Promising Care E-Book

Donald M. Berwick

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Jossey-Bass Public Health/Health Services Text
• Sprache: Englisch

Seitenzahl: 546

Veröffentlichungsjahr: 2013

Beschreibung

Promising Care: How We Can Rescue Health Care by Improving It collects 16 speeches given over a period of 10 years by Donald M. Berwick, an internationally acclaimed champion of health care improvement throughout the course of his long and storied career as a physician, health care educator and policy expert, leader of the Institute for Healthcare Improvement (IHI), and administrator of the Centers for Medicare & Medicaid Services. These landmark speeches (including all of Berwick's speeches delivered at IHI's annual National Forum on Quality Improvement in Health Care from 2003 to 2012) clearly show why our medical systems don't reliably contribute to our overall health. As a remedy he offers a vision for making our systems better — safer, more effective, more efficient, and more humane.

Each of Berwick's compelling speeches is preceded by a brief commentary by a prominent figure in health care, policy, or politics who has a unique connection to that particular speech. Contributors include such notables as Tom Daschle, Paul Batalden, and Lord Nigel Crisp. Their commentaries reflect on how it felt to hear the speech in the context in which it was delivered, and assess its relevance in today's health care environment. The introduction is by Maureen Bisognano, CEO of Institute for Healthcare Improvement, and author of Pursuing the Triple Aim.

Praise for previous books by Don Berwick

Curing Health Care:

"The book is an easy and affirming read for anyone who is familiar with and has used the TQM teachings of Dr. Joseph M. Juran and Dr. W. Edwards Deming and would be a simple and informative introduction to the concepts for anyone who has been hearing about TQM but has no idea what it is all about and wants to know more."
—Permanent Fixes (blog)

"Donald Berwick is the most clearly heard evangelist of applying industrial methods of continuous quality improvement in health care."
—Annals of Internal Medicine

Escape Fire:

"With an effective blend of common sense, real-life stories, persuasive metaphors, and out-of-the-box thinking, Dr. Berwick's presentations make for fascinating reading for anyone interested in improving America's $1.7 trillion health care system."
—Piper Report

"Anyone interested in change in the healthcare system would enjoy this book. In degree programs, the various speeches would be useful for discussion in a health policy readings course."
—The Annals of Pharmacotherapy

Leseprobe

Table of Contents

Title page

Copyright page

Dedication

Preface

Acknowledgments

The Author

The Commentary Authors

Chapter 1 My Right Knee

Chapter 2 Some Is Not a Number, Soon Is Not a Time

Chapter 3 Power

Chapter 4 Mont Sainte-Victoire

Chapter 5 A Message for Ramesh

Chapter 6 Eating Soup with a Fork

Chapter 7 What “Patient-Centered” Should Mean: Confessions of an Extremist

Chapter 8 Tense

Chapter 9 A Transatlantic Review of the NHS at Sixty

Chapter 10 The Epitaph of Profession

Chapter 11 Squirrel

Chapter 12 You Decide

Chapter 13 The Moral Test

Chapter 14 New Health System—New Professionalism

Chapter 15 To Isaiah

Chapter 16 And We Said, “No”

Introduction

Chapter 1: My Right Knee

Specification Number One Is “No Needless Deaths”

Specification Number Two in the RFP Is “No Needless Pain”

Specification Number Three Is “No Helplessness”

Specification Number Four Is “No Unwanted Waiting”

Specification Number Five Is “No Waste”

Chapter 2: Some Is Not a Number, Soon Is Not a Time

Chapter 3: Power

Chapter 4: Mont Sainte-Victoire

Part One of the Framework: The 100,000 Lives Campaign Isn't Over

Part Two of the Framework: If You Were In, You Are In, Unless You Specifically Opt Out

Part Three of the Framework: New Goals—Reducing Injuries from Care

Part Four of the Framework: Strengthening the Infrastructure

That Leads Me to Part Five of the Framework: We'll Still Focus on Hospital Care

1. Prevent Pressure Ulcers

2. Prevent MRSA Infections

3. Eliminate Injuries from High-Alert Medications

4. Reduce Complications of Surgery by Adopting SCIP

5. Make the Care of Congestive Heart Failure Reliable—Utterly Reliable

6. Get “Boards on Board”

Chapter 5: A Message for Ramesh

Chapter 6: Eating Soup with a Fork

Chapter 7: What “Patient-Centered” Should Mean: Confessions of an Extremist

Chapter 8: Tense

Act One: The Past

Act Two: The Present

Act Three: The Future

Chapter 9: A Transatlantic Review of the NHS at Sixty

Chapter 10: The Epitaph of Profession

Chapter 11: Squirrel

Chapter 12: You Decide

Chapter 13: The Moral Test

Chapter 14: New Health System—New Professionalism

Chapter 15: To Isaiah

Chapter 16: And We Said, “No”

Index

Cover design by JPuda

Cover image: (abstract) © Ralf Hiemisch/Getty; (tree) © Martin Ruegner/Getty

Copyright © 2014 by Donald M. Berwick. All rights reserved.

Published by Jossey-Bass

A Wiley Brand

One Montgomery Street, Suite 1200, San Francisco, CA 94104-4594 www.josseybass.com

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax [phone], or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax [phone], or online at www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read.

Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass directly call our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at 317-572-3986, or fax [phone].

Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com.

Library of Congress Cataloging-in-Publication Data

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

Promising care : how we can rescue health care by improving it / Donald M. Berwick. —First edition.

pages cm

Includes bibliographical references and index.

ISBN 978-1-118-79588-0 (cloth) — ISBN 978-1-118-79585-9 (pdf) —ISBN 978-1-118-79583-5 (epub)

1. Medical care—United States—Quality control. 2. Medical care—United States—Evaluation. 3. Health care reform—Citizen participation—United States. 4. Patient advocacy—United States. I. Title.

