Escape Fire E-Book

Donald M. Berwick

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 497

Veröffentlichungsjahr: 2010

Beschreibung

Spanning a decade (1992-2002), these speeches echo the theme that our health care system needs fundamental change and a revolutionary new design. Throughout the book, Berwick identifies innovations and ideas from a number of surprising sources—a girls' soccer team, a sinking ship, and the safety standards at NASA. Escape Fire takes its title from the 1949 Mann Gulch tragedy in which thirteen young firefighters were trapped in a wildfire on a Montana hillside. The firefighter's leader, Wag Dodge, devised a creative solution for avoiding the encroaching fire. He burned a patch of grass and lay down in the middle of the scorched earth. His team refused to join him, and most perished in the fire. Dodge survived. Berwick applies the lessons learned from the catastrophe to our ailing health care system—we must not let ingrained processes obstruct life-saving innovation.

Not content to simply define the problems with our flawed system, Berwick outlines new designs and suggests practical tools for change: name the problem, build on success, take leaps of faith, look outside of the medical field, set aims, understand systems, make action lists, and—the most fundamental of all—never lose sight of the patient as the central figure.

Leseprobe

Table of Contents

Title Page

Copyright Page

Dedication

Preface

Acknowledgments

Introduction

Notes

Chapter 1 - Kevin Speaks

4 Annual National Forum on Quality Improvement in Health Care

Chapter 2 - Buckling Down to Change

5 Annual National Forum on Quality Improvement in Health Care

Chapter 3 - Quality Comes Home

6 Annual National Forum on Quality Improvement in Health Care

Chapter 4 - Run to Space

7 Annual National Forum on Quality Improvement in Health Care

Chapter 5 - Sauerkraut, Sobriety, and the Spread of Change

8 Annual National Forum on Quality Improvement in Health Care

Chapter 6 - Why the Vasa Sank

9 Annual National Forum on Quality Improvement in Health Care

Chapter 7 - Eagles and Weasels

10 Annual National Forum on Quality Improvement in Health Care

Chapter 8 - Escape Fire

11 Annual National Forum on Quality Improvement in Health Care

Chapter 9 - Dirty Words and Magic Spells

12 Annual National Forum on Quality Improvement in Health Care

Chapter 10 - Every Single One

13 Annual National Forum on Quality Improvement in Health Care

Chapter 11 - Plenty

14 Annual National Forum on Quality Improvement in Health Care

About the Author

About the Commentary Authors

Index

Donald M. Berwick

Introduction by Frank Davidoff, MD

Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Berwick, Donald M. (Donald Mark), 1946-

Escape fire: designs for the future of health care / Donald M. Berwick; introduction by FrankDavidoff. p. ; cm.

Keynote speeches presented at the annual National Forum on Quality Improvement in Health Care, 1992-2002.

Includes bibliographical references and index.

ISBN 0-7879-7217-7

1. Health care reform—United States. 2. Health services administration—United States. 3. Medical care—United States—Quality control. 4. Patient advocacy—United States.

[DNLM: 1. Delivery of Health Care—trends—United States—Collected Works. 2. Organizational Innovation—United States—Collected Works. 4. Quality of Health Care—trends—United States—Collected Works. W 84 AA1 B49e 2004] I. Institute for Healthcare Improvement. National Forum. II. Title

RA395.A3B47 2004

362.1’0425—dc22 2003021193

To Ann, with thanks, for love and courage

Preface

To read these eleven speeches in one sitting, as I have now done, makes me dizzy. They pass before me at a speed disrespectful of the difficult decade they mark.

When I gave the first speech in this collection, “Kevin Speaks,” in 1992 in front of sixteen hundred self-starting mavericks, the Institute for Healthcare Improvement was a young organization with a handful of employees, and health care had no quality movement at all. Ben, my oldest child, was a high school junior, and Becca, my youngest, was in first grade. (Ben is now a legislative aide on Capitol Hill and Becca is a high school senior.) Hillary Clinton was just about to try to rescue American health care. Avedis Donabedian and W. Edwards Deming were alive and well. So was my father. My family had not yet lived for a year in Alaska, or even imagined doing so. We were all healthy. I ran twenty miles a week, and my wife’s two years of devastating illness were far in the future. The European Forum on Quality Improvement in Health Care and the Asia Pacific Forum did not exist. The Institute of Medicine (IOM) had no quality-of-care agenda on its screen. My hair was full and black.

