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Building of profound knowledge

D1X XStacy Roehrs, RPh, PharmD, BCPPS D2X X

Health systems are complex. Understanding the interrelationship among the four components of W. Edwards Deming's System of Profound Knowledge (theories of systems, theory of knowledge, understanding variation, and psychology of change) allows us to begin the work of quality improvement. Each system is perfectly designed to deliver the results it produces. One must gain knowl- edge of the system through small tests of change (Plan-Do-Study- Act Cycles). We also need to understand and prevent undesirable

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variation and encourage desirable variation. Leaders must under- stand the motivations of people and their behavior and provide the appropriate skills training for people to change and succeed. All four components of Deming's System of Profound Knowledge are necessary for the quality improvement work that will enhance the health care delivery system.

Curr Probl Pediatr Adolesc Health Care 2018; 48:196�197

P rofound Knowledgeenables transformation in

systems. 1 A system is interrelated processes

and people that work together to achieve a

common aim. Organizations consist of departments,

people, facilities and functions that are working together

to achieve a stated purpose. In healthcare, the organiza-

tion works to provide quality care and exemplary cus-

tomer service to patients. If each department is working

independently to maximize its own efficiency, the effi-

ciency of the entire system is compromised. Leadership

is tasked with optimizing the sytem as a whole to

achieve its stated purpose or aim. In order to optimize

the system one must understand the system.

Is the system working efficiently? How can the system

be improved? To answer these questions it is important

to understand the processes currently in place. It is

impossible to fix or improve what is not understood.

Many leaders believe they know the processes taking

place, but lack a true understanding of what is occuring

on the front line. The first step in gaining knowledge is

mapping the process. 2 An accurate mapping of the pro-

cess is important in undestanding and gaining knowl-

edge. When developing a process map, interview the

expertsx, who are the individuals involved in the pro-

cess. Then observe the process to determine the differ-

ence between what is thought to be happening and what

actually occurs. This step, while frequently skipped,

becomes the difference between profound knowledge

and strengthened biases. Direct observations are key to

uncovering targets for interventions. Share the final pro-

cess map with subject matter experts to gain insight into

opportunities for improvement, non-value added steps in

the process and steps that management believes are

always occuring but in reality are occurring less than

half the time. Mapping the process is an important first

step to gaining knowledge but this alone will not lead to

system improvement.

A theory of knowledge is needed to improve a sys-

tem. Do not mistake information for knowledge. A

theory of knowledge comes from application and

study. A change is made to a system with the predic-

tion of improvement. To determine if improvement

occurs, the change needs to be studied and measured.

Use of the Plan-Do-Study-Act Cycle (PDSA) enables

knowledge to be built through a series of predictions

and observations. 3 A change is developed based on

knowledge gained from process mapping; it is then

introduced into a system, and tested. These changes

typically start out small: 1 visit, 1 patient, 1 nurse, etc.

They are also tests, meaning they are modifiable, and

not typically the end change that is ultimately insti-

tuted. The change must be measured to determine if

the appropriate outcome has been realized: improve-

ment in the system. Action can then be taken depend-

ing on the outcome of the test of change. Running

these tests of change and studying the effects enable

the skillful accumilation of knowledge regarding how

to improve the system.

Curr Probl Pediatr Adolesc Health Care, August 2018

FIG 1. Deming's system of profound knowledge.

Understanding variation in a system is another

key component to system improvement. 4,5

Varia-

tion is inherent in every process or system and is

called common cause variation. A process where

only common cause variation occurs is considered

a stable process. Variation that arises due to a spe-

cial circumstance is considered special cause vari-

ation. 6 Special cause variation should be studied

and either prevented (if undesirable) or modeled

and encouraged (if desirable). Mistakes in process

improvement occur when people treat common

cause variation as special cause variation and try to

adjust the system when the system needs a funda-

mental change to see improvement. This is called

tampering. Tampering leads to misallocation of

resources, worsening quality, and a poor patient

experience. 1 In addition, if special cause variation

is not identified, then opportunities to fix a problem

are missed.

Finally, the psychology of change or the human

factor is the fourth aspect of Deming’s “System of

Profound Knowledge”. This pillar of Deming’s

system of profound knowledge is as important as

the other three to facilitate successful system

improvement. Deming understood that people have

an innate desire to take pride in what they do and

believed everyone had a right to joy in work. 1

Leaders must understand the motivations of people

and their behavior, but also provide the appropriate

skills and training for people to succeed. Leaders

value teams and utilize cooperation instead of

competition to drive change and encourage people

to test changes and observe the success of changes

by others. “The aim of leadership should be to

improve the performance of man and machine, to

improve quality, to increase output, and simulta-

neously to bring pride of workmanship to people.

Put in a negative way, the aim of leadership is not

merely to find and record failures of men, but to

remove the causes of failure: to help people to do a

better job with less effort.” 7

These principles (theories of a system, theory of

knowledge, understanding variation, and psychol-

ogy of change) together make up W. EdwardsDe-

ming’s System of Profound Knowledge (Fig. 1).

Profound knowledge is needed to improve our

healthcare systems. Systems exist to provide

high quality care for pediatric and adolescent

Curr Probl Pediatr Adolesc Health Care, August 2018

patients (anticipatory guidance, diagnosis, treat-

ment, healthcare maintenance, monitoring, self-

management support, transition). The following

papers and clinical examples 2�5,8,9

will illustrate

how systems of care delivery can be enhanced, as

well as how to begin important work of quality

improvement.

References 1. Deming WE. The New Economics for Industry, Government,

Education. 2nd ed. Cambridge, Mass: The MIT Press; 2000.

2. Marriott R. Process mapping. Curr Probl Pediatr Adolesc

Health Care 2018.

3. Christoff P. Change Theories�Running PDSA Cycles. Curr Probl Pediatr Adolesc Health Care 2018.

4. Williams B. Understanding Variation, Part 1: the Run Chart.

Curr Probl Pediatr Adolesc Health Care 2018.

5. Williams B. Understanding Variation, Part 2: the Control

Chart. Curr Probl Pediatr Adolesc Health Care 2018.

6. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL,

Provost LP. The Improvement Guide: A Practical Approach to

Enhancing Organizational Performance. 2nd ed. San Francisco,

Calif: Jossey-Bass; 2009.

7. Deming WE. Out of the Crisis. 1st ed. Cambridge, Mass: The

MIT Press; 2000.

8. Cox M, Sandberg KC. Modeling causal relationships. Curr

Probl Pediatr Adolesc Health Care 2018.

9. Sandberg KC. Leadership in quality improvement. Curr Probl

Pediatr Adolesc Health Care 2018.

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