Donald Berwick, M.D., says his time in Washington, D.C., intrigued him by the potential" for good government and is considering a run for governor of Massachusetts. The former head of the Institute for Healthcare Improvement and the Centers for Medicare & Medicaid Services adds that there needs to be continued vigilance toward achieving the Triple Aim. / Interviewed by Haydn Bush

What prompted your consideration of a run for governor of Massachusetts?

BERWICK: The work I've done in health care has made me excited about the possibility for large systems to improve. My time in Washington put me right at the center of public policy, and got me intrigued by the potential for really good government to work in cooperation with the private sector. Right now, Washington is rather stuck because of the political stalemate and rancor, and I think a lot of possibilities exist at the state level.

At CMS, I worked hard to form good relationships with other agencies, and the more we worked together, the more we could get done. When you broaden the frame to the well-being of societies, the importance of cooperation like that is even greater. The principles of improvement, cooperation and participation, and ambition that work so well in health care can have traction in the public sector. A government that's aware of that and really making it possible for the private sector to be contributors is a much healthier government.

How did your experience at CMS form your perspective?

BERWICK: Getting to lead CMS was a wonderful job. I loved it. The workforce just stunned me with its confidence, commitment and willingness. It was a great experience, but I did learn a lot about obstacles. There were good people whose belief systems, histories and investments are in being supported to do what they've always done. But that's not what we need. We need hospitals to seek to be empty, not full. We need specialists to ask tough questions. I saw how powerful the voice of the status quo is. It's done through lobbyists, political contributions and interpersonal relationships, and it's really powerful.

That helped me understand that the improvement movement needs to gain power, to gain the attention of the people who set policies.

What's your current assessment of the improvement movement?

BERWICK: There's a lot for the improvement movement to celebrate: the ability of clinicians, managers, all the stakeholders in health care systems, hospitals and clinics to actually make things better. It's never been better. We have great evidence. We know that there are problems in safety that we can conquer. But from the American perspective, we have a big, lumpy problem of social and technical transition to make health care something that can be afforded, sustainable and excellent everywhere. That's the next challenge for us.

I have been thinking a lot, partly reflecting on my experiences as CMS administrator — What's in the way? What's keeping us from finally changing? I think there are a series of barriers. Some are technical, some involve learning, but there are some that I would call political in the sense that they are very hard to talk about. They will mobilize opposition and almost combative energies as we try to get over these thresholds.

What are the key issues in that vein?

BERWICK: One is the problem of how to gain knowledge. How do we learn together the ability to force ourselves to understand the variation among us, and learn about what we have to do?

The second area is waste. American health care is far too costly, and at least a third of that cost is going into activities that don't help people. When you say there is too much of this or too much of that, you are running into a political minefield. What if it were true that half of the stents and the coronary surgeries that we do in this country may not be necessary, that patients would do just as well on medication? You almost can't talk about that, because the vested interests in the system are just too great. So that's one category of waste over treatment. How do we really confront this?

Another area is priorities. For reasons that are rather tragic and irresponsible, the ability to discuss palliative care in the federal policy context is not there. It's crucial that we are able to restore an American conversation about palliative care and care in the late stages of illness.

The last category is business transition. Hospitals face a dramatic change — to migrate away from the center of the American health care system to the periphery, where the whole system becomes oriented to keeping people out of hospitals and at home.

To what extent do you think the ACA, as well as private reform initiatives, will address these barriers?

BERWICK: I think the Affordable Care Act is really quite magnificent. It's got a lot of potential in it. The problem is the unspoken, unmentionable issues that remain silent. We can talk coordinated care, but not if hospitals have to struggle to be bigger and full and raise the new wing.

We can deal with patient safety and outcomes, but only if we confront overtreatment and say it's just wrong to be giving people care that scientifically can't help them at all. We can discuss knowledge growth, but it won't work if we don't move wholeheartedly to transparency where we really can turn the lights on and watch our care. The frameworks are there, but now it's a matter of overcoming these political barriers.

How can the improvement community help achieve some of those goals?

BERWICK: My advice is to keep going. Keep building our confidence that we know how to stop harm and eliminate overtreatment, and work on coordination and put patients in power.

I'm aware more than I was before that the people who speak are heard, and those who are silent aren't. I think the improvement movement has a burden to help policymakers understand that changing processes on behalf of better care is the way to go. They have to learn to be forceful about that, and not be naive.

The other thing is to fill the silence. When the political arena falls silent, someone had better fill that space, or the issues will not get attended to. I think that is a very worthy role for the improvers now.


THE BERWICK FILE

CV

• Practicing pediatrician in Newton, Mass.
• CMS administrator from July 2010 to December 2011.
• Co-founder and CEO of the Institute for Healthcare Improvement from 1992 to 2010.

Sir Don

In 2005, Queen Elizabeth named him Honorary Knight Commander of the British Empire for his work with the National Health Service.

In his spare time

Cross-country skate skiing. "Every weekend we can possibly go, my wife and I and our children go skiing. It's a real passion for me."

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