RA399.A3.B48 2014

362.10973—dc23

2013038794

To Howard H. Hiatt, MD—my mentor,friend, and model. For decades of gracious help,warm counsel, and constant encouragement.

As this book was nearing its final stages, we lost our colleague, friend, and editor, Andy Pasternack. Andy was, for over two decades, a generous and encouraging champion of our writing and of the health care improvement work that is the subject of this book. His optimism and energy fueled and guided us. We are deeply grateful to have had him with us on our journey. He made us better, and we miss him.

—Don Berwick

Preface

IF I HAD known in advance how important serendipity would be in shaping the arc of my career in health care improvement, I would have been very worried. Could so much, indeed, be left to pure chance?

But, there you have it. If it had not been raining on the night that I met a stranger named Paul Batalden at a dinner meeting, I would not have offered him a ride to his Boston hotel, and he would not have had a chance to tell me how important it was that I learn about W. Edwards Deming, whose name I had not known.

If I had not on a moment's impulse decided to cold-call AT&T Bell Laboratories and ask the switchboard who was in charge of quality there, Blan Godfrey would not have had the chance to answer his phone and invite me down there and, in a few short weeks, to become one of my most valued friends and mentors. Without Blan, there would have been no National Demonstration Project on Quality Improvement in Health Care (NDP); it was his idea. And without the NDP, there would have never been an Institute for Healthcare Improvement (IHI).

And if Dick Sharpe had not been assigned to Blan and me as our John A. Hartford Foundation Project Officer for the NDP, he would never have had the chance to suggest three years later that the NDP was promising enough that a new, nonprofit organization should be built upon its foundation—the idea that became the IHI.

If my father, and, after that, my wife, had not become seriously ill, I would never have had to confront the searing emotions that drove me into the arms of the patient-centeredness and patient safety movement (as I explained in my speeches “Quality Comes Home” and “Escape Fire”) from the inside—my experience—rather than from the outside—my intellect—emotions that, absolutely literally, turned my hair white.

The happenstance continues. It propelled my colleagues and me through the ten years punctuated by the eleven speeches collected in the book Escape Fire, which was “Volume One” of the collected IHI National Forum speeches from 1992 to 2002, and it equally propels the journey of sixteen more speeches now collected here, in “Volume Two,” Promising Care, which comprises talks from 2003 through 2012. This volume differs from Escape Fire in that it includes a few speeches that were not delivered at an IHI National Forum, such as “The Epitaph of Profession,” which was my John Hunt Lecture at the Royal College of General Practice in England, my address to my daughter's graduating Yale School of Medicine class, and “To Isaiah,” which I delivered as the 2012 Harvard Medical School and Harvard School of Dental Medicine Class Day speaker.

As the speeches in Promising Care click by in my mind, I can once again see serendipity at work, as my thinking evolved through the first decade of the twenty-first century. Dozens of transitions occur to me, but I discern five of particular power to shape my views.

First was the arrival of “spread” and “scale” at the center of my aims.

For the first decade and a half of my improvement work, I was satisfied, if not entirely content, to help encourage prototypes of success. The National Demonstration Project was aptly named; the goal was proof of concept, and “demonstration” was, we thought, adequate; the mainstream would follow along. We were wrong. We had underestimated the depth of the taproots of the status quo, and we did not at first understand that bringing good change to full scale needed to become an enterprise of its own. From about 2000 to 2005, IHI, and I, took on large-scale change with passion. The serendipity there had several forms. It just so happened that my second son, Dan, had been working on political campaigns for several years, and it just so happened that I asked him on a car ride how expert political campaigners thought about scale. His answer was complex and eloquent, but one line especially stuck with me: “Some is not a number, soon is not a time.” And from that idea was born the IHI's 100,000 Lives Campaign, and eventually its successor, the 5 Million Lives Campaign. One conversation; six years of work.

And, it just so happened that a college roommate of Ben's (my other son) named Joe McCannon walked into the doors of IHI looking for a job just about then. Joe's fertile mind and inconceivable level of energy brought the Campaigns into reality, and, I believe, changed history with respect to how we think today about large-scale spread.

Second was my new conceptualization of “patient-centeredness” as a foundation for improvement.

At the time of Escape Fire, I would not have written “foundation” in that sentence; I would have said, “component.” It took years of gentle prodding from scholars who knew it first—Maureen Bisognano, Susan Edgman-Levitan, and Bev Johnson, for example—and one unwelcome, serious illness in a loved one, for me rather suddenly to realize one day with a healthy dose of anger that authentic patient-centeredness (better, “person-centeredness”) is not an element of an agenda for improvement; it is a precondition of improvement. I collected those notions in my speech to the American Board of Internal Medicine Foundation, “The True Nature of Patient-Centered Care: Confessions of an Extremist.” The unexpected email that I received one day from Mrs. Jackie Gruzenski nailed down that idea for me irrevocably and shaped my Yale School of Medicine graduation speech.

A third twist (harder to pin down its accidental source) was my realization, as the first decade of the twenty-first century closed, that we simply could not tolerate a separation between what Brent James calls “care outcomes” and “cost outcomes.”

As a student of Deming's, I knew from the late 1980s on that we in health care ought generally to “adopt the new philosophy.” That phrase was one of Deming's famous “14 Points for Top Leaders,” explicated in his book Out of the Crisis. “The new philosophy” was to realize that better quality was the keystone to sustainable economies and jobs, with lower total cost as the link. We in the health care quality movement, and health care overall, had not made that link; indeed, we had no sound conception at all of “total cost,” nor, to judge us by results, do we yet get it. And I came to realize as the decade wore on, even before the Great Recession, and urgently after it, that if we do not find the discipline to use what we had learned about improvement to reduce costs, the loss will be incalculable. John Whittington and Tom Nolan had elegantly rung that bell with their framing of the “Triple Aim”: better care for individuals, better health for populations, and lower per capita cost, and the Triple Aim soon became a mainstay of my lectures. It has since swept the world at a pace and scale that no other IHI contribution rivals.

