Learning to Love Improvement Work: The Key is in the Relationships

By David C. Leach and Paul B. Batalden

Thomas Merton once asked his novices: “What was Adam’s sin?”  He then answered his own question by saying: “It was that he wanted to do good.”  The knowledge obtained from eating the fruit of the tree of the knowledge of good and evil, coupled with the serpent’s seductive approach announcing that now he could be really good and show God his abilities introduced Adam to pride.  Instead of being nurtured by his relationship with God he settled for self-sufficiency and we all know the result…

We also know the litany of flaws in the healthcare system and that many feel compelled to improve the situation.  Like Adam we want to do good. We may have even devoted time to “learning” how to improve, yet the results are mixed at best.  Many good people have put in lots of effort, but the system is still dangerous and expensive; somehow true improvement has eluded us. Learning from Adam, we feel that more attention should be given to the relationships in healthcare. At its base, a healthcare service is composed of relationships and actions.  They are held together by knowledge, skill, habit and vulnerability.  Yet, often our approaches to improvement have focused on “tools” or “analytic techniques” or recognition—even “belts” of different colors!  These externalities fight with the humility that comes when we seriously engage the hard work of helping smart people change their behaviors, which effectively hold relationships and actions together.  It has often seemed easier to assume that “relationship” takes care of itself. So the focus of improvement becomes the “action:”  Was it timely?  Was it reliable?  Was it safe?  Did it seem to be of good value?  Improvement work so conceived misses the whole work to be improved and risks impoverishing the relationships of those involved.

Professionals and patients form their relationship in time. But each comes from different ideas/legacies about time.[i]  The early Greeks described these legacies of “time” with different words: chronos and kairos.  Chronos refers to a quantity of time– longitudinal, measured in seconds, minutes, etc. Kairos refers to meaningfulness. A patient’s story is a story of meaning.  The on-duty (chronos) professional uses that story to understand the burden of illness and to begin to formulate a scientifically studied intervention-action that might fit the need and the situation.  Together they agree on the action and the path forward. The relationship between the patient and the professional blends these two different worlds of time and is enabled by trust and respect.

Illustrative examples of under-attending to the relationship part of a healthcare service are ubiquitous.  For example, the introduction of the electronic medical record put a priority on the content, form of documentation and initially diminished the human to human interactions between caregiver and patient.  Patients complained that the caregiver no longer looked at them but spent most of the visit looking at the computer, and the caregiver complained that the patient’s narrative could not be captured by the series of yes or no questions that the computer demanded to be answered. Neither party felt care was improved even though the advantages of having data in an electronic format were obvious.  Communication between primary care caregivers and specialists was also attenuated.  Conversations that enriched both parties were no longer feasible.  Likewise interactions between the various members of the local healthcare delivery team was compromised by the duties owed to the computer.  This was certainly not by design, but in hindsight, it seems that it could have been foreseen and prevented.  To do so the importance of human to human interactions would have to have been incorporated into the aim of the intervention.  Further, a deeper understanding of improvement efforts was required, one that realized the distorting effects that occur when improvement efforts are thought of solely as actions on structures and processes without due consideration of the human attributes of the system.  This would have meant that the owners of the various processes of creating and supporting the effort would have had to be part of the planning effort.  Basically it would require that all members of the improvement effort notice, develop and rely upon an explicit acknowledgement of both the relationships and the actions and their linkages for all involved in the work, including the patient.

This is not easy, but as Ayanian and Markel[ii] have recently reminded us, Avedis Donabedian, arguably the father of quality improvement in healthcare, said on his death bed: “Ultimately the secret of quality is love… If you love, you can then work backward to monitor and improve the system.”

David C. Leach MD, was trained and practiced as an endocrinologist.  He served as the Executive Director of the Accreditation Council for Graduate Medical Education (ACGME) from 1997 – 2007. He is a member of the Board of Trustees of Mercy Health.


Paul Batalden, MD
, was trained and practiced as a pediatrician.  He is nationally and internationally known for his work in improvement science.  He is currently
Professor Emeritus, The Dartmouth Institute, Geisel School of Medicine, Dartmouth College.


[i] Maren Batalden (2016, publication in press). Stories from patients and families: An invitation into coproductive partnership in healthcare service. http://futurehospital.rcpjournal.org/

[ii] John Z. Ayanian, M.D., M.P.P., and Howard Markel, M.D., Ph.D. (2016). Donabedian’s lasting framework for health care quality. NEJM 375(3): 205-207.

One thought on “Learning to Love Improvement Work: The Key is in the Relationships

  1. Thank you Drs. Leach and Batalden for highlighting engaging in the patient’s story , “a story of meaning” and the cultivation of a meaningful physician-patient relationship. Your caveat (and concern) about the impact of the EHR on this sacred relationship is well taken- we’ve published on preserving relationship centered care within the computerized setting (EHR curriculum in med Ed), Academic Medicine, 2014 and hope it’s informative and of practical use…http://bit.ly/2bDD1ua


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