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Davis Balestracci

Six Sigma

A Funny Thing Happened on the Way to Quality Improvement

The quality vs. transformation disconnect continues

Published: Wednesday, January 28, 2015 - 00:00

I've been presenting at the Institute for Healthcare Improvement (IHI) annual forum for 21 consecutive years. Maybe the biggest surprise from these two decades has been the awesome power of simply "plotting the dots," i.e., plotting important organizational data in their naturally occurring time order. I have evolved to using fewer, simpler tools in my consulting and have never been more effective.

My all-day course at the forum demonstrated this with a wide variety of data from real situations. I showed how the power of this simple philosophy could be the back door through which improvement practitioners could educate their managers and executives in the best possible way—by getting eye-opening results. I also emphasized the need to learn and use common-cause strategies, which are not generally taught. All this requires very few tools, but it does require a total change in mindset regarding improvement. I'm not comparing myself to Deming, but I realized that he was always criticized for the virtual lack of tools taught in his seminars. Twenty years of hard study has made me evolve to a similar approach to improvement.

I was surprised at some reactions to my seminar. I've never had the level of hostility exhibited by some evaluations, a higher percentage than I normally get. Several people visibly and angrily stormed out because I didn't get to any tools soon enough. Thank goodness there were also a few people who were truly excited about the potential for a quantum leap in their current results, but this percentage was lower than it's been in the past. I always get this dichotomy in my evaluations, but never to this extent. This made me reflect on my history with IHI's annual forum, its evolution into a predominant force, and improvement in healthcare.

From passion to 'just a job'

Something just felt different this year, and I wonder whether the torch has finally been passed to the next generation of improvement practitioners. I thought of the classic Rogers "diffusion of innovation" curve. The early forums had lots of excitement and sharing via the "innovators" (2.5%) and "early adopters" (13.5%). There was a collegial atmosphere with a hunger for dialogue and new information—a true passion for improvement. There were generally 500 to 1,000 attendees.

The 1998 forum (its 11th year) had perhaps 10 vendors in the exhibition hall. That year, I gave the first talk ever at this type of forum on culture as a factor in improvement. I did it again in 1999. Quality improvement seemed moribund, but it had begun to gain an increasing foothold in healthcare. Jobs in quality began appearing. As the risk of being perceived as a "boat rocker" lessened, some folks adopted this new idea of quality because they could finally see how it fit into their lives, and they could get paid for it.

Things were now "diffusing" to the next level: enter the "early majority" (34%). They needed skills (especially quality tools) and wanted examples. Organizational budgets for quality loosened because of increasing pressure for clinical results. Attendance hovered around 1,000 to 1,200. There was still a passion of sorts, but for many, quality had now become a "job." So, similar to what happened in manufacturing 60 years ago, a major quality subindustry was beginning to evolve.

Then, in 2005, IHI got media savvy and developed its "100K Lives Campaign." Several things converged as a "perfect storm" to make it hugely successful—the attention-getting slogan, increased publicity about horrendous medical experiences, and a skillfully marketed "what's in it for me" focus that attention-deficit executives could use to deal with the intense pressure from public and political outrage to such events. Increasingly, patients now wanted to exert their rights as customers, which had already been happening routinely in non-healthcare industries.

Then Six Sigma and lean finally caught up to healthcare, and "belts" began appearing: more jobs. Now the time was ripe for the "late majority" (34%)—the folks who adopt in reaction to peer pressure, emerging norms, or economic necessity. Quality has increasingly become a daily grind driven by goals... with a lot less passion. What was formerly "innovation" has become routine, and in many cases has hardened into bureaucracies driven by qualicrats. Improvement cultures have evolved by default rather than formal design.

With the 68 percent consisting of both "majorities" added to the 16 percent of "innovators" and "early adopters," there were now a little over four times as many people involved in quality. In addition, healthcare quality had also gone international, which added a new audience component: Attendance at this past forum was close to 6,000.

Of course, there remain the 16 percent "laggards," who will always be with us.

Bigger... better... faster... more... now!

Think about what has happened to technology during the past 25 years. It isn't necessarily a bad thing, but we must be careful. 

It took Deming almost 50 years to finally synthesize his system of profound knowledge. It evolved from an emphasis on "variation" (1950s to 1970s) to a management structure within which his teaching on variation could flourish—his 14 Points (around 1980)—to, finally, the four elements of his system of profound knowledge (1989), the overall theoretical environment within which he realized that improvement could truly flourish.

I can't even begin to tell you how many hundreds of hours I've spent reading, learning, and assimilating all aspects of improvement. I was introduced to Deming and his ideas in 1983. It took five years of hard study for me to only begin to truly understand them. Today, I remain a student, and subtle insights that allow better implementation are still constantly manifesting.

