In the health overhaul debate, most of the focus has been on cutting costs and finding the money to cover the uninsured. But often lost in the legislative tussling is a third, just as important goal: Improving the quality of care.
Dr. Donald Berwick, an internationally-known health care quality and patient safety expert, is working to make sure that doesn’t happen.
As co-founder, president and CEO of the Institute for Healthcare Improvement, Berwick for two decades has been both a bit of a nag and an inspirational leader encouraging front-line health workers and health care leaders to make changes to reduce hospital deaths and complications as well as making health systems more efficient.
The Cambridge, Mass.-based nonprofit partners with hospitals and other health care organizations worldwide to accelerate efforts to improve quality. It is funded largely through major health foundations, including The Robert Wood Johnson Foundation and health companies including Kaiser Permanente. In the past four years, IHI has organized major campaigns to get hospitals to adopt simple steps to cut preventable deaths and injuries. More than 4,000 hospitals have taken part.
Berwick, 63, has been a big promoter of efforts to reduce hospital infections, revamp the Medicare payment system to produce better patient outcomes and make public information on hospitals and doctor performance.
Berwick recently sat down with KHN’s Phil Galewitz to discuss progress, obstacles and health care overhaul. Here is the edited interview:
Q: Why is it so difficult to improve the quality of health care and get hospitals and physicians to adopt practices that have been proven to improve care?
A: Hospitals and health care systems are making phenomenal strides in quality and my optimism is very high. But the structures are still broken. We have fragmented payment systems and fragmented institutional boundaries. The enemy is fragmentation. We just don’t seem to form into the coalitions, the communities we need to make progress. Until we fix structures and finance it is going to be very hard to make fast progress.
Q: How do you see the health overhaul affecting the movement to improve quality?
A: I see in the (congressional) bills potentially very helpful changes — investments in better data and better research so we understand the comparative performance of different health care systems and clinical care. There’s lot of demonstration money for projects for integrative systems all over our country in many different locales.
Q: Has the concept of transparency – publicizing information on the comparative performances of hospitals, doctors and other providers — improved quality?
A: We really haven’t tried it. We have made progress to transparency. I have become a bit of an extremist on this. I think we have to really turn the lights on in the system. My main interest in that is for learning. I know there is variability in performance in health care around the country — individual physicians, hospitals and health systems vary tremendously in what they do, how they approach care, how they use resources and what results they get. That means we can learn….Without transparency, learning is really stymied.
Q: Are patients using the data to shop for doctors, hospitals or health plans?
A: I see transparency working at three levels, and in some ways, the patient level is weakest. The strongest lever is learning — that if I can find out who has the lowest mortality rate for cardiac surgery or the shortest waiting times, I can go learn from them.
The second level (on which transparency) works is the super-egos of those who give the care. They all want to do well and not want to see themselves at bottom of some list of performers and that is a tremendously powerful lever. I do not believe the fundamental dynamic through which improvement occurs through transparency is the public making its choices. I don’t think that’s the way it happens.
Q: What do you think of the transparency efforts in the House and Senate health reform bills — including publishing hospital infection rates and making public and penalizing hospitals with the highest readmission rates?
A: Being aware of variation in infection rates is going to stir the super-egos of the system quite a bit and I hope the public gets a bit outraged and mobilized as voters ask why we pay systems the amount of money we are and not have them adopt the best practices.
The penalizing is edgy stuff. I do think we need to create more and more consequences for good and bad performance but we need to learn our way into that because if we get that wrong we get into a gaming of the system which we an ill afford and we will frighten a system into defensiveness instead of stimulating it into progress.
Q: In July, you helped bring together health care providers from 10 communities who were holding down costs and providing high quality care: Tallahassee, Fla; Sayre, Pa; Sacramento, Calif.; Cedar Rapids, Iowa; Portland, Maine; Asheville, N.C.; Temple, Texas; Richmond, Va.; Everett, Wash. and La Crosse, Wisc. What did you learn?
A: They are all really, really inspiring. They are solving the problem. If every community in America looked like those ten, we would be done, health care would be affordable and of high enough quality in our country. What are they doing? I don’t think we know yet. But one hallmark is there is cooperation. They are cooperating at the local level – hospitals, physicians and other resources and payers are coming together and putting limits on system and doing the best with what they have and have a commitment not to harm any patients, but not to be so (wasteful) in ways of spending public funds.
Q: What can these types of communities get out of the health reform bills?
A: First, they need not to be stopped. I am a little bit worried if we get reform wrong, some of these creative coalitions and new structures could be impeded by mistakes in legislation.
They need encouragement to cooperate. Bundling payments, offering payments for outcomes and value by some definition will help. We need to stop paying for volume. That is the key. We have to stop paying for (volume) and start paying for the results we want which is health and safety and good outcomes for our patients.
Q: With health overhaul legislation moving forward, how are you feeling about major changes coming to our health system?
A: It’s a pretty exciting time. It’s time to commit to justice and that means universal coverage. We have got to go there. It’s embarrassing that we have not gone there. So that is job No. 1. But to do that simply by funding existing systems is a formula for a spiral we can’t endure. We have to restructure care and the system.
Can we do that from Capitol Hill and the White House? No. We can encourage it, we can support it, we can set some goals out at a price we can afford. But eventually this is going to devolve back to communities…only they can execute the changes and care structures that we really need. It could be an exciting time as we watch the mobilization of change at the level which change has to happen.
Related KHN story: Revolving-Door Patients Illustrate Health System Flaws (Kenen, 6/30)
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