Tuesday, December 08, 2009

Berwick at the National Forum

#IHI09 Don Berwick's opening address is always a highlight of the IHI National Forum, and with good reason. He not only presents the latest and best about quality and safety improvements but also places those advances in the context of the broader health care environment.

Much of today's talk was about how to overcome the "tragedy of the commons", the natural inclination of people to ignore the externalities associated with their actions. The original formulation of this was set forth by Garret Hardin, using the example of overusing a common grazing area.

Don noted,

Like the villagers, rational health care stakeholders are eroding the common good simply by doing what makes sense to each of them – separately. In the short term, we each win. But, in the long term, we all lose. We lose the Triple Aim: better care for individuals, better health for populations, and lower per capita cost, all at once.

Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ group – every single one of them says, “Oh, we need change! We need change!” But, when it comes to specifics, every single one of them demands to be kept whole or made better off. “Don’t stop my sheep; stop his.” So everybody draws on the Commons, the herds grow, and the Commons fails. If you don’t increase your herd, you’re a chump. And, who wants to be a chump?

Drawing on the work of Elinor Ostrom, Don stated the necessary conditions to offset those inclinations in a community of interest and pushed the attendees to action:

Here is my challenge. I challenge us to end the Tragedy of the Commons in health care. I challenge us to prove Garrett Hardin wrong.

It isn’t easy. Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.

But, I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, “What can I do from my limited perch to govern the Commons better? I’m already over my head.”

I am really not sure. But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day, and Elinor Ostrom’s brilliant explorations suggest that, in many contexts, higher authorities simply can’t do the job. Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds.... But, the odds of real reform, “re-form,” remain zero – the Commons is doomed – unless the action is closer to home – closer to you. So, drawing on Elinor Ostrom’s work, here’s are some ideas to start chewing on:

1. Understand your health care Commons. Understand its limits and boundaries. Understand who can and does draw upon the common pool of resource, and who it serves.

2. Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters....

3. Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself. One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.

4. Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them.

5. And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.

6. Identify and address conflicts early, often, and with confidence. Conflicts will be frequent and legitimate, and they will demand wisdom. The social capital – the commitment to protect the Commons – has got to trump these conflicts.

7. Expect and offer civility. This is the foundational transactional rule for effective, collaborative management of what we hold in trust.... Respect is a precondition.

He closed with this thought:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?


Michael Kirsch, M.D. said...

The power of inertia and entrenchment is stronger than the will to change and reform. As pointed out in your fine post, all of the stakeholders are in a circular tug of war. They fear that this a zero sum game, and that some constituency's gain will be at their expense. Powerful group have opposing interests and will defend them zealously. Even individual stakeholders (e.g. physicians, the public) are not homogeneous and have internal divisions. Everyone readily acknowledges that sacrifice is needed, as long as someone else is doing it. While Berwick offers a somewhat utopian view, I expect that it will be a very rough slog. www.MDWhistleblower.blogpspot.com

Sarah Fraser said...

As often is, the proof of the theory is in walking the talk. Right now at the conference we have our own tragedy of the commons. The wireless access user limit has been surpassed. Although IHI has worked brilliantly well (well done Blue shorts) to increase capacity, not everyone will get access.

So, who and how many are prepared to come off their wireless link so the commons can get a look in?

Change starts here. One person at a time.

Keith said...

I will remind you that an ever larger piece of the pie has gone to hospital administrators and CEO's over the past years as hospitals have been increasingly run as non profit buisineses with an emphasis on the buisiness side of medicine. It is hard to rally the troops to your cause when the CEO salary is 20 times that of a nurse or 10 times that of a primary care physician. It seems we constantly hear how important team effort is from our corporate leaders, but when bonus time comes, the hospital upper echelon not suprisingly finds their value to the organization to be of the greatest importance unsuprisingly. Nursing and staff are given a nice momento for their hard work (usually some item splashed with the corpoarte logo).

I find Mr. Spears' quotes to be spot on, but then it behoves hospital CEO's to stop demanding and accepting such outsized pay, which only serves to feed this mentality of grab what you can while the getting is good. After all, isn't that what the CEO is doing when he/she is so richly rewarded? And then to discover some of your fellow CEO's that double dip on corporate boards of health care companies that they do buisiness with adds to the outrage.