Ten years later I gave the last speech in this collection, “Plenty,” in a wholly different world. The National Forum on Quality Improvement in Health Care now had four thousand participants. A quality movement was expanding rapidly on at least three continents. The Institute for Healthcare Improvement employed seventy people and worked with more than four hundred faculty members worldwide. The 8th European Forum on Quality Improvement in Health Care—with one thousand participants from forty-three nations—lay just ahead, and the 2nd Asia Pacific Forum—with seven hundred people from twenty-three nations—lay just behind. So did September 11. Harry Potter had met Voldemort, and my wife, Ann, was in her long convalescence, walking and working again. Avedis Donabedian, W. Edwards Deming, and Philip Berwick, my father, had been laid to rest, each after a long and difficult illness full of compassion from their caregivers and defects in their care. The IOM had spoken, in To Err Is Human and Crossing the Quality Chasm: “Between the health care we have and the health care we could have lies not just a gap, but a chasm.” My right knee was totally blown and my jogging days were over. My hair had thinned and turned pure white.

With so much different, why do these speeches strike me as so repetitive? Metaphor after metaphor, list after list, story after story—but always the same. Year after year I can find only three messages at the core: focus on the suffering, build and use knowledge, and cooperate. There is no other suggestion in these pages—all else is fluff and padding, trying over and over again to make the signal comfortable enough to hear and eloquent enough to remember.

The words hide my impatience. Why is changing health care so hard?

Why don’t we yet remember more reliably that our work has no other raison d’être than to relieve pain? In “Kevin Speaks” I wrote, “We are not here so that our organizations survive; we are here so that Kevin survives.” Ten years later, recounting the story of a little girl, Alicia, who had cystic fibrosis, and her tireless father, Jim, I wrote, “We are here today for exactly—one reason—the same as Jim’s—to make Alicia’s senior prom night romantic.”

Why are science and practice still so far apart? In 1993 I wrote, “The commitment to improving the match between scientific knowledge and actual practice, the commitment to ‘appropriateness,’ must come from the professionals whose actions constitute care”; and in 2001, “We need to get serious about promising every patient the benefit of care that draws on the best knowledge available anywhere.”

Why do we continue trying to make great health care out of disconnected, separately perfected fragments instead of weaving the fabric of experience that our patients need from us? Kevin asked in 1992, “Do you ever talk to each other?” And a decade later I echoed him in my exhortation, “Cooperation is the highest professional value of all.”

Though frustrated, I do find comfort in Joseph Juran’s admonition, “The pace of change is majestic.” From that higher perspective, improved results for the vast majority of patients still seem elusive; but the optimist in me thinks that something momentous—something substantial, meaningful, and rational—may have, after all, begun. I do sense a movement—not fast enough yet, but maybe a little “majestic.” From a fringe collection of oddly placed provocateurs, the advocates of fundamentally changed health care have joined the mainstream. The IOM reports—To Err Is Human and Crossing the Quality Chasm—have chartered a whole new wave of scientifically grounded efforts to improve. A federal agency, the Agency for Healthcare Research and Quality (AHRQ), has changed its name to include “quality” and doubled its budget in pursuit of that aim. Big federal programs such as the Veterans Health Administration, the Bureau of Primary Health Care in the Health Resources and Services Administration, and Medicare have led the nation in embracing quality improvement aims. Patient safety, the cutting edge of quality, has front-page status. The Leapfrog Group—a progressive purchaser consortium in the United States—is trying to put quality criteria into health care contracting, making quality of care begin to seem like a serious business issue. Health care quality is now a major theme in medical literature, and both the Joint Commission Journal and the British Medical Journal Publishing Group’s journal Quality and Safety in Health Care are completely devoted to the issue. Training and residency programs are beginning to include quality and improvement in their required curricula for medical students. The National Health Service in the United Kingdom has established the Modernisation Agency, which now has eight hundred employees and massive improvement agendas, and is in the midst of the largest single-system improvement effort ever undertaken in any industry. Australia, New Zealand, and much of Scandinavia have all begun to place improvement of care at the center of their government-sponsored systems. The World Health Organization now has a chartering policy statement on patient safety from its 2002 World Health Assembly.