The new philosophy acquired precision with the arrival of “Lean thinking” and “Lean production” full force in health care. I had been acquainted with this powerful framing ever since my (chance) encounter with the MIT project, “The Future of the Automobile,” and my tutoring by one of its genius scholars, Jim Womack. But it was the enthusiasm of expert practitioners like Patty Gabow, John Toussaint, and Gary Kaplan, and the generous, brilliant help of my accidental new friend, Amory Lovins, that gave me an entirely new and durable understanding of the nature of abundance itself. From that time onward, cost has been for me a dimension of quality, period.

Fourth, pure chance brought me, with utter surprise, to the interface between the quality movement and the world of politics.

Inklings came in the IHI National Forum plenary addresses by Gloria Steinem and, later, Paul O'Neill, which hinted at the power of political influences on improvement and of the potential for mobilization of interest groups for improvement. But who could have known that, the day after Christmas 2008, I would get a call from Senator Tom Daschle, then the probable nominee for Health and Human Services Secretary, asking me if I would consider taking a job in the new administration of Barack Obama as administrator of the Centers for Medicare & Medicaid Services. It took a while—eighteen months to be exact—before the winds of Washington would carry me into that job as a “recess appointee” for the next seventeen months, reporting not to Senator Daschle but to Secretary Kathleen Sebelius, but it was a life-changing, mind-changing happenstance. Indelibly, that experience taught me the need for and the power of political work to permit improvement to thrive. It changed how I think and how I act, and the speeches herein from the time that followed that service—“The Moral Test” and “To Isaiah”—mark that change. The personal experience of illness that led me to write “Escape Fire” in 1999 radicalized my passion for improvement; the personal experience of Washington radicalized my view of the role of power in protecting the vulnerable and the future. I can never go back.

Fifth, chance favored a mental turn for me that is still in its early stages but is foreshadowed in this volume.

It is an awkward turn, because I do not yet fully comprehend it, nor is it particularly consistent with my style and theory to date. To give it a name, let's call it “spirituality,” or, in a common term of the day, “mindfulness.”

I owe this turn to chance encounters again, this time to stumbling upon some new mentors, including Jon Kabat-Zinn, Richie Davidson, David Kindig, and Wayne Jonas. I have known for some time that our normal view of health care and health is much too confining. It is minimalist, and not fully in accord with the World Health Organization's very definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The words for the future are, I think, ones like Kaiser Permanente's slogan: “Thrive”; Wayne Jonas's term: “flourishing”; and Jon Kabat-Zinn's: “mindfulness” and “lovingkindness.” These thoughts seep into my latest speeches, most directly in the speech called, “Squirrel,” which, if I must choose, I probably would select as my favorite of this collection, especially when it asks, “What do you want? What do you really want? What do you really, really want?” I have never met a more powerful sequence of questions in three decades of search for the keys to improvement.

Indeed, if my work ever sees a third volume of collected speeches ten or twelve more years ahead, I will not be surprised if the search for mindfulness, presence, and deep-founded generosity prove to be at their collective core, much as process-mindedness infused Escape Fire, and the hope for large-scale change runs as a vein through the speeches in Pro­mising Care.

So, kind reader, I hope that you enjoy reading these talks, as I enjoyed writing them. But, do not hope that you will find herein a clearly mapped and fully preconceived story unfolding, a structure brick upon brick. You won't. That is not how my career or my thinking has evolved. Accidents good and bad have punctuated the flow every step of the way, about which perhaps the best that can be said, what I hope can be said, is this: “He learned.”

Acknowledgments

I offer deep thanks to my IHI colleagues Jane Roessner, Val Weber, and Dan Schummers for their skill and entrepreneurship in guiding this project in a breathtakingly short time, and to Markus Josephson for helping to keep it on track. Each of the commenters whom we asked for brief introductory essays delivered on time and with eloquence, though their frequent flattering remarks about me belie the essential fact about all of this work: a team—a large team—of IHI colleagues and many others is behind every achievement I report or celebrate in these speeches. I continue to feel deeply grateful to the Institute for Healthcare Improvement, including its board, executives, staff, and faculty, for decades of support, mentoring, and encouragement of my efforts. Most of the ideas in these speeches came first from them, not me.

I offer special thanks to Maureen Bisognano, my successor as IHI CEO, and Tom Nolan, my mentor-in-chief, whose constant thoughtfulness has infused my work every step of the way.

And, last, thanks to my family—Ann, Ben, Beth, Dan, Jessica, Andrew, Becca, Joey, Nathaniel, Caleb, Bob, Sue, David, and Davy—who make it all worthwhile.

The Author

DONALD M. BERWICK, MD, MPP, FRCP, is president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), an organization that Dr. Berwick cofounded and led as president and chief executive officer for eighteen years. He is one of the nation's leading authorities on health care quality and improvement. In July 2010, President Barack Obama appointed Dr. Berwick to the position of administrator of the Centers for Medicare & Medicaid Services (CMS), a position he held until December 2011. A pediatrician by background, Dr. Berwick has served as clinical professor of Pediatrics and Health Care Policy at the Harvard Medical School, professor of Health Policy and Management at the Harvard School of Public Health, and as a member of the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He has also served as vice chair of the U.S. Preventive Services Task Force, the first “Independent Member” of the board of trustees of the American Hospital Association, and chair of the National Advisory Council of the Agency for Healthcare Research and Quality. An elected member of the Institute of Medicine (IOM), Dr. Berwick served two terms on the IOM's governing council and was a member of the IOM's Global Health Board. He served on President Bill Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.

He is a recipient of numerous awards, including the 1999 Joint Commission's Ernest Amory Codman Award, the 2002 American Hospital Association's Award of Honor, the 2006 John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations, the 2007 William B. Graham Prize for Health Services Research, the 2007 Heinz Award for Public Policy from the Heinz Family Foundation, the 2012 Gustav O. Lienhard Award from the IOM, and the 2013 Nathan Davis Award from the American Medical Association. In 2005, he was appointed “Honorary Knight Commander of the British Empire” by Queen Elizabeth II, the highest honor awarded by the United Kingdom to non-British subjects, in recognition of his work with the British National Health Service.

