Friday, October 30, 2009

Berwick jumps in, too

Following up on the post below, Don Berwick, CEO of the Institute for Healthcare Improvement is offering the keynote address at the BCBSMA conference. I'll try to pick up his major themes as he goes along.

Don offered stage-setting remarks for the CEO presentations to follow. He noted that the MA universal coverage law is being used as an example by people in Washington, DC, even though there remains lots to do with its implementation. He termed that law a "moral commitment," but one that requires lots of attention to the offshoots and results of that kind of commitment.

Don said that the work of the Lead group is also path-finding in its own way.

Regarding the current debate in DC, Don suggests that most of what seems to be playing out is an oscillation between two kinds of alternatives: Spend more or do less. The political process has the means to get through this kind of dialectic. But what the CEOs here know is that there is actually a third option: Redesign the care. The quality movement is formed by a kind of optimism. It always can be better; therefore we should stive. "Better is the option: Redesign is the plan."

Until now, it has not been necessary to do this in the health care system, and many parts of the system are still delivering care based on old models. Congress and the Administration don't get this because they don't deliver care. They don't know what the potential is and how to achieve it.

Don suggests that there are other elements in achieving this potential. The first domain of care is inherent in the Institute of Medicine list: Safe, effective, patient centered, timely, efficient, and equitable. He notes that we have gotten better in this domain, and he presented lots of examples across hospitals. "We know a lot, and it can be done."

The second part of the story has to be based on value, a system that we can afford. "I do not regard it as ethical that health care takes up 16% or more of the national economy." This steals wealth from other important causes like education, culture, and infrastructure. The health care system is way overbuilt. "Health care is not entitled to the growth in GDP that it demands." This will not be solved by focus on the IOM domains. We have to use scientific knowledge about process improvements and knowledge of systems to achieve the IHI triple aim: Better care, better health, and lower per capita costs.

There are some high value areas of the US. We brought together 10 of those regions and did a debrief. These places have broken the back of supply-driven demand. They also evidence high degrees of cooperation between medical groups and hospitals, among hospitals, and with payers. In every one of those communities, people in positions of responsibility both inside and outside of the health care system have chosen to exercise that responsibility. The attributes of the executives in the successful markets include: Confidence in possibility; appeal to the heart of the work force; constancy of purpose; alignment of resources for achievement of the long-term aims (money and time -- use a low discount rate in evaluating investment choices); review and reflection; translation into finance (bridge between the world of improvement and the world of money -- the CFO is at the table); management of spread (take pockets of excellence and help them be be pervasive); formats for cooperation ("not love, not even peace, but some way to get together") -- move good news from one place to another; celebration at the community level.


Anonymous said...

Well articulated, and a synopsis of what has been widely circulated among those in the know on this subject. Unfortunately, the politicians are not listening one iota. Also, key stakeholders such as many physicians are not buying in. How do we change this?

nonlocal MD

76 Degrees in San Diego said...

The answer is in the last paragraph. Which were the "ten regions"?

Great pumpkins!

Paul Levy said...

I'm not sure, but I think Don expands on this in an article with Atul Gawande.

e-Patient Dave said...

Trying to find that Gawande/Berwick article ... here's an August NYTimes op-ed with them, Dartmouth's Elliott Fisher, and Mark McLellan of Brookings Institute. It lists the ten regions but doesn't seem to list the 10 suggestions!

Jim Conway said...

Paul, thanks for the summary... I needed to be at another meeting. People can find out about the 10 communities and a lot more at

Best wishes, Jim Conway, IHI