The Value of Curiosity in Quality Improvement
In the late summer of 1854, more than five hundred people in a few streets of Soho died of cholera in ten days. The accepted explanation was that bad air arising from filth caused the disease, but physician Dr John Snow had long suspected that cholera travels in water. This concept was so radical that he set out not simply to assert he was right. He looked for cases that didn’t fit the typical or expected pattern.
Why had a workhouse and a brewery, a few yards from the worst of the outbreak, largely escaped? Why had someone died far from Broad Street? The common factor in each case was the same pump, or the absence of it. These outliers were where the insight lay but that on its own was not sufficient.
Asking What are we not seeing here? What are we missing? is the difference between defending a process and understanding it
The value of curiosity in quality improvement cannot be ignored and there's more to this tale. A local curate, Henry Whitehead in the Soho parish that included Broad Street, was initially sceptical of Snow’s theory of water-borne disease and set out to prove the pump’s innocence. He knew the area well, and knew almost all the families living there. He painstakingly went from house to house speaking to the families of victims, including that of baby Frances Lewis. She lived opposite the pump, and her family was the only one with ready access to a cesspool in front of the house, where her mother routinely disposed of soiled water. Baby Lewis’ never appeared in the cholera tally because her death was recorded as “exhaustion from diarrhoea". Without Whitehead’s investigation, she would never have been identified as the index case, the pump would not have been excavated, and the direct connection between the well and the Broad Street cesspool might not have been uncovered.
Stay curious, even when you think you’ve found the answer, and ask the right people closest to the work about their lived experiences
The curiosity of Whitehead and Snow has saved countless lives. Neither person could have solved the case alone. Snow provided the hypothesis, while Whitehead had the trust and local knowledge to ask the right questions of the right people. Here are two lessons for all of us committed to quality improvement. Stay curious, even when you think you’ve found the answer, and ask the right people closest to the work about their lived experiences.
Asking What are we not seeing here? What are we missing? may sound modest, but here lies the difference between defending a process and understanding it. Committing to answer these questions alongside the people closest to the work is most likely to yield the right answers.
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