Dr. Berwick is the author or coauthor of more than 160 scientific articles and four books. He also serves as lecturer in the Department of Health Care Policy at Harvard Medical School.

The Commentary Authors

Chapter 1 My Right Knee

Gary S. Kaplan, MD, FACP, FACMPE, FACPE, has served as chairman and CEO of the Virginia Mason Health System in Seattle since 2000. Board certified in internal medicine, he is also a practicing internal medicine physician at Virginia Mason. During his tenure, Virginia Mason has received significant national and international praise for its efforts to transform health care, most notably as the leader in adapting the Toyota Production System for health care. Recognized as one of the most influential physician executives in health care, Dr. Kaplan has been honored nationally for his leadership. In 2009, he received the John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the National Quality Forum and the Joint Commission; and the Harry J. Harwick Lifetime Achievement Award from the Medical Group Management Association and the American College of Medical Practice Executives. Other accolades include being named on the Modern Physician and Modern Healthcare list of “50 Most Influential Physician Executives” in the United States eight times; Modern Healthcare 2012 list of the “100 Most Influential People in Healthcare”; and Becker's Hospital Review 2011 list of the “13 Most Influential Patient Safety Advocates in the United States” and one of the most important US “Health and Hospital Leaders to Know.” Dr. Kaplan is a founding member of Health CEOs for Health Reform. He has held leadership positions with numerous organizations, including the National Patient Safety Foundation, the Medical Group Management Association, and the Washington Healthcare Forum. He is the chair of the Institute for Healthcare Improvement Board of Directors and the 2013–2014 chair of the Seattle Metropolitan Chamber of Commerce Board of Directors.

Chapter 2 Some Is Not a Number, Soon Is Not a Time

C. Joseph McCannon was senior advisor to the administrator at the Centers for Medicare & Medicaid Services (CMS), where he advised on agency policy, launched and led several large organizational initiatives to improve health care quality (including the Partnership for Patients), and was a member of the founding team at the Center for Medicare and Medicaid Innovation (CMMI). Previously, he served as vice president and faculty on dissemination and large-scale improvement at the Institute for Healthcare Improvement (IHI), where he also led organizational efforts to spread change in Africa, the United States, and several other regions. Mr. McCannon supported IHI's collaboration with the World Health Organization to design and amplify the “3 by 5” initiative, an effort to deliver antiretroviral drugs to three million people globally by the end of 2005. He also directed IHI's major US initiatives to improve patient safety—the 100,000 Lives Campaign and the 5 Million Lives Campaign—which involved more than four thousand hospitals and seventy field offices. He has advised or consulted to other national quality improvement efforts in the United States, England, Japan, Canada, and Denmark, and to initiatives outside of health care (for example, ending homelessness and corrections reform). His career began in the publishing industry with roles at Fast Company, the Atlantic Monthly, and Outside magazine. He is a graduate of Harvard University and was a Reuters and Merck Fellow at Stanford University in 2003–2004.

Chapter 3 Power

Dale Ann Micalizzi is a nationally known health care improvement advisor and trusted advocate for pediatric patient safety and transparency in medicine. Her eleven-year-old son, Justin, died following a “simple” incision and drainage of an infected ankle in 2001. She has worked tirelessly in search of answers about her son's death, giving rise to a quest to improve pediatric health care. Her efforts focus on compassion and support for grieving families, full disclosure of adverse medical events, and education and reform that will restore ethics and safety in medicine. She has presented as a faculty member for the Institute for Healthcare Improvement (IHI) beginning in 2005, and has acted as a consultant, speaker, board member, and improvement advisor for numerous health care organizations, medical schools, and patient/family support programs. Ms. Micalizzi is the founder and director of Justin's HOPE Project at the Task Force for Global Health, and she has partnered with IHI in providing yearly National Forum scholarships in Justin's memory to health caregivers who work with underserved pediatric populations internationally to improve safety and quality. She has channeled her grief, exacerbated by the absence of disclosure and apology, into programs that advance pediatric safety and educate a new generation about the importance of caring for families in the aftermath of tragic errors, learning from the event, and working with them to improve care together. She is coauthor of the chapter “The Heart of Health Care: Parents' Perspectives on Patient Safety” in Pediatric Clinics of North America and coauthor of an article in Pediatric Anesthesia titled “What Happens When Things Go Wrong?”

Chapter 4 Mont Sainte-Victoire

Jason Leitch, DDS, FDS, MPH, has worked for the Scottish government since 2007; he is currently the clinical director of the Quality Unit in the Health and Social Care Directorate. He is a member of the Health and Social Care Management Board and a member of the senior team responsible for implementation of the NHS Scotland Quality Strategy. He is also the medical director of the Tayside Centre for Organisational Effectiveness and an honorary professor at the University of Dundee. Professor Leitch was named the 2011 HFMA UK Clinician of the Year. He is a nonexecutive board member of AQuA in the North-East of England. He was a 2005–2006 Quality Improvement Fellow at the Institute for Healthcare Improvement (IHI), sponsored by the Health Foundation. He is also a trustee of the UK wing of the Indian Rural Evangelical Fellowship, which runs orphanages in southeast India. He has a doctorate from the University of Glasgow, an MPH from Harvard, and is a fellow of the Royal College of Surgeons of England, the Royal College of Physicians and Surgeons of Glasgow, and the Royal College of Surgeons of Edinburgh. He is also a fellow of the Higher Education Academy.