The fact of the matter is that when CEO's are confronted with this, they point to their counterparts on the for profit side claiming they are underpaid in comparison! This is exactly what Mr. Spears is speaking out against!

It is up to you at the top of the pyramid to break this cycle if you truly believe what you have quoted. How about someone setting an example of ethical behavior and actually setting goals of health care delivery to the impoverished of their community rather than hospital financial performance, which is the usual measure of CEO success. Do you not, after all, manage a non profit buisiness with a stated mission? I bet it says nothing in the mission about maximization of profit!

leanne berge said...

I found this post quite inspiring and worth saving and re-reading so that I can be reminded of the guiding principles for action that have not only an idealistic quality but a basic concrete benefit to us all. Thanks for sharing.

Engineer on Medicare said...

The government seems to have decided that a substantial level of health care is an entitlement, and that we are spending too much of GDP for it. The only way that we can even approach a solution to that equation is to ration health care, and find the least expensive way to deliver whatever level the country can or will provide.

Since the government is going to be the payer for more than 50% if the population, and will have a hand in the rationing, the only fair way is to put rationing on the same basis for EVERYONE, from the homeless person living under the bridge to every member of congress and including the CEO of every health care provider. The rationing rules should be totally transparent and there should be no exceptions.

If the government is going to require that health payers accept all comers regardless of preconditions, then they should take the actuarial risk. Using the principle that he who has the gold makes the rules, the government should pay for it. Why should there be an insurance company if the actuarial risk is all borne by the government?

Michael Kirsch, M.D. said...

We'd all like every human being on the planet, not only in our own country, to have Cadillac medical care. This is not reality. I am troubled by the comment: "the only fair way is to put rationing on the same basis for EVERYONE..." Are you suggesting that every individual has an equal right to the same degree of health care?

Anonymous said...

Dr. Kirsch;

I am puzzled by your question. Are you suggesting that every individual does NOT have an equal right to the same degree of health care?

Keep in mind, I ask this question contingent upon Engineer on Medicare's assumption that health care is now an "entitlement." There is, of course, disagreement as to whether health care is a right (entitlement) or not. But, if one decides that it is a right, then some people have more rights than others? (and if it is a right, then it should not be employer-based, I would assume).

nonlocal MD

Michael Kirsch, M.D. said...

I think we should strive for a system that gives everyone access to decent health care. If an individual wants to purchase a higher level of care, he should be free to do so. Is health care a right or a societal goal? I struggle with this issue. See http://bit.ly/3JMqV

Engineer on Medicare said...

Congress and the President seem to be saying that all of the people deserve to have health insurance and health care, paid for by the government if necessary. They also seem to be saying, or it is implied by the concept, that there will have to be rationing because the system can't deliver the same care to all and can't do it for the same fraction of GDP.

Now if there is going to be rationing, someone has to decide who gets less and who gets more.

The implied promise to me as a contributor to Medicare for as long as it has existed is at least as valid as the "implied" but not written contracts with the government affiliated mortgage agencies that went belly-up. If congress is going to impose rationing on me, then they should be restricted to the same standard.

Anonymous said...

Personally, I would agree that an individual should be free to purchase a higher level of care, just as he is free to waste his money on a Mercedes as opposed to a minivan. (:) But I would oppose any one group being automatically given a higher level by their exalted position, such as being a member of Congress. I understand that there is a specific provision in the health care bill exempting Congress from having to have the same care as others (I am unsure as to the exact provisions, but it basically ensures they retain their Cadillac plan). This, I think, is the unfairness to which Engineer refers, and I concur.

As to the right vs. societal goal, I share your struggle.


Anonymous said...

Keith's comments on hospital CEO salary does force some real soul searching for Paul Levy and others in leadership positions with salaries over $1M. Isnt CEO salary part of the commons? As Don Berwick said "it is all your money...just trace it back". The tragedy of the commons is that we are still fighting for our piece of the pie while so many in our community have inequitable care.
Let's really talk transparency.

Paul Levy said...

I have been totally open about my salary and benefits and the process by which they are set. Look here: http://runningahospital.blogspot.com/2007/01/do-i-get-paid-too-much.html

Is there something more you have in mind when you suggest transparency?