The change is preadolescent but massive. These eleven speeches punctuate a decade of stage setting, a getting-ready-to-change that in 1992 I could not even have begun to imagine. It would have seemed crazy even to hope for it.

Eleven National Forum speeches from now, how different will the message be? Now I can hope even more, without feeling crazy. The pedal point will be the same, of course: help people—every single person; use knowledge—all the knowledge; work together—cooperate, above all else. But maybe our hard work on these themes will at last have paid off so that new themes can also emerge out of results won, problems solved, and sensemaking returned.

In 2012—twenty years after “Kevin Speaks”—will a National Forum keynote speaker be fortunate enough to say that millions upon millions of patients—Kevin’s successors—are safer, in less pain, more honored in their values and choices, wasting less time and money, and more confident in the reliability and gentleness of their care? Will we live longer and die less lonely and less afraid? Will we be able to celebrate that our health care remembers us in continuity, through our lives and across our communities, achieving well-being for populations as its measure of success rather than counting fragments and calling that “productivity”? Will we have replaced nineteenth-century information systems with twenty-first-century ones? Will we have restored joy in work for all professionals and staff, and be unembarrassed to say so? Will our young people, learning their craft, feel the highest sense of honor and delight in their choice of profession? Will we have come to think truly globally about the health we seek—for everyone—for all races, for all regions, for all nations?

Eleven speeches . . . a decade of change . . . a challenge defined ... a movement well begun. Now, I’d say, things get really interesting.

September 2003

Donald M. Berwick, MD, MPP Boston, Massachusetts

Acknowledgments

The abundance I have found in colleagues and teachers awes me. At a very deep level, these speeches contain nothing original from me; they are more accurately recitations of lessons learned from others. The hundreds who have helped me will, I hope, excuse my mentioning by name only a few of the most central players in the phase of my career that this collection spans. Whatever expertise in technical improvement is mine comes from the patient and personal instruction of a generous, world-class varsity, including, among many others, Blan Godfrey, Kevin Nolan, Lloyd Provost, Jerry Langley, Ron Moen, Paul Plsek, Bob King, Ray Carey, Bob Lloyd, Jim Reason, Avedis Donabedian, Shan Cretin, Jim Reinertsen, and Brian Jarman. At greater distance, but deeply influential, have been W. Edwards Deming and Joseph Juran. In more recent years, Tom Nolan in particular has become, to my delight and honor, my major mentor and honest critic; it is remarkable to me how much I hear Tom’s voice and ideas reflected in my own speeches.

Just as important in shaping my thinking have been my friends and colleagues on the founding board of the Institute for Healthcare Improvement (IHI): Paul Batalden, Dave Gustafson, Jim Schlosser, Vin Sahney, Jim Bakken, Gene Nelson, and Jim Roberts. Successive IHI board members have provided an endless supply of wise guidance and skill-building: Heinz Galli, David Lawrence, Louise Liang, Ellen Gaucher, Judy Miller, Gayle Capozzalo, Bob Waller, Rick Norling, Martin Harris, Ruby Hearn, Howard Hiatt, Aleta Holub Belletete, David Leach, Gary Mecklenburg, Rudy Pierce, Sister Mary Jean Ryan, Sheila Ryan, Pete Velez, Gail Warden, and Mike Wood. My very career, and the existence of the IHI, can be traced directly to two of these people, both advisers and close friends: Howard Hiatt, who has guided and influenced my work more than any other single individual in my entire life, and Paul Batalden, whose vision and wisdom inform me every day.

Both senior IHI faculty and many colleagues in other countries have added scope to my knowledge, including Laura Adams, Helen Bevan, David Fillingham, Dean Lea, Margareta Palmberg, Wim Schellekens, Richard Smith, and Ross Wilson.