Chapter 5 A Message for Ramesh

Paul Farmer, MD, PhD, is Kolokotrones University Professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School, chief of the Division of Global Health Equity at Brigham and Women's Hospital in Boston, and cofounder of Partners In Health. He also serves as UN special advisor to the secretary-general on Community Based Medicine and Lessons from Haiti. Dr. Farmer and his colleagues have pioneered novel, community-based treatment strategies that demonstrate the delivery of high-quality health care in resource-poor settings. He is a member of the Institute of Medicine of the National Academy of Sciences and of the American Academy of Arts and Sciences. Dr. Farmer has written extensively on health, human rights, and the consequences of social inequality. His most recent book is To Repair the World: Paul Farmer Speaks to the Next Generation. Other titles include Haiti After the Earthquake; Partner to the Poor: A Paul Farmer Reader; Pathologies of Power: Health, Human Rights, and the New War on the Poor; The Uses of Haiti; Infections and Inequalities: The Modern Plagues; and AIDS and Accusation: Haiti and the Geography of Blame.

Chapter 6 Eating Soup with a Fork

Paul B. Batalden, MD, professor emeritus of Pediatrics, Community, and Family Medicine and the Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth College, is also guest professor of Quality Improvement and Leadership at Jönköping University in Sweden. He teaches about the leadership of improvement of health care quality, safety, and value at Dartmouth, the Institute for Healthcare Improvement (IHI), and the Jönköping Academy for the Improvement of Health and Welfare in Sweden. He chairs the Improvement Science Development Group of the Health Foundation in London and the Leadership Preventive Medicine Residency Advisory Committee at Dartmouth. He is a member of the Board of Advisors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; the National Advisory Board, Active Aging Research Center, University of Wisconsin; External Advisory Council, Anderson Center, Cincinnati Children's Hospital and Medical Center; the Research and Education Board of Health Partners in St. Paul, Minnesota; and serves as senior fellow and governing board advisor for IHI. Previously he founded, created, or helped develop the IHI, the VA National Quality Scholars program, the IHI Health Professions Education Collaborative, the General Competencies of the ACGME, the Center for Leadership and Improvement at Dartmouth, the Dartmouth Hitchcock Leadership Preventive Medicine Residency, the annual health professional faculty development “summer camp,” the SQUIRE publication guidelines for the improvement of health care, and the Improvement Science Fellowship Program of the Health Foundation in the UK and of the Vinnvård Improvement Science Fellowships in Sweden. He is a member of the Minnesota Academy of Medicine and the Institute of Medicine of the US National Academy of Sciences. He is currently interested in the multiple knowledge systems and disciplines that inform the improvement of health and health care.

Chapter 7 What “Patient-Centered” Should Mean: Confessions of an Extremist

Frederick S. Southwick, MD, received his BA from Yale College and his MD from Columbia College of Physicians and Surgeons. He received his clinical training at Boston City Hospital and the Massachusetts General Hospitals in Internal Medicine and Infectious Diseases, and served on the faculty at Harvard University and the University of Pennsylvania before serving as chief of Infectious Diseases at the University of Florida for nineteen years. Dr. Southwick has been an active NIH-funded biomedical investigator for more than thirty years, studying how bacteria interact with the human host. From 2010 to 2011, he was an Advanced Leadership Fellow at the Harvard Business School, where he studied leadership, teamwork, campaign strategies, and the principles of health care quality and safety. As part of his fellowship he completed a book entitled Critically Ill: A 5-Point Plan to Cure Healthcare Delivery. Most recently he was appointed quality projects manager for the senior vice president for Health Affairs at UF & Shands System.

Chapter 8 Tense

Jessica Berwick, MD, MPH, grew up in Newton, Massachusetts. She received her AB in government from Harvard College, an MD from Yale School of Medicine, and an MPH from Johns Hopkins Bloomberg School of Public Health. Throughout high school and college she spent time in Costa Rica, Ecuador, and Peru. She has worked at an HIV clinical trials site in Cape Town, South Africa, both during college and in the year preceding medical school. She has completed her training in Internal Medicine/Primary Care at Brigham and Women's Hospital. She is a hospitalist at Beth Israel Deaconness Medical Center, and plans to spend significant portions of her time working at the University of Zimbabwe College of Health Sciences in Harare, Zimbabwe. She is now living in Harare with her husband, Andrew, and her son, Nathaniel, dividing her time between Zimbabwe and the US.

Chapter 9 A Transatlantic Review of the NHS at Sixty

Lord Nigel Crisp is an independent crossbench member of the House of Lords in the United Kingdom, where he cochairs the All Party Parliamentary Group on Global Health. He was chief executive of the NHS in England—the largest health care organization in the world, with 1.4 million employees—and permanent secretary of the UK Department of Health between 2000 and 2006. Previously he was chief executive of the Oxford Radcliffe Hospital NHS Trust. Lord Crisp chairs Sightsavers, the Kings Partners Global Health Advisory Board, and the Zambian and Ugandan UK Health Alliances. He is a senior fellow of the Institute for Healthcare Improvement, and he is affiliated with the Harvard School of Public Health and the London School of Hygiene and Tropical Medicine. He has written extensively on health. His book Turning the World Upside Down: The Search for Global Health in the 21st Century takes further the ideas about partnership and mutual learning developed in his report for the prime minister, Global Health Partnerships.

Chapter 10 The Epitaph of Profession

Christine K. Cassel, MD, joined the National Quality Forum as president and CEO in July 2013. Previously, she served as president and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation. She is a leading expert in geriatric medicine, medical ethics, and quality of care. Dr. Cassel is a member of the President's Council of Advisors on Science and Technology (PCAST). She is the cochair and physician leader of PCAST working groups that have made recommendations to the president on issues relating to health information technology and ways to promote scientific innovation in drug development and evaluation. Dr. Cassel is a member of the Commonwealth Fund's Commission on a High Performance Health System and has served on the Institute of Medicine Committees that wrote the influential reports To Err Is Human and Crossing the Quality Chasm. She is an adjunct professor of medicine and senior fellow in the Department of Medical Ethics and Health Policy at the University of Pennsylvania School of Medicine, former dean of medicine at Oregon Health and Science University, chair of geriatrics at Mount Sinai School of Medicine in New York, and chief of General Internal Medicine at the University of Chicago. Dr. Cassel is a prolific scholar, having authored and edited fourteen books and more than two hundred published articles.