Here is a sobering quote from The New York Times' Roger Cohen:

"The modern world's tech-giddy control and facilitation makes us stupid. Awareness atrophies. Dumb gets dumber. Lists are everywhere—the five things you need to know about so-and-so; the eight essential qualities of such-and-such; the 11 delights of somewhere or other. We demand shortcuts, as if there are shortcuts to genuine experience. These lists are meaningless.... When you are not told what to do, you begin to think what to do. You begin to see without distraction."

Society is now shaped by a "bigger, better, faster, more, now!" mentality. There is an increasingly dangerous assumption that everything one needs to know is just an app or Google search away, that information supplied by ubiquitous self-appointed "experts" and software systems promising to guide one to "the answer" have somehow relieved us of the responsibility for time-consuming analysis.

Critical thinking as a skill has taken a back seat to tools and technology. I wonder whether most people would now have the patience to sit through a four-day Deming seminar. Would Deming still get the respect he had earned during the last 10 years of his life? Would the current generation tolerate his famously crusty, rambling style that didn't suffer fools gladly?

For the level of excellence being demanded, there is no app, video, game, or role play that will teach the integrity, listening skills, creativity, coaching, critical thinking, or "level of caring and quality" needed to transform to a culture of excellence. These skills are not learned through conceptual understanding and rote practice. People must discover these for themselves, within themselves, and break through to new levels of understanding—with resulting changes in behaviors. No technology in the world will do this.

So take Brian Joiner's advice and "don't just do something, stand there!" Stand there and ponder: How much of your work is driven by critical thinking?

This year, resolve to stop confusing activity with impact. Simply "plot some dots," change some conversations, and watch the reactions to your eye-opening results.

Despite all these transitions, my passion for improvement remains undeterred. Like Deming, I hope I may keep teaching—and learning—and mentoring people until I'm at least 93.

Until next time....

Editor's note:
Be sure to check out excerpts of Davis Balestracci's latest revision of Data Sanity: A Quantum Leap to Unprecedented Results.
Chapter summaries

Preorder: Data Sanity: A Quantum Leap to Unprecedented Results.


About The Author

Davis Balestracci’s picture

Davis Balestracci

Davis Balestracci is a past chair of ASQ’s statistics division. He has synthesized W. Edwards Deming’s philosophy as Deming intended—as an approach to leadership—in the second edition of Data Sanity (Medical Group Management Association, 2015), with a foreword by Donald Berwick, M.D. Shipped free or as an ebook, Data Sanity offers a new way of thinking using a common organizational language based in process and understanding variation (data sanity), applied to everyday data and management. It also integrates Balestracci’s 20 years of studying organizational psychology into an “improvement as built in” approach as opposed to most current “quality as bolt-on” programs. Balestracci would love to wake up your conferences with his dynamic style and entertaining insights into the places where process, statistics, organizational culture, and quality meet.


Common-cause strategies?

"I also emphasized the need to learn and use common-cause strategies, which are not generally taught. "

Could you say more about this?  What are some of the common-cause strategies that you find useful?

Common cause strategies -- here you go!

Hi, there,

Thanks for reading.  I did a series on common cause strategies.  Here is a link to the final article, in which you will find links for the other articles:


Kind regards,


Nice Article

The "Quality Belt Era" has perpetuated the lack of critical thinking. Check the box of the tools you learned and get a prize or certification. Without critical thinking skills no new tools to solve problems will be developed. Stuck in an era of copying old tools. Does innovation really matter in this era?

Our education systems are setting up for failure with this same thinking. Standardized tests are dominating our schools. How many tests do you sit down and take at work? Wrong skills and wrong method. The ability to read a control chart - a fundamental for any organization is still not being taught in most schools. My daughter's math teacher didn't even know what a control chart was - ashame.

The challenging part of the Deming philosophy is that it is not a "connect the dots" exercise - it is a learning one. Thank God!

Nice article...

I am a green belt who moved into healthcare from automotive via food. At a senior level, my organisation appears to value black belts or master black belts but not green belts. It also seems to be doing Service Improvement as a knee-jerk reaction, playing catch up, and bandies around words learnt at Toyota without doing the study. They are enforcing '8 steps' and 'PDSA' from on high, and it's turning people off. I wanted to implement G8D 6 years ago, when I arrived, but was told it wouldn't work. I live by the Deming Cycle, and luckily, so do the teams I work most closely with. Don't get me started on control charts; I was once asked by a manager here why I even knew about SPC!

I know I still have much to learn, I've been involved in Quality for 20 years, the last 9 in managerial roles. It saddens me that Qualicrats even exist - and they do here. My philosophy has always been that Quality and Gemba are intrinsically linked, and other than some supervision and responsibility (as per ISO etc), Gemba is where Quality is made to happen, not from some disconnected ivory tower. I love my job, and am passionate about our patients, but so frustrated by the Qualicracy. There are some good people in the Qualicracy here, don't get me wrong, but I feel a deep sense of unease about what's expected and how it should be delivered; a disturbance in the Force, if you will.

Connecting the dots and ticking the boxes sets my teeth on edge - it's not why we are here, we are here to investigate and learn!