The managers and staff of the IHI provide me with the support and encouragement without which none of my current work, including this book, would be possible. Penny Carver, Carol Haraden, Pat Rutherford, Jonathan Small, Tom Novak, Andrea Kabcenell, and Joanne Healy make up our executive team, and not one of us, least of all me, would have a fraction of our success in hand without the incomparable, wise, optimistic, and patient leadership of Maureen Bisognano—executive vice president and chief operating officer of the IHI and my soul mate, adviser, and comrade in arms.

These speeches, and much of my latter-day writing, have been lovingly and meticulously edited and improved by an IHI publications team whose generosity and competence set a whole new standard for such work: Frank Davidoff, Jane Roessner, and Val Weber. This book is theirs as much as it is mine, except for its defects, which I own.

To my friends Judi and Ken Greenberg—and to their children, Laura, Amy, and Lisa—I owe thanks for the many evenings and long trail hikes over the years, during which they tolerated, with only mild derision, my draft-quality ideas and improved them by thinking with me.

Finally, I thank my family. My children—Ben, Dan, Jessica, and Becca, from whom I have learned what is important and what is not, have played many roles in these speeches. Not always delighted to do so, they appear over and over again as metaphors and examples—soccer players, health care volunteers, wilderness hikers, and always learners—enriching my stories as they enrich my life.

Above all, I thank my wife, Ann, who after all is said and done is by far my best teacher, closest friend, and strongest support. What is not evident to the reader is my debt to Ann and the kids in the hours and hours and days and days of distraction and travel that these speeches represent—precious time borrowed and stolen from the family, testing their patience and drawing on their generosity. They, and I, can only hope that the price we have paid in time lost together will be returned in good measure through whatever impact this book, these speeches, and the work they summarize can have on the future burden of illness for us, for those we love, and for countless others whom we will never know.

Introduction

Frank Davidoff, MD

Don Berwick preaches revolution.

He might not put it quite that way himself—although by his own reckoning he has become increasingly “radicalized” in recent years about the shortcomings of health care. But as the speeches collected in this volume testify, his assessment of the scope and nature of health care’s ills and his vision of what health care can and should be are nothing short of revolutionary; nonviolent revolution, to be sure; velvet revolution, perhaps; but revolution nevertheless.

What’s he trying to overthrow? His target is a health care system that has evolved primarily to serve the needs and interests of those who work in the system—doctors, nurses, administrators, payers, insurers—rather than the needs and interests of patients. To make matters worse, it’s a system (at least in the United States) increasingly caught up in the need to realize investor profits. It’s a system characterized by many ills, including ineffectiveness, waste, inefficiency, unnecessary waiting, disorganization, self-interest, harm to patients, disrespect, inequity. In effect, it’s a stupid system. Indeed, these speeches make the case that the present state of health care is sufficiently bad that tinkering around the edges is a recipe for failure; only fundamental change—revolution of a kind—will do the job. Berwick’s target is definitely not people—neither individual people nor groups or classes of people. On the contrary, his fundamental assumption is that most people who work in the system are smart, dedicated, caring, good people; their frustration as they try to help their scared, hurting patients get better, or get along, in a stupid system is a national, and international, tragedy.

How does Berwick advocate changing the system? All of the speeches in this book reflect three important aspects of Berwick’s revolutionary posture. First, he’s positive. In his landmark 1989 article, “Continuous Improvement as an Ideal in Health Care,”1 Berwick turned quality improvement in medicine on its ear by exposing fundamental flaws in the then-current “blame” approach (getting rid of the “bad apples,” the outliers at the extremes of the performance curve) and shifting to a process of continuous learning from errors (“every defect is a treasure,” moving the entire performance curve upward), as had been happening for years outside of medicine. Ever since then he has been passionate about the need to avoid blame and to maintain hope, even as he lays out the challenge of confronting medical care’s ugly realities and doing something effective about them—not an easy balancing act. Second, he recognizes that even at its biological best, medicine is always—always—a social act; he understands that changing the system requires fundamental changes in the network of human interactions that drive it—in effect, new and better organization, new and better communication, and new and better system management, at many different levels. Third, he’s action oriented; he both expects performance and offers tools for getting it.