Chapter 11 Squirrel

Diana Chapman Walsh, PhD, president emerita, Wellesley College, serves on the governing boards of the Broad Institute of MIT and Harvard; the Kaiser Family Foundation; the Institute for Healthcare Improvement; the Massachusetts Institute of Technology; and the Mind and Life Institute; as well as on several national advisory boards. She was a director of the State Street Corporation (1999 to 2007) and a trustee of Amherst College (1998 to 2010). A member of the American Academy of Arts and Sciences and Phi Beta Kappa, Dr. Walsh writes, speaks, and consults on higher education and leadership. Before assuming the Wellesley presidency, she was Norman Professor and Chair of Health and Social Behavior at the Harvard School of Public Health. Her tenure as twelfth president of Wellesley College (1993 to 2007) was marked by educational innovation, including a revision of the curriculum and expanded programs in global education, the humanities, internships and service learning, interdisciplinary teaching and learning, and religious and spiritual life. President Walsh evolved a distinctive style of reflective leadership rooted in a network of resilient partnerships and anchored in the belief that trustworthy leadership starts from within.

Chapter 12 You Decide

Beverley H. Johnson is president and CEO of the Institute for Patient- and Family-Centered Care in Bethesda, Maryland. She has provided technical assistance to more than 250 hospitals, health systems, primary care practices, and federal, state, and provincial agencies. She has authored and coauthored many publications on patient- and family-centered practice. She recently served as project director for a multiyear initiative to develop resource materials for senior leaders in hospital, ambulatory, and long-term care settings on how to partner with patients, residents, and families to enhance the quality, safety, and the experience of care. Ms. Johnson serves on the selection committee for the American Hospital Association-McKesson Quest for Quality Prize and is a member of the Patient-Centered Primary Care Collaborative Board of Directors. She is also a member of Premier's QUEST/PACT Advisory Panel and the American College of Physicians' Advisory Board for Patient Partnership in Healthcare. She was presented with the Humanitarian Award by Pediatric Nursing in 1990, and the Lloyd Bentsen Award in 1992. In 2007, she was honored with The Changemaker Award by the Board for the Center for Health Care Design and the Gravens Award for leadership in promoting optimal environments and developmental care for high-risk infants and their families. She is also a recipient of the Dorland Health 2011 People Award.

Chapter 13 The Moral Test

Tom Daschle is a senior policy advisor to the law firm DLA Piper, where he provides strategic advice on public policy issues such as climate change, energy, health care, trade, financial services, and telecommunications. In 2007, he joined with former Senate Majority Leaders George Mitchell, Bob Dole, and Howard Baker to form the Bipartisan Policy Center, an organization dedicated to finding common ground on some of the most pressing public policy issues of our time. Senator Daschle is also the vice chair of the National Democratic Institute and a board member of the Center for American Progress. He is the author of the books Like No Other Time: The 107th Congress and the Two Years That Changed America Forever; Critical: What We Can Do About the Health-Care Crisis; Getting It Done: How Obama and Congress Finally Broke the Stalemate to Make Way for Health Reform; and The US Senate: Fundamentals of American Government. He is a graduate of South Dakota State University.

Chapter 14 New Health System—New Professionalism

James Reason, PhD, graduated from the University of Manchester in 1962 and received his PhD from the University of Leicester in 1967. He was professor of psychology at Manchester from 1976 to 2001, and is now emeritus professor. His main research area has been the human contribution both to accidents in complex technological systems and to recovering these systems when they slide towards disaster. He is best known for his “Swiss Cheese” model of accident causation. Dr. Reason has consulted in many hazardous domains, but recently he has focused on patient safety. He has authored or coauthored more than a dozen books and several journal articles. His most recent book is A Life in Error. He is a fellow of the British Academy, the Royal Aeronautical Society, the Royal College of General Practitioners, and the British Psychological Society. He is married with two daughters and three grandchildren.

Chapter 15 To Isaiah

Mark D. Smith, MD, MBA, has been president and chief executive officer of the California HealthCare Foundation (CHCF) since its founding in 1996 until 2013. CHCF is an independent philanthropy headquartered in Oakland, California, that is dedicated to improving the health of the people of California, with special concern for the underserved. A board-certified internist, Dr. Smith is a member of the clinical faculty at the University of California, San Francisco, and an attending physician at the Positive Health Program for AIDS Care at San Francisco General Hospital. He is a member of the Institute of Medicine, National Academy of Sciences, and chaired the Committee on the Learning Healthcare System in America. He has served on the Performance Measurement Committee of the National Committee for Quality Assurance, the National Business Group on Health Board of Directors, and the editorial board of the Annals of Internal Medicine. He is author of On Practical Progress. Dr. Smith received a bachelor's degree from Harvard College, an MD from the University of North Carolina at Chapel Hill, and an MBA from the Wharton School at the University of Pennsylvania.

Chapter 16 And We Said, “No”

Patricia A. Gabow, MD, was CEO of Denver Health from 1992 until her retirement in 2012, transforming it from a department of city government to a successful, independent governmental entity. She is a member of the Medicaid and CHIP Access and Payment Commission (MACPAC), the Robert Wood Johnson Foundation Board, the Institute of Medicine Roundtable on Value and Science Driven Health Care, and the National Governors Association Health Advisory Board. She is a professor of medicine at the University of Colorado School of Medicine and has authored more than 150 articles and book chapters. She received her MD degree from the University of Pennsylvania School of Medicine. She trained in Internal Medicine and Nephrology at the Hospital of the University of Pennsylvania, Harbor General Hospital, and San Francisco General Hospital. Dr. Gabow has received the AMA Nathan Davis Award for Outstanding Public Servant, the Ohtli Award from the Mexican government, the National Healthcare Leadership Award, the David E. Rogers Award from AAMC, the Health Quality Leader Award from NCQA, and was elected to the Association for Manufacturing Excellence Hall of Fame for her work on Toyota Production Systems in health care.

Introduction

IN HIS PREFACE, Don talks about the role serendipity played in connecting him with so many influential and inspiring people—both in his life and his career. I have a slightly different take. I agree that serendipity and circumstance have been pivotal, but his accomplishments and impact are by no means accidental. For me, it's not so much who Don has interacted with as it is how he engages them. It's how he engages patients, like Isaiah, and like all those he has met in his “second” career as a health care leader. It's how he engages other leaders—from health care systems and from governments all over the world. And, perhaps most important, it's how he engages caregivers—the people at the point of care, whose devotion and commitment to the patients they care for forms the heart of health care and inspires us all to improve.

In all these interactions, from those with government leaders to those with front-line staff, the two words that best characterize the nature of Don's engagement are, for me, humanity and humility. Roles aren't important to Don … people are. He approaches everyone as a person first, a whole person. His curiosity is about the humanity in each of us and how that drives us all to be better caregivers, better leaders, and better colleagues. He knows how to get the best from each of us and how to honor and use the assets we all have. And he does this always with a genuine humility—the kind of humility he displays in his Preface, and the humility that runs throughout all of these collected speeches. Don always wants to be a member of a team, of a movement. He knows that collective action is the key to system transformation, and that everyone has a crucial role to play.

I first met Don in 1987, when I was a new CEO at a Massachusetts hospital, and he invited me to join the National Demonstration Project on Quality Improvement in Health Care—the NDP, for short. I was young, and green, and a bit daunted by the opportunity to join improvement's pioneers—Blan Godfrey, Paul Batalden, and Don—to learn how we might best improve health care by taking lessons from outside the industry. My own mentors at the time were from Florida Power & Light, a utility company in Miami. They taught me how to innovate and improve, and they set me on the path that, serendipitously, crossed Don's and changed my life.

In those early days, Don coached, inspired, and taught. But he also always listened, learned, and honored. Whether he's tracking down Isaiah to follow up on his blood work or launching a national campaign to save lives, Don begins by first understanding the strengths and capabilities of all, and then capturing them with his own enthusiasm and passion.

The National Demonstration Project brought twenty-one hospi­tals together with twenty industry leaders outside of health care to learn together about quality, safety, customer satisfaction, and cost. The leaders engaged in the project saw real improvements. And the lessons they learned and momentum they generated formed the foundation for what became the Institute for Healthcare Improvement—a foundation still solid some twenty-five years later.

I will say this: Don does have his limits. He hits the wall when he sees injustice, indifference, or complacency. In these assembled speeches, as with the earlier collection, Escape Fire (2004), you can feel his impatience with the health care system as it is. He sees that the medical systems we have don't reliably contribute to health, that care sometimes harms, and that it all costs far too much. You can feel his frustration when the patient's voice isn't heard or when illogical rules—like visiting hours—keep loved ones apart. Through these speeches, Don inspires us to make our systems better, make them more effective, and make them more humane.

Don's is the needed voice for reforming health care. The Triple Aim concept, which he codesigned with John Whittington and Tom Nolan, is pushing us to improve the health of populations, to improve the experience of care, and to reduce per capita costs. He defines this agenda as our “moral test,” and pulls us all to this vision, over the rough roads of payment disincentives, regulatory complexity, professional silos, and fragmented systems. He does this in two important ways. Above all, Don gives us the heart and courage we need if we are going to change. He puts the voices and faces of patients before us and dares us to walk away from their need. He defines compassion for each other, and the joys we can find in working together. He tells us about patients like Isaiah to open our eyes to the meaning of life, health, and caring. He puts the hard choice to us: to change, or not to change.

And he also gives us science, systems theory, tools, and mechanisms to support us once we set our ambitious aims. The stories in these speeches describe data, scientific approaches, and new models to innovate and improve. He defines the ways policy and regulation can support change. He shows us the way to see systems and pathways across complex organizational barriers. He teaches how to use science and data and evaluation for improvement, not for judgment.

I've been to every National Forum since the first one in 1989. And though there are thousands of others in the room, I always look forward to Don's talk as his hour with me. I know I'm not alone in feeling this. He connects with our individuality, with our uniqueness. But then the lights come up, and the audience stands (they always stand), and I'm reminded that I'm part of something big, something greater than myself. Don reminds us all, those in the room, and the thousands more watching from all corners of the globe, that we are one big team, with one common mission: we have to rescue health care by improving it.

I've had the honor to watch Don write and refine these speeches, the privilege to be a sounding board and reviewer, and the joyful opportunity to hear most of them delivered in person. And as wonderful as these speeches are on their own, the commentaries that accompany them are just as extraordinary. It's telling that among this group of luminaries who contributed their thoughts and impressions, not one of them hesitated when invited to write a commentary. I'm sure they felt just as flattered and humbled as I did when asked to write this introduction. Don has that effect on people.

With this book, Don will once again inspire and teach the world. He'll help you renew your promise to Isaiah, see your Baby Gray, find your Ramesh Kumar, answer the question, “What do you really, really want?,” and help us all find the courage and wisdom to make health care better, safer, and more efficient. You'll never sit by a patient's bedside without feeling what empathic caring can be like. You'll never feel alone in pointing out a system fault and suggesting a possible solution. You might even start to understand what it feels like to root for the Boston Red Sox. Enjoy!

Maureen Bisognano

President and CEO

Institute for Healthcare Improvement

Chapter 1

My Right Knee

Plenary Address

Institute for Healthcare Improvement

15th Annual National Forum on Quality Improvement in Health Care

New Orleans, Louisiana, December 4, 2003

Commentary

Gary S. Kaplan, MD

AT THE INSTITUTE for Healthcare Improvement (IHI) National Forum in 2003, then-President and CEO Don Berwick, MD, gave a keynote speech titled “My Right Knee.” I always look forward to hearing Don speak, but I wasn't quite prepared to hear a speech that would provide a defining moment in my own leadership journey and quest for quality. His keynote was a mandate for transformational change in health care.

