In the Spirit of Continuous Improvement… Please, Don’t. By Hurley Smith

If one can improve something, should they? An idealist may reply, “Absolutely. Improvement is intrinsically good, therefore, one should improve everything one can.” If the cost of improvement is zero then who would disagree? Though not always obvious, the cost of improvement is not zero. Consider the recent supply chain crisis and related increase in prices for goods. Many declared, “We need to improve the reliability of our supply chain!” Why not, right? Can industry make supply chains more reliable? Yes. Will costs increase as a result? According to the Wall Street Journal, also yes.

“After the pandemic and the Ukraine war disrupted supply chains, many business leaders adopted new processes to increase reliability even if they cost more, such as by moving production closer to home or buying from multiple suppliers. And tensions between Western democracies and Russia and China raise concerns about a possible further retreat from globalization and rise of protectionism, which would raise production costs.”

The point is not to agree or disagree with the decision to improve supply chain reliability, but to point out the less obvious cost of doing so. The need for cost/benefit analysis prior to improvement is hardly a novel concept, nonetheless organizations make resourcing decisions contrary to this wisdom. One reason this happens is exhortations. Sound made up? Edwards Deming felt so strongly about the hazard of exhortations in the workplace that he included it as one of his 14 Points for Management: “#10 – Eliminate exhortations.”

Consider the following pithy exhortations:

  • “In the spirit of continuous improvement, we will work on this problem!”
  • “We believe in the power if incremental improvement, let’s make this happen!”
  • “We believe in innovation, and this is an innovative project! Let’s do it.”
  • “We strive for excellence, and this is not excellence, let’s fix it.”

These nice-sounding exhortations contain flawed logic that can be easily overlooked. They lay the foundation for a logical fallacy called “affirming the consequent”. This means using an argument which uses a true conditional statement (i.e. “If you believe in the spirit of continue improvement, then you work on problems”) and invalidly infers it’s converse (“If you work on problems, then you believe in continuous improvement”). What if someone challenges the decision to solve a problem? Might they be a non-believer of continuous improvement? If flawed logic becomes organizational doctrine, wasteful resourcing decisions (and much worse) can abound.

Exhorting logical fallacies isn’t the only thing that contributes to wasteful resourcing, so too are plain misunderstandings. In the 1970s, Philip Crosby proclaimed that “Quality is Free”. One interpretation of this is “Quality doesn’t cost anything!”

“I call it… Hypothetical future value accounting” -Jeff Skilling, COO, Enron

What Crosby meant was that the cost of solving a problem can be offset by the waste reduction realized by solving it. And Crosby is right, it can, but it doesn’t always. Sometimes solving a problem is worth the resources, sometimes it isn’t. Due diligence is necessary.

How can one help their organization be better stewards of improvement resources? Humbly ask questions and challenge assumptions. Here are some questions to help improvers discern their way into responsible improvement work.

  1. What is our organizational and or local mission & vision and how would solving this problem add or detract from those things?

    Consider where the organization aspires to be in the next 5-10 years. Consider what is mission-critical. Ask probing questions to cut through the ambiguity of common adjectives like “world class” and “innovative”. For example, ask, “world class according to whom? Is the aspiration to be top ranked? In which benchmark? What will it take to get there?”

  2. How impactful would solving this problem be on our mission and vision and how impactful is it relative to other problems we could solve?

    Consider the problem relative to other problems. How many lives will it impact? What does “impact” mean? Will this impact experience, health outcomes, or something else? By how much? Why do we care? Remember, the goal is to make an informed decision, not to find the correct answers to these questions.


In conclusion, IGNORE the song of the sirens that sing improvement exhortations!

Ask questions. Be humble. Leave the organization better than you found it.

Always be discerning.

Karen Frush, MD, is the former Chief Quality Officer at Stanford Health Care. She is a Clinical Professor of Emergency Medicine and Pediatrics. She also serves as a member of the Stanford Medicine Center for Improvement Advisory Committee.