What are those tools? Here are some of the most noteworthy:

• Name the problem. “Dirty Words and Magic Spells” reflects on the power of accepting reality, of facing up to just how big, how ubiquitous, and how damaging the problems in the health care system really are, and on the power of language—for better or for worse—in defining that reality. (This is not unlike the essential first step in recovery from substance abuse—accepting that you have a problem and that it’s gotten out of control.)

• Build on successes. We hear about them over and over—for example, the 90 percent reduction in inappropriate use of ICU bed days in one year at York Hospital, and the 50 percent reduction in emergency room waiting time at St. Joseph’s Mercy Hospital—in “Why the Vasa Sank.”

• Take leaps of faith. Curing childhood leukemia, long seen as “impossible,” happened because some very smart, hardworking people had the courage and imagination to think it wasn’t impossible (see “Eagles and Weasels”).

• Look outside medicine. Medicine can take important lessons from the experiences of General Motors, Canon, General Electric, Alcoa, the airline industry, the Swedish navy, the U.S. Forest Service, and coaching girls soccer, not to mention serious wilderness hiking (see “Run to Space” and “Why the Vasa Sank”)—and it needs to stop pretending it’s unique and has nothing to learn from those outside.

• Set aims and show constancy of purpose. Define explicitly where you want to go and when you want to get there, and stick to those goals. These are crucial tasks, and harder to do than they look (see “Buckling Down to Change”).

• Understand systems. It’s not enough to listen well, motivate people, and give them feedback; you also have to understand, explicitly and in detail, how systems work (such as the hierarchy of health care system levels described in “Every Single One”), what it takes to prevent them from collapsing under stress (such as sensemaking through improvisation, virtual role systems, attitude of wisdom, and respectful interaction, described in “Escape Fire”), and how to catalyze the diffusion of innovations within systems (see Berwick’s rules in “Sauerkraut, Sobriety, and the Spread of Change”)—and leaders can’t delegate this understanding.

• Make action lists. The speeches included here are full of them. For example, in “Run to Space” we have the following:

1. Reduce waste in all 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.

Such lists belong on the walls of health care organizations, in their daily meetings and talks, and in the consciousness of everyone who works in health care.

• Never—ever—lose sight of the patient as the central figure. Making patients and their families truly the force that drives everything else in health care is perhaps the most revolutionary tool of all. Its importance is evident at the system level (see “Every Single One”), but it comes through even more strongly at the personal level (see “Kevin Speaks,” “Quality Comes Home,” “Escape Fire,” and “Dirty Words and Magic Spells”).

Why publish these speeches, and why now? Speeches often don’t make good reading, for many reasons. First, the rhetoric of speeches is fundamentally different from that of printed text: Verba volent, scripta manent—spoken words fly away, written words remain. Because readers can go back over printed text as often as they want, important messages need be stated only once. In contrast, speakers need to underscore key points by repeating them many times and in many ways, which can get in the way in written text. Second, the contexts of the two media are different—the medium really is the message. Speeches are real-time social events, and speakers connect directly and immediately with their audiences. Moreover, keynote speeches, such as the ones in this volume, are designed to set the tone for particular meetings and rally the audience to the work at hand. In contrast, print is passive, generic, nonliving; it puts distance, in both time and space, between authors and readers, which can drain the life out of a speech. Third, the audience hears only one speech at a time, so each speech has to stand on its own; publishing all of them together (they’re published here almost exactly as they were delivered live) can result in unintended redundancy.

That said, the speeches in this volume have a kind of coherence and energy that translates well to the printed page, which is why several of them have already appeared (slightly edited, to be sure) in print (“Buckling Down to Change” was published in JAMA as “Eleven Worthy Aims for Clinical Leadership of Health System Reform”2; “Quality Comes Home” was published in the Annals of Internal Medicine3; “Escape Fire” was published by the Commonwealth Fund4; and “Sauerkraut, Sobriety, and the Spread of Change” was published as “Disseminating Innovations in Health Care” in JAMA5). Besides, people who have heard the speeches live, and others who have heard about them, keep asking for copies. They are telling us that these speeches are helpful to them in the never-ending tasks of setting the tone, rallying people to the cause, and giving people the tools for improvement. Finally, having all the speeches available together makes it possible to examine the trajectory of improvement in medicine over a decade of intense and rapidly developing work, and allows the intrinsic synergy among the speeches to emerge—in fact, not all redundancy is bad, as advertisers and politicians understand very well.

