Mary Dolansky called and asked if I could speak to the history of this course: where it came from, and who are some of the people who started it. I was hesitant; A good course stands on its own merit. Its value today perhaps has nothing to do with its history. But history matters. When this school started, healthcare was different. The University was different. The differences are very large, and many of our students are not aware of how radically the world was different. To them it seems that it has always been like now. We have always had quality improvement teams. We have always improved, we have always taught in teams with medical management, and nursing students in same class. What's the norm today, was not possible just a couple of decades ago. The course you are engaged to take is the product of many trends that were novel one day, and the norm today. Over the years I have aged, have become older and more contemplative. My students on the other hand have not. They remain forever young. Forever stuck in their 20s and 30s. They remain exuberant and forward looking. To them everything is possible. There's some continuously forever young, but increasingly unaware of how things were 40 years ago. As time has passed, I look back and see radical change. They don't. They see today as a continuation of yesterday. The world is not really that different from yesterday from their perspective. To them, the world has always been this way. They do not see how difficult it was to get here. They do not see what I see. They, meaning you, are blissfully unaware of history. 40 years ago, there was no course on process improvement, not here, not at most universities, not in medical schools, not in nursing schools, and not in engineering schools. Few if any medical students were exposed to process improvement. Management students were told that quality is in the domain of clinicians. Nursing students had not been taught about improvement teams. Quality was essentially taught through Donabedian's 1966 article highlighting structure, process and outcomes. Everywhere you looked, there were quality assurance efforts. These efforts were all based on peer evaluation. Doctors evaluated doctors, and nurses evaluated nurses. If a problem was found, a letter was sent to reprimand the person. Unless you really messed up, there was rarely any consequences. It was all a search for the bad apple. It was a search for the single clinician who had messed up badly. It had to be a glaring mistake. Every peer had to agree that it was a mistake. The single clinician was blamed and everyone else was okay. Horror stories were told. Oh, he was drunk when doing the surgery and left a knife in the patient's body. The idea was to find the bad apple and save others. Then came Edward Deming, and his idea on continuous quality improvement. Now quality was no longer a search for bad apples. It was everyone's problem, and no-one's. It was a system. It was the fault of the system. No one was to be blamed. Everyone, even the best were to improve. One of Deming's idea was that marketing and production had to work as a team. In health care, this translated to the need for interdisciplinary teams. But clinicians were already trained to work in silos and not in teams. If change had to occur, then it had to occur in the training of clinicians and managers. It has to occur upstream, where people were creating their work habits. If professionals were to work as teams, then they had to be trained as teams. This idea was to create an interdisciplinary faculty to teach managers, physicians, nurses and other health professionals in the same class. At the time, Institute for Health Improvement had started a new collaborative for people to learn, how to create interdisciplinary faculty. Linda Headrick was one of the people who started the collaborative. Linda was a physician, and focused on training of physicians and how it could include collaboration with other professionals, from her first days of graduating as a new physician til today, she has pursued the goal of getting physicians to work in interdisciplinary teams. Duncan was another founding member of the group. Duncan was well, it, I should say is, at heart an epidemiologist, he was the editor of Medical Care and well funded with various projects, he had published extensively and his involvement gave the project a real anchor. He would cheer us on, he would say good, good, let us try that as a pilot on a small scale. Let us see how it works. He just kept us going. Dr. Moore was another of the founding members of the group. She came out of the school of nursing and brought with her great insights on how we could all work together. She saw through the real meaning of what faculty we are talking about. And would show us how the course affected individual patients. This is me. I am an engineer, and I was teaching quality improvement to managers. I joined the team to represent the perspective of the managers and engineers working on quality improvement. There were others too, for a while a faculty member from the School of Business in Case Western Reserve joined us. Francine Heckelmen, who was focused on faculty training in the School of Nursing at CWRU, also joined us before she retired. Nancy Cassis, who recently passed away, was a student in one of the early classes, and taught in subsequent classes from the perspective of a practitioner. There were many more others who contributed a great deal. I'm sure that I'm forgetting to name some of the key people. Like David Aaron, I just remembered him. This is one of the early classes. There were 13 sessions. Each session for three hours. So, one of, one of us would teach it. Students were composed of health professionals, including medical students, nurses, and nutrition and other fields. Management students would also attend. Everybody took the same course content, was graded on the same assignments. These diverse students were also taught by diverse faculty. In those days, one of us would take turns to teach the class. Duncan was teaching the class that day. Sometimes we taught the class in groups-- team teaching-- but most of the time, it was taught by one of us. We would meet in person, or later on the phone, to discuss the course content, the reading, the assignments, grading, and all sorts of class related issues. Later on, as course content was set, we focused on research and reading and learning. Let me describe our process for creating this course, what I call the dance of ideas. This is what would happen, a person had an idea, for example, Duncan would introduce us to personal improvement. We would read about it, we would invite people to come and talk to us. We would then change it and bounce the idea off of each other. We would then pilot test it, then come back and talk about it. As a result of all this give and take, the idea would take shape. The end result would be a course in which personal improvement is actively used throughout the lectures. The end result of the same discussions also lead to a book that would apply personal improvement to weight loss and exercise. Shirley even did a NIH funded study evaluating personal process improvement as a method of rehab. Others would also publish about it and apply it in still different contexts. So an idea would go around many times, be examined in many different ways. This month, Atlantic Monthly has an article about how it takes two people to be creative. Some of the most important advances have been made because individuals run their ideas against each other. Here you see the Beatles doing so. A healthy competition emerges, a surge occurs, for better ideas from different perspective. This is how the course unfolded too. Creativity and marriage from faculty talking with each other and coming up with content and new ways of teaching. Soon our work together went beyond the class. We would read books together, discuss it, we would talk about research ideas. We would dream things up, collaborate, we would serve as each other's references. We even one time went dancing together. I think we went dancing after a meeting in Nashville, Tennessee. We had to break the ice and this was helpful. Through these meetings we ended up learning from each other. We set out to teach in an interdisciplinary fashion and we ended up learning more than we taught. We wanted to teach teamwork, but ended up being transformed by our teaching. You're about to start a new course. Keep in mind that what seems obvious and plain, was not easy at first. Nothing in the course came easy. People had to argue about it. Consensus had to be reached. Even the faculty had to compromise with each other. The course content, the methods of teaching, and a great deal more had to be created from scratch and with collaboration of different professions. What seems normal today was not so, even a few decades ago.