Dr. Frush has been an MCHB funded researcher and helped lead an effort funded by the CMS Innovation Center to improve patient safety and quality across 70 small community and rural hospitals through the LifePoint Hospital Engagement Network. LifePoint was recognized with the John M Eisenberg Patient Safety and Quality Award in 2017 for this work. Dr. Frush has published peer review manuscripts in the areas of pediatric emergency care, patient safety and quality, teamwork, safety culture, interprofessional care, and quality improvement, and she has authored multiple books on these subjects, including Improving Patient Safety through Teamwork and Team Training, with Eduardo Salasin 2012. She is a Team STEPPS Master Trainer and served on the Department of Defense, Team STEPPS Technical Expert Panel (2008-2010). She is an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship program, served on the American Academy of Pediatrics Steering Committee for Quality Improvement in Pediatrics(2006-2011), and has been named one of 50 experts leading the field of patient safety by Becker’s for the past five years. She served on the Board of Advisors and the Board of Directors for the National Patient Safety Foundation and currently serves as Chair of the Institute for Healthcare Improvement (IHI)Certification Board for Professionals in Patient Safety.

Former Leadership positions include Chief Patient Safety Officer of the Duke University Health System (2004-2018); member of the Board of Trustees, North Carolina Center for Hospital Quality and Patient Safety (2005-2012), and Vice President for Quality, LifePoint Health and Duke-LifePoint Healthcare (2011-2018). Dr. Frush received a BSN from the University of Pittsburgh School of Nursing and then attended the Duke University School of Medicine where she earned her MD.

Alice R. Georgitso, MPH, joins the SMCI Advisory Committee as our first Patient Partner. Alice has served as a Patient Partner with the Stanford Health Care (SHC) Patient & Family Partner Program for over 4 years and was appointed Chairperson of the Adult Congenital Heart Program Patient & Family Advisory Council in January 2020. She assisted in developing the Stanford Adult Congenital Heart Program’s Peer-to-Peer Program and serves as a Mentor to ACHD patients pre-and-post-organ transplantation. Alice has presented Stanford Health Care’s C-I-CARE framework for structuring best practice communications and developing relationship-based care approaches with patients and colleagues to 500+ Stanford Medicine Directors, Managers and Clinical Staff.

Alice is a Patient Relations Manager at Stanford Health Care. Within her role, she provides a channel for problem resolution to promote the highest quality of care and service excellence. Alice has also worked as an Unrelated Donor Search Coordinator with the Blood & Marrow Transplant at Stanford Health Care to coordinate allogeneic hematopoietic stem cell transplants through collaborative planning and partnership with the National Marrow Donor Program and SHC clinicians. Prior to her work with SHC, she was the Community Service Foundation Director at San Mateo County Medical Association where she partnered with local stakeholders and clinicians to expand county-wide community health programs to diverse populations. She has also delivered invaluable community health services through her work with the American Heart Association.

Alice earned her Bachelor of Arts in Sociology and Biology at Saint Bonaventure University in Olean, NY and her Master of Public Health from SUNY Buffalo in Buffalo, NY. Alice is a member of The Beryl Institute and Adult Congenital Heart Association professional associations, Donor Network West partner advocating for organ, eye, tissue, and blood donation, and remains an active volunteer with SHC. Alice continues to promote patient-and-family-centered care in both hospital and community settings to support precision health and improve the healthcare experience for patients, families, and clinicians.

John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota's headquarters, he became the company's first American kacho (manager) in Japan. In the U.S., Shook joined Toyota’s North American engineering, research and development center in Ann Arbor, Michigan as general manager of administration and planning. His last position with Toyota was as senior American manager with the Toyota Supplier Support Center in Lexington, Kentucky, assisting North American companies adopt the Toyota Production System. Shook co-authored Learning to See, the book that introduced the world to value-stream mapping. He also co-authored Kaizen Express, a bi-lingual manual of the essential concepts and tools of the Toyota Production System. With Managing to Learn, Shook revealed the deeper workings of the A3 management process that is at the heart of Toyota’s management and leadership.
Shook is an industrial anthropologist with a master’s degree from the University of Hawaii, a bachelor’s degree from the University of Tennessee, and is a graduate of the Japan-America Institute of Management Science. At the University of Michigan, he was director of the Japan Technological Management Program and faculty member of the Department of Industrial and Operations Engineering.
Shook is the author of numerous articles, including "How to Change a Culture: Lessons from NUMMI"; Sloan Management Review, January 2010, which won Sloan’s Richard Beckhard Memorial Prize for outstanding article in the field of organizational development.

The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.

Dr. Paul Maggio is the Chief Quality Officer of Stanford Health Care. Prior to being appointed the SHC CQO, he was Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.

Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.

Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.

As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.