PSP-One Hosts Dialogue with Dr. Donald Berwick, Institute for Health Care Improvement

Dr. Donald Berwick is President and CEO of the Institute for Healthcare Improvement, a nonprofit organization dedicated to accelerating the pace of improvement of the health care systems in the United States and Canada. Dr. Berwick is a leader in the field of quality improvement, and began championing its importance and writing about it as far back as the 1980s. He was recently appointed an honorary KBE (Knight Commander, Order of the British Empire) by HM Queen Elizabeth II in recognition of his “distinguished service to healthcare improvement in Britain’s National Health Service.” His writings include "Curing Health Care" (1990) and "New Rules: Regulation, Markets, and the Quality of American Health Care" (1996). Dr. Berwick has contributed to the issues surrounding improvement of quality by bringing to our attention innovative strategies for improving the health care system and making the process of receiving care safer for all of us. In June 2005, we asked Dr. Berwick to discuss the state of quality improvement in health today and to share his opinions with us.

Participate

Read this dialogue, and then send your own comments, questions, and other input to info@psp-one.com.

“Some is not a number. Soon is not a time. The number is 100,000. The time is now.”

Question: What led you to become interested in the field of quality assurance/quality improvement? Were there any significant people or events that influenced you to become interested in this field?

Dr. Berwick:
Convergence of Training
My training (medicine, public policy, decision theory, cost effective analysis, analytic techniques, and preventative medicine) fostered my interest in the field of quality assurance.

Work Experience
I worked in quality assurance in a large HMO and performance wasn’t improving. At that point, I became curious about how to accelerate change and not just measure quality.

Influential People
In the 1980s, I met several influential people that influenced my interest in the field. For example, Howard Hiatt, then Dean of Harvard School of Public Health, W. Edwards Deming, and Joseph Juran helped me through a several year period of learning and exploration. I also encountered others and we began learning together, which led to the John A. Hartford Foundation funding our first experiment and founding of our non-profit organization.

Question: What is significant that is happening now with regards to improving quality in the public sector?

Dr. Berwick:

Access to Data and Knowledge
Globally, we have access to more data and knowledge about issues in quality. It’s not enough, but we have increasing information about topics such as threats to patient’s safety.

Advocacy
In some countries there is a problem with the gap between science and practice. Also, in some countries, patient groups have become more active and are speaking out. At the leadership level, Dr. Lee, of WHO, has given focus to HIV/AIDS efforts.

Patient’s Safety
Sir Liam Donaldson, the Chief Medical Officer of the National Health Service in the UK, shepherded through a resolution at the World Health Assembly on patient’s safety, which helped establish the Global Alliance on Patient Safety. The Alliance is a very promising endeavor; over 160 countries have signed up to participate. Patient safety is a good place to start for improving quality.

Question: What do you feel have been the major achievements in the last 5-10 years in this field?

Dr. Berwick:
A major achievement in the United States has been the recognition of quality as a problem by the Institute of Medicine (IOM) (www.iom.edu). The fact that the IOM of the National Academies of Science, an objective, scientific body, took on quality was pivotal, and took quality from an advocacy issue to a scientific issue.

Measurement Systems
Development of measurement systems like HEDIS and the assessment programs of the Joint Commission on Accreditation of Healthcare Organizations are also major achievements in the field.

Successful Organizations
The emergence of successful organizations, like individual hospitals and clinics achieving results is also an achievement. Visit www.ihi.org to view success stories such as the work on medication safety at McLeod Regional Medical Center in South Carolina and Cincinnati Children’s Hospital Medical Center in Ohio efforts in transparency in patient outcomes.

Globally
Globally, a few countries, like the United Kingdom and their National Health Service, have made progress in quality. Also one county (Jönköping) in Sweden has made excellent progress. South Africa, Albania, and Vietnam are also making strides in quality. Dr. Rashad Massoud has worked to scale-up an improved approach to respiratory distress syndrome, pregnancy-induced hypertension, adult hypertension, and perinatal outcomes, in Russia that now covers almost half the Russian population. In Peru, Socios en Salud, an NGO related to Partners in Health, also developed a very successful program to improve Tuberculosis care. Bill Tierney of the Regenstrief Institute in Indianapolis has worked in Kenya on developing an electronic patient record system that works well in a limited resource setting.

Question: What do you see as the major issues and challenges facing the private sector (that is the private practitioner in solo or group practice or commercial networks) with regards to assurance quality of services provided?

Dr. Berwick:

Thinking in Systems Terms
You have to think in systems terms. There is always a tendency in any organization (public or private) to further sub-optimize individual projects and programs. Globally, systems thinking is important in connecting a community to a quality care system. Workforce development should also be viewed as a systems problem.

Cooperation
Cooperation is crucial, especially in countries where resources are already strained. The Ministry of Health may have one view of how national health care should be provided, and the private sector may have a different idea. We have to work across that boundary. It is especially important in countries where achieving continuity is difficult, because the Ministry of Health may be unstable or always changing.

Question: What are the major efforts underway that you think are most promising in the private sector?

Dr. Berwick:

Private Non-Profit Organizations
These types of organizations are beginning to view improving systems as an issue, like the Aga Khan Foundation’s work in Pakistan, which promotes community health in rural areas.

Ministries of Health
Ministries are struggling to find ways to keep their costs down and invest resources wisely. In this, there is a problem of inconsistency from differing donor strategies. In countries like Mozambique, Rwanda, South Africa, Peru, and Singapore, many of the Ministries of Health are trying to build systems but are stretched very thin and overworked.