What don’t the speeches deal with? First, apart from a few passing references (such as to excessive cesarean section rates, inadequate use of risk-reducing medications following myocardial infarction, and inappropriate use of antibiotics), the speeches touch very little on purely clinical, “bedside” issues. This may be because clinical decisions are made between individual patients and their providers, and Berwick is concerned primarily with addressing problems at the systems level. Second, the speeches don’t deal head on with a related and difficult problem: the reality of the few people working in health care who aren’t up to the job—those who can’t judge their limits, others who aren’t caring people, still others who are fundamentally disorganized or incompetent, and the very few who are mean-spirited, malicious, or otherwise out of control. The problems created by these people clearly present important challenges for health care, but they’re primarily problems with individual people, and although they need serious attention, they very likely require an approach different from, albeit complementary to, system-level interventions. Third, although the intensely positive focus of the speeches is an important part of their effectiveness, they tend to avoid the dark side of improvement work: the barriers to change, the deep sources of resistance to improvement (such as the shame that blossoms in response to the criticism of past performance that is implicit in improvement efforts), the hypertrophied autonomy needs of health care providers, the irrational but locked-in malpractice litigation system, and the perverse financial incentives. Berwick’s message is clear in this regard, however: the “blame game” hasn’t fixed a stupid system, hence we need to continue avoiding blame, rewarding success, providing hope, and infusing energy.

One of the most important messages of these speeches is that meaningful improvement work depends on collective wisdom—the kind of new meaning, new mental models, and new insights that grow out of true, ongoing dialogue (the word dialogue comes from Greek roots: “the meaning flows through”). Much of the power of these speeches comes from Berwick’s ability to link ideas spread across wildly different domains, to synthesize ideas that have developed within a huge network of like-minded but widely scattered people, to harness them into a shared vision, and to create a set of working tools for change. By adding large measures of personal energy, passion, and eloquence, Berwick helps listeners, and now readers, to carry the vision, and the tools, around in their heads rather than leave them behind in the lecture hall, or on the page.

Have these speeches changed anything for the better in health care? We don’t know now and probably never will, but it’s a good bet that they have. Indeed, it’s just possible that fifty years from now people will look back and say that Don Berwick’s keynote speeches from the 1990s provided one of the sparks that helped set off the revolution in health care. Whether or not that’s the future view, these speeches make extraordinarily good reading right now. We know that no one who reads all eleven of them will fail to learn a lot, we doubt that any reader will fail to be entertained, and we challenge any reader to get through all eleven without being deeply moved—perhaps even to the point of personally mounting the improvement barricades.

Notes

1 Berwick, D. M. “Continuous Improvement as an Ideal in Health Care.” New England Journal of Medicine, 1989, 320(1), 53-56.

2 Berwick, D. M. “Eleven Worthy Aims for Clinical Leadership of Health System Reform.” JAMA, 1994, 272, 797-802.

3 Berwick, D. M. “Quality Comes Home.” Annals of Internal Medicine, 1996, 125, 839-843.

4 Berwick, D. M. “Escape Fire.” New York: The Commonwealth Fund, 2002.

5 Berwick, D. M. “Disseminating Innovations in Health Care.” JAMA, 2003, 289, 1969-1975.

1

Kevin Speaks

Commentary

Susan Edgman- Levitan

Ten years ago, Donald Berwick made an eloquent plea that we should listen to the words of those we serve—our patients and their families. He was right. None of us in health care would have work, do research, teach, or do all of the other things we love without them. Yet serve is probably not the right word. Used might be a better term for what patients and their families feel about how we care for and interact with them.

The Institute of Medicine has defined eight dimensions of patient-centered care in its report, Crossing the Quality Chasm: access to care, respect for patients’ preferences, information and education, coordination of care, emotional support, physical comfort, involvement of family and friends, and transition and continuity. These are the most important aspects of care, according to patients and their families.

Has anything changed for patients in this regard since Donald Berwick first told us about the requests of a young patient named Kevin? A few things have improved, including the following: