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?