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The Road to Health Care Reform Is Paved with Missed Opportunities

What has really changed these past 15 to 20 years?

After reading Joe De Feo’s July 8, 2011, Quality Digest Daily article, “A Positive Prognosis: Transforming Health Care in America,” I took another look at the wonderful book, Escape Fire (Jossey-Bass, 2003), a compendium of Dr. Donald Berwick’s inspiring plenary speeches at the Institute for Healthcare Improvement’s (IHI) 1992–2002 annual forum. Berwick is probably the leading health care-improvement thinker in the world. He is the former CEO of IHI and, as some of you know, a controversial Obama appointee as head of the Centers for Medicare and Medicaid Administration. In my opinion, he is most definitely the person for the job. As if it wasn’t difficult enough to deal only with health care cultures, he now has the thankless job of integrating messy political agendas into the very serious business of health improvement.

But let’s get back to when all Berwick had to worry about was the current state of health care itself. I’ve extracted three lists that appeared in separate speeches of his and added context from his text. Note that the most recent one is from 1997. It’s all inspiring rhetoric, but truly, what has really changed these past 15 to 20 years?

I will not deny the nontrivial improvements cited by De Feo, but in the great scheme of things, it’s all a mere drop in the bucket. All it proves is if you put focused attention on anything, it improves. Regarding the alleged improvements, my experience is in line with Tripp Babbitt’s Jan. 4, 2011, Quality Digest Daily article, “That Giant Sucking Sound from Missed Opportunity”:

“Missed opportunities for improvement represent a 20–60 percent chunk carved out of the bottom line. Scores of programs and projects that claim improvement but never materialize in the financials are a travesty.”

Lest you think I sound cynical, I’ll let you draw your own conclusions as to how close the current state of health care is to what Berwick envisioned—sort of like the No Child Left Behind Act in education. It all seems so logical, but ask yourself: “Why the glacial progress on such basic issues?”

The following three excerpts are from Berwick’s speeches at the National Forum on Quality Improvement in Health Care, the annual forum of the IHI now in its 23rd year. 

From “Buckling Down to Change” (1993)

“Now, in health care, among the people at this Forum, we have made the needed preparations for change. Our preparations are sufficient. We have studied enough. We have reviewed our cultures enough. We have spent the time we needed, enough time, in training and planning and filling our kit with new and useful tools and methods. We know how. Now, we must remember why….

“I propose 11 aims for our work over the next two years—11 needed results that, if achieved, would represent the first solid steps toward the systemic change that is worthy of the name ‘health care reform’:

“1. Reduce the use of inappropriate surgery, hospital admissions, and diagnostic tests
2. Improve health status through reduction in underlying root causes of illness
3. Reduce cesarean section rates to below 10 percent without compromise in maternal or fetal outcomes
4. Reduce the use of unwanted and ineffective medical procedures at the end of life
5. Adopt simplified formularies and streamline pharmaceutical use
6. Increase the frequency with which patients participate in decision making about medical interventions
7. Decrease uninformative waiting of all type
8. Reduce inventory levels
9. Record only useful information only once
10. Reduce the total supply of high-technology medical and surgical care, and consolidate high-technology services into regional and communitywide centers
11. Reduce the racial gap in health status, beginning with infant mortality and low birth weight”

Two years, eh? 

From “Run to Space” (1995)

In my opinion this speech was his all-time best. Berwick applies an analogy of coaching grade-school girls’ soccer to improving medicine. In a thinly veiled poke at the medical world, he talks about his five strategies for motivating his “team” the Angels:

“1. I began with laissez-faire. Empowerment.

‘You’re professionals. You know what to do. Go for it.’

Angels 1, Pixies 4.

2. I elected to switch my strategy. Perhaps, I thought, these girls are not as motivated as I had initially believed. We need a results orientation.

I gave them feedback. When they scored a goal, I yelled from the sidelines, ‘You scored a goal! You scored a goal!’ When they missed, I yelled, ‘You missed! Next time, don’t miss!’

We lost.

3. No more Mr. Nice Guy.

We were in crisis. It was time for performance pay. No score, no cookies. Score: Hershey Bar.

