Intended for healthcare professionals


Medical associations: guilds or leaders?

BMJ 1997; 314 doi: (Published 31 May 1997) Cite this as: BMJ 1997;314:1564

Either play the role of victim or actively work to improve healthcare systems

  1. Donald M Berwick, Presidenta
  1. a Institute for Healthcare Improvement, 135 Francis Street, Boston MA 02215, USA

    In many Western nations traditional medical associations are encountering an opportunity in threat's clothing. If they see through the disguise, and act accordingly, they can lead health care. If they do not, they may find themselves bewildered by their sense of helplessness.

    The opportunity comes from the social need for better health care. Any honest review of the literature in clinical science and health services research must conclude that there is a large gap between how health care could perform and how it does perform. In medical care error rates are too high, waste is too pervasive, technically correct clinical services are too often withheld, and technically incorrect procedures are too often used.1 Service characteristics of health care–such as waiting times, consistency of response, and attention to dignity–are well below those of many other industries.2 The patients whom we serve are neither insatiable nor ungrateful when they demand that we do better, although that demand is becoming more strident, inducing new forms of surveillance, regulation, market pressure, and media attention.

    Therein lies the opportunity for new leadership from medical associations: not to explain why we cannot do better but to set about the task of leading improvements. Unfortunately (because it makes the job harder), leading improvement requires most medical associations to change both their attitude and agenda. The change in attitude is necessary because the associations' traditional aim–to perfect and protect the profession–will not suffice to meet the social need for improved care. To improve health care we require not better professions but better systems of work.

    A “system” in this sense is a set of elements interacting to achieve a shared aim. Here is the trick: to improve the performance of a system, you need to attend more to the interactions than to the elements.3 Great doctors do not make great health care. Great doctors interacting well with all of the other elements of the healthcare system make great health care. Medical associations that wish to lead socially responsive improvements in technical care, service, outcomes, and costs have no choice but to invest in improving interdependency among individuals, professions, and organisations. This is not their traditional concern.

    The following principles guide the best modern approaches to system improvement. They must become the principles that guide the work of professional associations as well.

    (1) Improvement requires clear aims for improvement. Complex systems, involving many people and elements, do not improve without a clear agenda for improvement. Errors in administration of medications, currently at seven per 100 hospital admissions,4 will not decline until system leaders, including medical associations, intend them to decline.

    (2) Improving a system requires system leadership. You cannot lead a system towards better interactions by defending your prerogatives. Indeed, the first act of leadership towards improving a system is often to subordinate visibly and publicly your prerogatives in the service of that aim. Doctors tend not to be good at this. Their critical faculty–the ability to show what is wrong with an idea–is better developed than their contributory faculty–the ability to find something they can do to advance the common cause. They are better hecklers than citizens.

    (3) Measuring progress is an essential activity in pursuing improved systems. Medical associations, like the legal and social contexts in which they exist, are far more familiar with measurement as an assessment or judgment than as a learning activity. Because of this, doctors, like others, tend to regard measurement of performance as a threat. In their new role as system leaders, both individual doctors and medical associations will need to embrace the measurement of performance as a step in their own learning.

    (4) All improvement of systems requires changes in those systems: one definition of insanity is “doing the same thing over and over again and expecting a different result.” Medical associations that fight to maintain the status quo will thereby be champions of the current level of performance. To agree wholeheartedly to lead improvement requires a commitment to change the existing methods of work continually.

    (5) Not all changes are improvements. Therefore, changes in systems must be tested in real life. The challenge for professional leaders is to create and sustain a context for themselves and others that welcomes and encourages the testing of new approaches to work. Clinging too tightly to “the way we do things, and always have, around here” is no formula for improvement.

    (6) Sociologically, professions tend to reserve the right to judge the “quality” of their own work. The best route to the future is for the medical profession to externalise the definition of “quality.” This is not to say that patients should, or would care to, choose their own drugs, diagnoses, or surgical procedures. It is to say that the ultimate measure by which to judge the quality of a medical effort is whether it helps patients (and their families) as they see it. Anything done in health care that does not help a patient or family is, by definition, waste, whether or not the professions and their associations traditionally hallow it.

    (7) Reducing waste is consistent with the pursuit of “quality.” To see waste as both pervasive and as “non-quality”5 is characteristic of modern systems thinking as applied to all industries, and it should be so in health care. For medical associations, this means embracing cost reduction as part of their mission, not rejecting it as an external threat.

    (8) Inspection alone cannot improve quality. Since performance is a characteristic of a system, you cannot “select” or “judge” a system into improving. The best you can get from inspection is to harvest the best of the status quo. For health care, that is nowhere near good enough. The widespread initiatives in both public policy and association activity in many Western nations to increase the stringency of surveillance and accreditation will never guide their healthcare systems into new performance levels. Inspecting bridges to see if they are about to fall down does not make future bridges better; it only makes current bridges safer. Inspection is important for safety, but unless it is linked to strategies for improvement it produces tremendous waste and timid aspirations.

    Doctors and their medical associations have a choice: to become citizens in system improvement or to play the role of victim. For those associations that prefer the former, here are some steps to take as soon as possible.

    (1) Define an agenda of improvement. State and restate publicly a clearly defined and continually revised list of aims for improving care. Promise improvement. The agenda for improvement should specifically unify the pursuit of cost reduction (that is, reducing waste) with the pursuit of better service and outcomes.

    (2) Welcome, and participate in establishing, systems of measurement to monitor social progress toward achieving those improvement aims. Avoid reliance on surveillant, judgmental measurement; the measurements we need are those that can guide our own progress. Medical associations should not confuse accreditation, discipline, or certification with improvement; they are not the same.

    (3) Define continually the scientific basis for change. Medical associations should not so much defend the old work as define the new work. For example, when new and effective approaches to managing asthma are published, medical associations should be among the first to call for all doctors to adopt those approaches. If committed to reducing errors in treatment, medical associations should be among the first to state the principles of system design and engineering of human factors that should constitute the new standards for professional behaviour.

    (4) Promote widespread tests of change in local work processes. Medical associations should promote local innovations in care and take responsibility for spreading information on lessons learned.

    (5) Break down barriers between disciplines and between organisations. Medical associations should sponsor forums in which all who want to improve health care are welcome to do so together as equals; and in those contexts they should be the first to show evidence of their willingness to subordinate their own self interest and traditional habits in the service of common aims. Nurses, managers, paramedical staff, pharmacists, and others should feel welcome as equal co-professionals in the efforts of medical associations to improve care. There is merit in maintaining the pride and dignity of a well organised profession, but there is equal merit in creating a context for cooperation among professions.

    Welcome or unwelcome, the choice presses itself on medical associations throughout the world. They can behave as guilds, or they can behave as leaders toward new and better systems of care. They cannot do both, and healthcare systems as a whole may hang in the balance.


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