick:
It’s just true that in a service industry, especially healthcare or education, the customer, the student, the family, the patient won’t be treated better than the workforce feels. If the workforce is happy and buoyant and energetic, then that’s what’s the student or family or patients going to feel. There’s energy here. W. Edwards Deming, the great scholar, talked about pride in work. He said, “It’s all about pride in work.” So that when people feel good about their work, virtuous cycles begin. And so, I push it as hard as I feel, which is we need to have joy in work. It is not a kind of icing on a cake. It’s the cake. So, exploring what it is that creates joy and meaning and pride. That’s part of leadership. If you don’t attend to it, you’re going to get in a bad relationship with your workers and your staff as a leader. You’ll be then in transactional mode instead of relationship mode.

The good news is especially in service professions, like healthcare and education, of course, they want to be proud. You want to be proud that you can help a kid thrive. My goodness, of course, you do. So we discovering that and connecting the meaning back to the work is crucial. Part of it is infrastructure. You then have to have conditions of work, which are respectful. You have to have respect. Paul O’Neill, who was the long-time CEO of Alcoa aluminum and then he became treasury secretary, Paul was one of the great students and teachers of improvement really in the world. His focus was largely on safety, worker safety, which is why Alcoa became the safest heavy industry in the world to work for.

Paul used to say that, although he was a very much a student and teacher of improvement, like you and I have been talking about, Stacey, he said, “It was preconditioned for excellence.” He didn’t say it conditioned, he said precondition, which is that every single person in the organization can say, “Every day I was treated with respect and dignity by everyone I encountered. I was given the tools and support to do the work that gives meaning to my life, adds meaning to my life.” And the third was that someone notices. He said those are preconditions for excellence. It didn’t quite go as far as joy. But if you think about meaning and work, that’s joy and it’s absolutely essential. I would think in our two industries, education and healthcare, it ought to be right at hand. We’re doing good stuff.

Stacey Caillier:
I have to shift so that you can see the thing behind me that says, “Be the one-

Don Berwick:
“Be the one who notices.” I love that. Yeah. O’Neill’s triad, I use all the time. I get treated with respect and dignity by everyone I encounter. I have the tools and supports to do the work that has meaning in my life, and someone notice this.

Stacey Caillier:
I love that.

Don Berwick:
Again, wouldn’t that be true of raising a happy child or having to have in classroom.

Stacey Caillier:
Definitely. Yeah, definitely. So building off of that, one of the things I was really struck by in our conversation last time, too, is that you talked about the role that a leader needs to play to be able to support that kind of culture and how you described leaders who help build a culture where improvement and learning can flourish, is that they have this authentic curiosity and also humility. Can you say a little bit more about just like –

Don Berwick:
It’s related to the comments on fear and on learning that I made earlier, which is I think the leaders that are at best at nurturing the environments for learning themselves are learners. That’s who they are, that’s what they do. And so, that means that there’s a certain level of humility, a high level of humility, and empathy and relationship building and curiosity. I don’t think a good leader shows up with answers much. You’re just not smarter than the people you’re leading. You have been paid more maybe, and you have a degree after your name, but you’re not likely to be that much smarter. We’re all smarter together than separately. And so, a leader who knows that and who’s curious like, “What could I learn today? What do I not know that I could know?” that’s a very important asset in improvement. It also signals the workforce that that’s a good question for them too. There’s also, frankly, a level of nurturance in this too. You really have to care about the mission and about the people. Inauthenticity will be detected fast by the workforce. They’ll know a show from the real thing.

Stacey Caillier:
So, at our last team meeting, and this wasn’t even primed by me, this was somebody else who’s a fan, we actually watched the clip of a talk that you gave in 2008, I think, for IHI, where you were essentially your “confessions of an extremist,” and just talking about where you were arguing for this radical transfer of power and a bolder meeting for patient-centered care and sharing your own fears of becoming a patient and why. We were all really struck that you ended with this statement of, “If we be healers then…” And it wasn’t like if we’d be doctors or teachers or whatever, but if we be healers. That idea of being a healer feels so important right now in education too. Could you say a little bit more about what that means to you to be a healer?

Don Berwick:
I mean, to me, the word healing invokes a larger frame than just treating or doctoring. The human condition is complex and people come to us with their needs in whatever they be. I think the job is to help people… My job in that role is to help people pursue, I guess, what matters to them and healing to me is to give people, as much as I can, the power to go where they wish. It is just so different from the professionally dominated model, where I know you don’t follow my directions. We call them doctor’s orders. To me, that’s the less transactional than doctoring and it is more holistic, more the whole person.

Within education, I don’t know. A teacher could say, “My job today is to make sure that this child can solve this algebra equation.” That’s an achievement. Or “Can learn the conceptual underpinnings of problem solving itself.” That’s another achievement. Or “Can become a more connected, confident, and compassionate person, first of all, to themselves.” I think, to me, yeah, I want kids to learn algebra, but I think that you can do that in a way that leaves them even happier with themselves. I think that’s probably the equivalent transition, maybe. I don’t know.

Stacey Caillier:
I love that.

Don Berwick:
You don’t have an algebra student in front of you, you have a whole person.