Simple, direct, informative.

We lost.

4. The team rewards were of course insufficient motivation. Report cards became individualized. I posted the scores by individual players, protecting their anonymity, of course.

They insisted that I case-mix adjust the individual scores according to the competence of the other team, the weather, and so forth. I said, ‘You don’t get the point: We have to beat them no matter who they are.’

Angels 0, Gerbils 6.

5. Guidelines were the answer. The real problem was lack of standards for plays. We soon produced our first soccer guideline:

Do you have the ball? If not, get it. Shoot. Score.

We then lost again.

“Rebecca came up to me at halftime and said, ‘I’m sick of losing.’

“‘Oh, yeah?’ I said, sipping my cappuccino. ‘If you’re so sick of losing, why not win? I point out the scoreboard, I motivate, I make guidelines, I tell you pass-pass-pass-shoot. That’s my job.’

“‘You don’t get it. It doesn’t help me when you yell, “Pass-pass-pass-shoot.” You have to tell me how. How do you play soccer?’”


Berwick’s point? Leaders have to be able to coach on methods. These were his six ideas that represent the “appropriate foundations of design for the era of change that will be responsive to the new context of care:”
1. Reduce waste in all of its forms
2. Study and apply the principle of continuous flow
3. Reduce demand
4. Plot measurements related to aims over time
5. Match capacity to demand
6. Cooperate


How are we doing 16 years later? There has been lots of activity, but, impact—I mean real, deep, fundamental impact?  

From “Why the Vasa Sank” (1997)

Background: The Vasa was a Swedish warship built in 1628. It was supposed to be the grandest, largest, and most powerful warship of its time. King Gustavus Adolphus himself took a keen personal interest in it and insisted on an entire extra deck above the waterline to add to the majesty and comfort of the ship, and to make room for the 64 guns he wanted it to carry. This innovation went beyond the shipbuilder knowledge of the time—and would make it unstable. No one dared tell him. On its maiden voyage, it sailed less than a mile and sank to the bottom of Stockholm harbor.

“I want to see health care become world class,” said Berwick. “I want us to promise our patients and their families things that we have never before been able to promise them. I am not satisfied with what we give them today. And as much respect as I have for the stresses and demoralizing erosion of trust in our industry, I am getting tired of excuses.

“To get there we must become bold. We are never going to get there if timidity guides our aims. Marginal aims can be achieved with marginal change, but bold aims require bold changes. The managerial systems and culture that support progress at the world-class level don’t look like business as usual:
1. Bold aims, with tight deadlines
2. Improvement as the strategy
3. Signals and monitors—providing evidence of commitment to aim, giving visible evidence of strategy via management of monitors
4. Idealized designs
5. Insatiable curiosity and incessant search
6. Total relationships with customers
7. Redefining productivity and throughput
8. Understanding waste
9. Cooperation
10. Extreme levels of trust”

“The lesson about the Vasa is not about the risk of ambition. It is about the risk of ambition without change, ambition without method.”

Standing ovation, and we all say, “So true, so true,” then go back to work… and the phone rings….

Are any of the issues from these three speeches any less relevant today? Think about the last 14 years regarding quality improvement. Are quality professionals unwittingly helping their organizations get top-heavy regarding improvement? If progress is glacial, maybe organizations are perfectly designed to have it be glacial? How do quality improvement professionals need to change? How do they help organizations to change and not sink under an excruciatingly formal improvement process?

Have quality improvement professionals become all-too-willing accomplices in management’s efforts to change a culture by focusing on the structure, rewards, or roles and core competencies? It all seems so logical, but as those of us in quality improvement know, when human psychology is involved, logic is almost never persuasive.

I think Tripp Babbitt, in the same article quoted above, nails the real root cause of it all:

“It’s possible to discover new, counterintuitive truths, but focusing on process or traditional approaches to improvement won’t get you there. That giant sucking sound from the bottom line is the missed opportunity to address the big problem—management thinking.”

Maybe when we choose to stop building Vasas, we’ll see some real progress.


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