Donald Berwick

Donald Berwick, M.D.,  former head of the Centers for Medicare & Medicaid Services and now a senior fellow with the Institute of Healthcare Improvement, got a lot of attention with his recent remarks about the wide gap between what health care is and what it could and should be.

He identified two modern eras in modern medicine:  Science, discovery and the trusted doctor captaining the care team defined the first era. The  current, and in some ways, psychologically harsher era can be defined by accountability, measurement, control and punishment.  Dr. Berwick believes that we’re overdo for a third era that puts together the best of  Eras 1 and 2.

Dr. Berwick offers healthcare leaders nine steps to begin to move into what he calls “the moral era” of medicine:

1. “Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find  {a certain patient in need} in that glare. I vote for a 50 percent reduction in all metrics currently being used.
2. “Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
3. “Decrease focus on finance: This could be impossible. I feel naïve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? … If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
4. “Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
5. “Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process-control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
6. “Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
7. “Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient — these are not funny.
8. “Listen. Really listen: These terms — co-production, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
9. “Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.”