| Departments — Sparks of Inspiration | Spring 2008 |
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Deliver the Goods Joanne, an administrator in a radiology department at Harvard Community Health Plan, had “Joanne, you’ve knocked the socks off this problem!” he exclaimed. “What did you do?” Joanne looked at him: “It was easy. All I did was lie.” Color Coded At the time, Berwick was the group’s vice-president for quality-of-care measurement. Joanne had sent her data in response to an assessment Her story opened Berwick’s eyes. “I saw that so long as we kept beating up the workforce,” he says, “so long as we just kept asking good people to try harder to fix chronic issues, we’d never, ever get going. This upended my whole way of thinking.” Berwick, a clinical professor of pediatrics and health care policy at Harvard Medical School, has dedicated himself to changing the way people approach health care improvement. He believes he has struck upon a better way to work for the Joannes out there—and for all the patients she and so many other health care professionals seek to serve while operating within a hobbling system. In his approach, problems associated with the practice and delivery of health care—problems like medical errors, waste, and a systemic inability to look inward and learn—are dissected as problems of process, not of people. And, taking a page from industry’s push to improve productivity, workplace morale, and product quality, he encourages the health care industry to follow a new paradigm. With searing clarity, Berwick points out the flaws of the health care system and analyzes how they can be overcome through redesign. He and the growing legion of hospitals and health professionals that work with him have shown that specifying processes and streamlining systems can avoid needless deaths, alleviate pain and suffering among patients, eliminate waiting and waste, and help banish the helplessness that patients and their families too often experience. Most health professionals are painfully aware of the need for improvement. If they aren’t, numbers might help convince them. A patient safety study conducted between 2004 and 2006 by HealthGrades, a health care ratings organization, presented data on the costs of medical errors gleaned from an analysis of 41 million records of Medicare patients. Its findings showed that patient safety errors resulted in nearly a quarter of a million preventable deaths during the period studied. It further found that more than 60 percent of the common medical errors reported involved bedsores, failure to save patients once complications arose, and postoperative respiratory failure. With fewer such errors, the study analysts estimated thousands of lives and up to $2 billion in outright costs could have been saved. Industrial Strength The idea for applying the principles of what is known as continuous quality improvement to the service-based industry of health care came to Berwick in the mid-1980s, soon after Joanne had confessed the secret behind her success. Berwick had registered for a weekend lecture series in Washington, DC, featuring W. Edwards Deming, a mathematical physicist who had successfully applied statistical methods to industrial quality control questions. Largely unsung in the United States, Deming was a hero among Japan’s industrialists who had used his theories to propel that nation’s postmodern economic boom. “For the first day and a half,” says Berwick, “I sat there listening to Deming explain his statistics-based, engineering-based theory for how proper management should work to achieve continual improvement. By noon of the second day I had left and flown back to Boston. I thought it was all nonsense.” But the night of his return proved to be a restless one for Berwick. Agitated, sweating, and unable to sleep, he wandered into his living room and sat down to think. “Suddenly it hit me,” he says. “I realized my discomfort wasn’t the result of my being exposed to a theory that was wrong. I was uncomfortable because what I had heard made sense to me—and it violated almost every theory that I had been following. I returned to DC and completed the seminar.” Berwick walked away from this epiphany with an idea for fixing health care that was unlike almost anything that had yet been tried. In 1987, his innovation led to a role as co-principal investigator on an experiment known as the National Demonstration Project on Quality Improvement in Health Care. Teaming with A. Blanton Godfrey, who was then a quality management theoretician with Bell Laboratories, Berwick set out to test whether methods used to improve industrial quality were applicable to health care. Berwick and Godfrey matched 21 professionals from health care organizations with a similar number of industrial quality assurance professionals from academia and industry. After 18 months of work, the groups reported their results on projects ranging from better billing procedures to improved ways of transporting infants between hospitals. The results were so stunning that the study sponsors granted the investigators funding for three more years. The researchers used the time to inaugurate forums on quality improvement in health care, to establish a network of hospitals that shares information on implementation efforts, and to develop courses on how to adapt industrial quality improvement methods to health care. To spread the word further, in 1989 Berwick wrote a commentary for the New England Journal of Medicine. The title, “Continuous Improvement as an Ideal in Health Care,” only hints at its true purpose: It is at heart a manifesto declaring the need for the profession to look anew at itself and its approach to improvement. Berwick outlines why an approach that blames problems of quality on workers’ poor intentions only serves to make people game the system—distort the data, fault others for perceived shortcomings, and fearfully avoid anyone associated with quality measurement and improvement. On the other hand, Berwick points out, if problems with quality are seen for what they truly are—fundamental flaws of a complex system—they can be understood and revised on the basis of data about the processes themselves, not the people implementing them. The potential for improvement in quality is nearly boundless, says Berwick, if we remove fear from the equation, learn from accurate information, and enlist the talents and spirit of dedicated professionals. All Ahead Full The principles set forth in his article are ones Berwick applies in practice. In his work at the Institute for Healthcare Improvement, a not-for-profit organization based in Cambridge, Massachusetts, that he helped establish in 1991, Berwick has focused on fixing health care systems in the United States and abroad. One of the institute’s more visible efforts launched in 2004 when it began a campaign to improve hospital safety. The 100,000 Lives Campaign was designed to help hospitals reduce unnecessary deaths by encouraging them to implement over a two-year period a handful of scientifically proven improvements in care delivery, such as rapid response teams for critical care interventions, the prevention of surgical site and central-line infections, and the reduction of medication errors. The campaign exceeded its goal: Hospitals participating in the campaign and in other initiatives prevented an estimated 122,300 unnecessary deaths within an 18-month campaign period. In December 2006, the Institute for Healthcare Improvement launched a second such effort, this time with a goal of preventing five million incidents of medical harm in the United States. With initiatives to transform medical and surgical care, perinatal care, clinical office practice, surgical outcomes, and a host of other improvements, the work of Berwick and his team is steaming ahead. Berwick knows, though, that the task is great and that protracted implementation means more lives lost, more frustrated health professionals, and a continued escalation of costs in an increasingly inequitable health care system. Incremental change, he feels, is not the answer. Instead he believes the U.S. health care system needs fundamental change. And if that means building it anew, well, Berwick may just be the one to spark that transformation. Ann Marie Menting is associate editor of the Harvard Medical Alumni Bulletin Photo captions: M.C. Escher’s Waterfall (story top); Donald Berwick Photos: M. C. Escher’s Waterfall ©2008, the M. C. Escher Company–Holland. All rights reserved. www.mcescher.com; Institute for Healthcare Improvement |
showed me our approach to health care reform was bankrupt.”
survey he had circulated. From Berwick’s shocked expression she knew a fuller explanation was needed.
“Let me tell you what happens around here,” she said. “When I send you data that shows all the problems, you send that to my boss’s boss’s boss, and he circles it with red ink. Then he sends it to my boss’s boss, and he circles it in yellow marker and sends it to my boss, who circles it in orange ink and writes, ‘Joanne, do something about this.’ It then comes back to my desk—as if I didn’t know we had a problem and wasn’t already doing everything I could to resolve it. So I made up the data. I knew both you and I would be happier if I did.”
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