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Editorials |

Is Every Defect Really a Treasure?

Frank Davidoff, MD
[+] Article, Author, and Disclosure Information

From Institute for Healthcare Improvement, Wethersfield, CT 06109.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0681.

Requests for Single Reprints: Frank Davidoff, MD, Institute for Healthcare Improvement, 143 Garden Street, Wethersfield, CT 06109; e-mail, mailto:fdavidoff@cox.net.

Ann Intern Med. 2012;156(9):664-665. doi:10.7326/0003-4819-156-9-201205010-00013
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In this issue, Bradley and colleagues examined the imperfections in care implicit in the wide variation in risk-standardized mortality rates (11% to 25%) for patients hospitalized with AMI in U.S. hospitals. The editorialist discusses the study in light of the Japanese concept of kaizen, which holds that “every defect is a treasure,” and speculates how organizations can best convert the discovery of imperfections into improvements in care.

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The Best Medical Therapy Available
Posted on April 30, 2012
Elizabeth H.Bradley, Professor, Leslie A. Curry, Harlan M. Krumholz
Yale School of Public Health
Conflict of Interest: None Declared

We are delighted that concepts like kaizen and a "web of relationships in organizations among people, events, technologies, and environments" have made the top-tier medical journals such as the Annals. Our work over the last decade has identified multiple strategies to achieve top performance in acute myocardial infarction (AMI). In beta- blocker use, it was standing orders, physician champions, and data feedback (1). For door-to-balloon time, it was single call catheterization laboratory activation by emergency medicine, standards about post-call arrival times, cardiologist always on site, and data feedback (2). For 30- day mortality after AMI, it is meeting regularly with Emergency Medical Services (EMS), having physician and nurse champions, specialized nurses, cardiologist always on site, and pharmacists on rounds (3). For each outcome, a different set of strategies were important.

Nevertheless, common factors also emerged. These included indicators of a strong culture committed to learning and solving problems. After a decade of positive deviance research using mixed methods (4,5), we have concluded that a supportive organizational culture is likely a common theme for top performance across process and outcomes measures for AMI. The insight of this work is we have to invest in the tasks and the relationships that together, create our organizational cultures. Many times, in search of a silver bullet, we have focused on the tasks and been disappointed. In complex systems, such as hospitals, recognizing and strengthening the web of relationships so that foster continuous engagement and problem solving may be among the best medical therapy available.


1. Bradley EH, Herrin J, Mattera JA, Holmboe ES, Wang Y, Frederick P, et al. Quality improvement efforts and hospital performance: rates of beta -blocker prescription after acute myocardial infarction. Med Care. 2005;43(3):282-92. [PMID: 15725985]

2. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308-20. [PMID: 17101617]

3. Bradley EH, Curry L, Spatz ES, Herrin J, Cherlin EJ, Curtis JP, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Int Med. 2012;156:618-626.

4. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25. [PMID: 19426507]

5. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provides unique contributions to outcomes research. Circulation. 2009;119(10):1442-52. [PMID:19289649]

Conflict of Interest:

None declared

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