ORLANDO — Health care has made tremendous strides in recent years, improving the quality and lowering the costs of the services it delivers to patients. And yet, there’s still a long way to go, rooting out the variation and opaqueness that still plague the field.
Don Berwick, M.D. — former head of the Centers for Medicare & Medicaid Services and senior fellow with the Institute of Healthcare Improvement — illustrated the wide gap between what health care is and what it could be with two patient stories during his closing keynote at the IHI Forum Wednesday. The good: Sean, a young teen suffering from severe depression due to an abusive father, whose life was turned around by a compassionate team of health care professionals. On the flip side: An unnamed friend of Berwick, whose trip to the emergency department ended with a confusing, nonsensical bill for $7,300 and little discernible benefit to his health and well being.
Health care has pretty much lived in two eras during its modern life, Berwick believes. Science, discovery and the trusted doc captaining the care team all defined the first era. The erosion of that trust and emergence of the consumer patient have led to the current era of accountability, measurement, control and punishment. Berwick believes it’s time for the field to build yet another new era that takes the best of both worlds and provides a health care experience of which we have only dreamed.
“There’s an enormous space between the story of Sean and the story of that bill. They’re worlds apart,” Berwick told attendees. “Sean’s care by a big team with mom in the middle, over years, is full of meaning, at least to me. An ED visit with a hassled doctor, fragmented management process, a silent scribe, overuse, endless paperwork — that’s meaning lost.
“One story is about connecting, about relating, growing together. The other is about processing — next patient, next patient, next patient — and we’re caught in that space where the tension, I think, between the beauty of a real healing relationship and the beast of care as production. I don’t know how we got here, but I do know that the tension is nearly unbearable, and if we’re not careful, it can break us.”
Berwick offered health care leaders nine steps they can take to begin moving into this new age, which he tentatively dubbed as “the moral era”. Here they are, in his own words:
- Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find Sean in that glare. I vote for a 50 percent reduction in all metrics currently being used.
- Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
- Decrease focus on finance: This could be impossible. I feel naïve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? … If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
- Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
- Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
- Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
- Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient — these are not funny.
- Listen. Really listen: These terms — coproduction, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
- Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.
There’s a lot more I, as the reporter, could say about what was a wonderful, wonderful speech, probably the best I’ve seen in my four short years covering health care conferences, but I’ll leave it at that. Berwick closed by relating a tip from one chief nursing officer that’s resonated with him. Every time a baby was born, she would ask herself, “Is this a president?” Berwick says the sentiment of that small encounter has stuck with him, and he thinks it’s important that health care workers carry the thought behind that question into all that they do. Relationships will be the foundation of the health care’s new age, he believes.
“That’s Era 3,” he said. “The quest is clear. It’s not power or accountability or reward or punishment or score sheets or metrics or profit for its own sake. It’s a search for meaning in the value of the person who has come to honor us with his or her quest for some help. And we think to ourselves, is this a president? Is this a hero? Is this a mother? Is this a father? An artist? A craftsman? An honest laborer? A climber of hills? A singer of songs? Who is this person who honors me with their presence, and what can I do to help them?”