Question:
What books, tools, or reports do you suggest every private sector health professional should have on his/her desk?

Dr. Berwick:
“Crossing the Quality Chasm,” an Institute of Medicine Report is an important resource for all health professionals. I believe it should be redone with a global focus.

• Crossing the Quality Chasm – A New Health System for the 21st Century, an Institute of Medicine Report (2001) available online at www.iom.com
• Gerald J. Langley, Kevin M. Nolan, Clifford L. Norman, Lloyd P. Provost, Thomas W. Nolan - The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (Jossey-Bass Business and Management Series, 1996).
• Chris Argyris - Overcoming Organizational Defenses: Facilitating Organizational Learning (Prentice Hall, 1990).
• Jim Collins - Good to Great: Why Some Companies Make the Leap... and Others Don't (Harper Business, 2001).

Question: What do you think are the most important steps that a health facility can take to improve quality in their facility?

Dr. Berwick:
Steps
I believe the classic steps a health facility can take to improve quality are to first decide what to improve by identifying things to make better, form teams to address what you want to make better, and get to work. It is important to give teams training and support in order to conduct successful projects. Don’t assume you know everything. Go and find an organization or place that is doing what you want to do, build on what they’ve done, and make it better.

Institute for Health Care Improvement Website
On our web site, we are building a global section where we list projects and organizations that are doing work in quality and safety.

Question: Are there particular US based organizations that are making progress in improving quality in their facility/network? If so, what specifically are they doing?

Dr. Berwick:
In Minnesota, the Mayo Clinic’s use of standardization as a mechanism to improve safety; the American mid-west, Ascension Health’s work to eliminate patient injury and death by 2008; Baptist Memorial Healthcare in Tennessee as members of the Innovation Community on Reducing Mortality Rates...you’ll see names that come up over and over again on our web site. The Veterans Health Administration, a government sponsored health system, has done great work.

Question: Where do you see the biggest mismatches between what is receiving funding and what should be receiving funding domestically?

Dr. Berwick:
Large Scale Measurement Systems
I believe there is too much investment domestically in development of large-scale measurement systems. The purpose of public health performance measurement has never been measurement for the sake of measurement. The intent is to gather information that is useful in improving public health practice and the purpose of measurement must be clear.

Technical Assistance
I believe we are under-invested in providing technical assistance for small and rural hospitals and physician practices. We need to be able to expend support to these hospitals and practices. Currently, we are relying on the private market and consultants to provide knowledge to the field. We need a federal technical assistance service, like the Agriculture Extension Service, that goes to rural hospitals, small physician practices, and midsize community hospitals to move knowledge into the field quickly on promising new methods and safe care, patient centered care, pain control, and cost control. We need to have the assistance standardized and face-to-face

Electronic Health Records
Another investment we should make is in developing a federally financed electronic health record system that is web based and can be accessed for free by medical personnel. The Veterans Health Administration and the Department of Defense have good electronic record systems.

Question: At a global level, what do we need to do to improve quality?

Dr. Berwick:
Learning World
I wrote an editorial for the British Medical Journal, Learning World for the Global Fund (BMJ 2002;325:55-56 (13 July ) about increasing the effectiveness of the Fund by creating and supporting a learning world, “in which skills, information, and designs for the continual improvement of the prevention and treatment of these diseases are freely exchanged and actively spread within and among all nations.” A “Learning World” has fellowships with leaders who can accelerate change, collaborative national and international improvement projects, design teams to find and invent better processes, and web-based global support systems to reduce the cost and increase the speed of learning.

Question: Professionals from around the world have gathered to meet at the Global Health Conference. What would you like to see as the principle quality-related messages or results coming from the conference?

Dr. Berwick:
Hope
The world needs hope. People need to feel it’s possible.

Scale Up
We need to elevate dignity and precision of methods to scale up. We need to approach scale up with a systematic method. For example, with smallpox, Dr. Bill Foege brought in new people from the field every month to discuss what worked and what didn’t work. This way, they never approached smallpox eradication in a particular area the same way and were successful in eradicating this terrible disease.

Method for Learning
The dominance of markets, accountability, assessments, standards, can be demoralizing unless you have a method for learning. Dr. Rashad Massoud wrote "An Approach to Rapid Scale-Up using HIV/AIDS Treatment and Care" as an Example for the WHO, and I authored "A Primer on Leading the Improvement of Systems" (BMJ 1996;312:619-622 (9 March) in an attempt to set out a technical method for learning.

Question: Who do you see as today’s crucial leaders in improving quality in the private or public health care field around the world?

Dr. Berwick:

• Sir Liam Donaldson, Chief Medical Officer, UK National Health System
• Dr. Paul Batalden, Director of Health Care Improvement Leadership Development in the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, USA
• Sven-Olof Karlsson, Göran Henriks, Mats Bojestig, Jönköping County, Sweden
• Sir John Oldham, United Kingdom
• Dr. Jaime Bayona and Rocío Sapag, <>Socios en Salud, Peru
• Dr. Paul Farmer, Partners in Health, USA (know for his unflagging efforts in Haiti).
• Dr. Jim Kim, The World Health Organization, Geneva and Partners in Health, USA

Question: Do you have any other comments that you would like to make?

Dr. Berwick:
IHI’s IMPACT is a membership network of optimistic and enterprising organizations committed to building a better future for health care. IMPACT hosts several informational calls outlining how to get involved in upcoming Learning Communities. To become a part of the calls, please dial 412-458-4600 to join.

Do you have a question for Dr. Berwick? If so, please email to info@psp-one.com and we will synthesize your questions for Dr. Berwick to respond. Thank you!