By Susan Carr

I don't recall exactly when I first heard or read Dr. Paul Batalden's observation, "Every system is perfectly designed to get the results it gets," which provided me with an important Aha! moment as I began to learn about patient safety and quality in healthcare. It is so often quoted, I think of it as a guiding principle for quality improvement, as does the Institute for Healthcare Improvement (IHI), which displays the quotation prominently in its offices.

Batalden's observation was also displayed prominently and with an inaccurate citation in the May/June of PSQH. When I first reviewed the manuscript that credited the quotation to a book published in 1984, I paused for a moment, but didn't go beyond double-checking the details of the reference supplied. When IHI questioned the citation, saying that the correct source is Batalden, I promised to run a correction and welcomed the opportunity to learn more about Batalden and the quotation itself. I've done some research and found myriad sources and numerous versions of Batalden's observation. I've seen it attributed in print to various texts: Cybernetics: A New Management Tool by Barry Clemson (Abacus Press, 1984), and Designing Organizations for High Performance by David Hanna (Addison Wesley, 1988). In my experience, the quotation is most often attributed to IHI President and CEO Don Berwick, MD, quality-improvement guru W. Edwards Deming and, occasionally, to Batalden.

A Google search for "every system is perfectly designed" yields 1,400 hits. The malpractice and health quality coordinator of the American Medical Student Association credits David Beckwith, MD, for "coining the new mantra of health quality improvement efforts" (www.amsa.org/hp/malpractice.cfm). David Beckwith... Donald Berwick... hmmm; this takes on the quality of a child's game of "telephone," with the quotation itself and the reference mutating through time. A school system in Michigan introduces a website offering "Baldrige-based checklists" for quality improvement by saying, "Getting started begins with the simple, self-evident premise that every system is perfectly designed to deliver the results it produces" (www.grand-blanc.k12.mi.us/qip/quickcheck.htm). I hope that Dr. Batalden takes it as a compliment that his observation is so disarming and frequently intoned as to have become a "self-evident" mantra.

When I contacted Batalden by email as I prepared this column, he reflected on the significance and purpose of his famous observation:

The observation invites personal reflection and awareness‹the place where the lasting improvement of quality usually begins. By directing people's attention to design, the words offer a powerful invitation to deeply consider how the present situation was created‹and invites its re-creation.

Batalden holds leadership positions at Dartmouth Medical School and IHI, of which he was a founding member and the original chairman of the board. He is the director of The Center for Leadership and Improvement in The Dartmouth Institute for Health Policy and Clinical Practice and leads the Dartmouth-Hitchcock Leadership Preventive Medicine Residency, a combined residency with other Dartmouth-Hitchcock graduate medical programs in learning to lead change for the improvement of quality, value, and safety of patient care. At IHI, he continues to serve on the Board of Directors. Batalden's career in medicine has included quality improvement since the mid-1970s and direct study with Deming in the 1980s, so the attribution of "every system is perfectly designed..." to Berwick and Deming holds some logic, as they have shared in Batalden's discoveries about quality.

Batalden also sent along a poem by William Stafford, of which this discussion had reminded him. This experience has been a welcome opportunity to learn more about a ground-level principle that guides healthcare improvement.

How These Words Happened
In winter, in the dark hours, when others
were asleep, I found these words and put them
together by their appetites and respect for
each other. In stillness, they jostled. They traded
meanings while pretending to have only one.

Monstrous alliances never dreamed of before
began. Sometimes they last. Never again
do they separate in this world. They die
together. They have a fidelity that no
purpose or pretense can ever break.

And all of this happens like magic to the words
in those dark hours when others sleep.

— William Stafford
© 1991, 1998, the estate of William Stafford.
Reprinted from The Way It Is: New & Selected Poems
with permission from Graywolf Press.