Stacey Caillier:
Right. One of the things I have really appreciated about talking with you and reading your work has been that my first introduction to improvement was very technical, and actually, I did not like it at all. Coming from a background in ethnography and as a teacher, I was like, “No.” It’s not all just about these tools and charts. I think those tools in charts are really helpful and important, but I think sometimes improvement gets characterized as this technical, highly rational process that can feel like a big turnoff to a lot of folks. And I’ve been struck by that when you talk about it, you talk about it as deeply relational. We’ve touched on this throughout, but I’m just curious if there’s anything you would say about this characterization as this technical process.

Don Berwick:
Yeah, it’s a mix. It’s a wonderful for me, a wonderful mixture of technical and spiritual relational stuff. The root sciences of the improvement that I understand are in fact engineering sciences. They came out of systems theory, general systems theory, and statistics and physics. But soon upon adoption in industries, people like Deming and Juran realized it’s not just tools, it’s context, it’s culture. Together, they’re quite powerful. But the tools overgrew, partly because the consultancies. They’re quality improvement consultants and they make their money by patenting a fishbone diagrams or whatever.

Now, I think just take a breath. Maybe for a novice, learning some tools is good. But if I’m right, and I may not be right, but I think the whole heart of this is learning, then you keep asking the question, “How can we know more?” If the tool is there can help you, it almost always helps to put something on a graph if you’re tracking over time. Well, then use them. But they’re not the boss, you’re the boss. And so, if it helps, use it. I just don’t like it when… It doesn’t start with tools. It starts with aim. It starts with commitment, heart and I think, yeah, relationships, Stacey.

I’ll show you something. I just gave a speech yesterday and I was talking about… So this is my favorite text, The Improvement Guide. it’s really, really good. It was written by friends of mine and associates. It goes over both the technique and the culture. But what I was talking about yesterday was Appendix A. What they did here is they search their own experience for what they call design ideas or change concepts. These are basic good ideas. If you know the idea and you’re doing a redesign, then you might think of using it. I’ll tell you one idea. One idea is process things in parallel, instead of in series. In general, if you’re doing different series, it’s a little more costly and more prone to problems than if you process in parallel. That’s a general idea.

Another would be, well, what I said about earlier, remove excess steps, study how many steps you’re taking and then take the ones away that don’t seem to help. So these are change concepts. Now, whether you call that tactical or cultural, I don’t know, but you’re really smart to use them. You’re really smart to go to Appendix A in Improvement Guide and say, “Are there any ideas here we could put to use?” That level of technique is like a recipe book. We want to learn pea soup, I guess we look at the pea soup recipe and say, “How’s that one?” That’s all, but don’t get trapped in the tools, Stacey. You’re absolutely right. They’re just there if you need them.

Stacey Caillier:
Cool. Thank you. Is there anything we haven’t touched on that were lessons from Healthcare Improvement efforts that you feel like education really needs to learn?

Don Berwick:
The two that I would reinforce, one is you said earlier. One is get the kid in the room, do this with the child, not to the child. The development of better teaching education and learning to me is a co-design thing. With my 11-year-old grandson, it’ll be better than if you don’t include him, that I’m sure of it. That might even be true to my three-year-old granddaughters. I don’t know, but I think you could push it. Certainly, for parents, they’re living complex lives, get them in the room, do this together. Don’t feel so much smarter than them. You’ll have to be very gentle and very welcoming and respectful in order to begin to elicit all the help that we can get from the abundance of supports that the people we’re trying to help bring to us to help them.

I think the other is take some risks here, try stuff. If you just keep changing in an informative, reflective way and share what you’re learning, I just think that the sky is the limit. You’ve got your wonderful industry. I mean, gee, I guess if I were to start again, maybe I’d be in education. I love what I see.

Stacey Caillier:
It’s not too late.

Don Berwick:
I will tell you this, this is not part of what you want to interview me about. So I come from healthcare, which is spending 18% of our gross domestic product. We’re almost a $4 trillion industry in this country and we complain in healthcare that we don’t get paid enough. I go to schools and I see what resource constraints your wonderful teachers and principals and workforce. The resource constraints schools are under are shocking to me. I hope that just politically there’ll be some rebalancing at some point when we begin to understand that investing in the development of young person isn’t just the nicest thing we can do, it’s the smartest thing we can do. I hope that, I call it inequity can get somehow addressed and we can put the resources where they’re needed. Meanwhile, it makes it even more important that education learning use the tools of improvement because in their essence, what they’re really trying to do is make the best of what you have to help the people you want to help. And so, I think the stakes are pretty high.

Stacey Caillier:
Anything else you want to say?

Don Berwick:
No, thanks a lot. I hope this won’t be our last conversation.

Stacey Caillier:
I won’t let it be, if you want. Thank you so much, Dr. Berwick.

Don Berwick:
It’s my pleasure, Stacey. It’s Don from now on. Okay?

Stacey Caillier:
Okay.

Alec Patton:
High Tech High Unboxed is hosted and produced by me, Alec Patton. Our theme music is by Brother Hershel. Huge thanks to Stacey Caillier for interviewing Don Berwick and for having the idea for this episode in the first place. You can learn more about Don Berwick in the Institute for Healthcare Improvement on the institute’s website, www.ihi.org. You can find that link, plus link to the book that Don Berwick mentioned, The Improvement Guide, in our show notes. There’s also a link to a full episode transcript. Thanks for listening.