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Donald M. Berwick, MD, MPP

JAMA. 2002;288:1523-1524.

	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

Students of improvement in complex, human systems have mixed feelings about public report cards on performance. Here is the problem: On the one hand, all improvement is change, and human systems resist change. Therefore, improvement requires a source of tension, discomfort with the status quo, sufficient to overcome this inertia. Sometimes a charismatic leader or a call upon ambition is enough, but usually not. In the commercial world, conventional wisdom holds that "burning platforms" or "threats to survival" are necessary to build will for improvement.

On the other hand, not all changes are improvements. To make a complex system better requires learning and local experiments, best of all involving all workers, inviting them to use their knowledge and skills to learn together. As educators know, people do not learn especially well when they are afraid. For health care to improve, learning must occur in . . . [Full Text of this Article]

Author Affiliation: Institute for Healthcare Improvement, Boston, Mass.

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