I have known Don for decades and, in addition to my service as chairman and CEO of Virginia Mason Health System in Seattle, I am proud to serve as the current chair of the IHI Board of Directors. In 2003, the team at Virginia Mason was in the very early stages of adopting the Toyota Production System as our management method. We were intrigued by this system because it is sharply focused on achieving perfect quality. Although zero defects is an admirable goal, many said it was impossible. After all, Virginia Mason is in the business of providing health care, not manufacturing cars.

It was Don's description of his own experience in search of high-quality, patient-focused care, and the disappointments and successes he experienced along the way, that gave me courage to stay the course in pursuit of the perfect patient experience.

Don's vision was that radical transformation was not possible until “we look at the people we want to help, and see ourselves; when we realize that their needs, out there, are our needs, in here.” His insistence that we view health care through the eyes of our patients prompted my own thoughts of my parents, my wife, my children, and my future grandchildren. This was confirmation that zero defects is the only acceptable goal in health care.

A baseball fan (a gross understatement), Don tied the likelihood of whole-system transformation in health care to the chances of the Boston Red Sox winning the World Series.

So, what has happened in the decade since Don gave that pivotal speech? The Red Sox won the World Series—twice—in 2004 and again in 2007. What seemed like an unlikely accomplishment on the baseball field was a harbinger of things to come in health care.

IHI continued to drive improvement in health care quality and safety with its groundbreaking 100,000 Lives and 5 Million Lives Campaigns, motivating hospitals across America to significantly reduce morbidity, mortality, and errors in health care by adopting practices focused on patient safety.

For organizations faced with interpreting the Institute of Medicine's (IOM) landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century, IHI created the clarity we needed in health care to engage in this work by reframing the IOM aims for improvement—care that is safe, effective, patient-centered, timely, efficient, and equitable—as “no needless pain, no needless death, and no needless waste.” This mantra became the rallying cry for whole-system change in health care.

In addition to its work in the United States, IHI continued to expand its international reach. The Surviving Sepsis Campaign, in partnership with IHI, developed international guidelines for the management of severe sepsis and septic shock. Further, IHI's work with the World Health Organization (WHO) includes the promotion and spread of WHO's important surgical safety programs.

Throughout the country, we are now implementing the Patient Protection and Affordable Care Act, and with IHI providing successful models, we are seeing health care–associated infections and hospital readmissions decrease. At the same time we are providing more preventive care with better coordination through increased use of electronic medical records.

A decade after Don's speech, organizations like Virginia Mason continue to experience what it means to be a learning organization. We do this by employing a management method, the Virginia Mason Production System, that insists on patient-focused alignment throughout our health system. This pursuit of the perfect patient experience requires transparency and a focus on respect for our patients as team members. As Don revealed, the only way we can achieve this is by walking in our patients' shoes.

“My Right Knee” was a personal turning point for me, and it raised the bar for the health care industry. Ten years later, are we where we need to be, ensuring no needless pain, no needless death, and no needless waste? Honestly, no. Yet the Red Sox did win the World Series, proving there is a cure for the curse of the Bambino. Similarly, I believe there is a cure for what ails health care.

My Right Knee

A DARK CLOUD hangs over IHI's home base, Boston, this year. It's the cloud of the Boston Red Sox. This is very painful for us, and especially for Maureen Bisognano, my closest colleague and IHI's brilliant executive vice president and COO. Maureen is as avid a Red Sox fan as she is a golfer. That's saying a lot, if you know about Maureen and golf. Just this fall, she phoned me after a weekend round of golf to say that it had been terrible. She was on the third tee when her golfing partner, Fred, dropped dead of a heart attack.

I said, “Maureen, that must have been so hard for you.”

“You have no idea how hard it was,” she said. “It took forever … hit the ball, drag Fred, hit the ball, drag Fred. …”

So, Maureen was a mess when, again, the Red Sox, her beloved team, got knocked out of the semi-final round—the American League Championship Series—by our archrivals, the New York Yankees, Satan's team. We came so close.

If you're not from the United States, let me explain. The Boston Red Sox suffer from a problem we call the “curse of the Bambino.” “The Bambino” is Babe Ruth—it's his nickname—who was probably the greatest baseball player of all time. Babe Ruth started his professional career with the Red Sox, but in 1920, in search of filthy lucre, the owner of the Red Sox sold the Babe to the New York Yankees, Satan's team. With Babe Ruth on board, the Red Sox won the baseball championship, which we Americans humbly call the World Series, in 1918, but they haven't ever won it since. Meanwhile the Yankees have won the World Series twenty-six times. Bostonians know that the gods, themselves, have engineered this century of failure for the Red Sox—always a bridesmaid, never a bride—because of that treacherous trade; so they call it the “curse of the Bambino.”

The Red Sox have fixed this problem lots of times, not by winning the World Series, but by firing people. In a famous instant in the 1986 World Series—Red Sox versus the New York Mets, Satan's other team—oh, it is seared in my sons' memories, and don't even think of mentioning it to Maureen—our first baseman, Bill Buckner, muffed an easy ground ball, and the Mets went on to beat us. Buckner was gone the next year. This year, in the seventh and final game of the American League playoffs, the Red Sox manager, Grady Little, left our worn-out star pitcher in one inning too long, and that let the Yankees come back from way behind to beat us. Grady Little is now the former manager of the Red Sox. That'll fix it!

This all has led to a common bet in Boston: people bet on which will happen first—“X” or the Red Sox winning the World Series. Graduate students' supervisors ask them if they'll finish their PhD theses before the Red Sox win the World Series. Their mothers ask them if they'll get married before the Red Sox win the World Series. I ask my kids if they'll please clean their rooms before the Red Sox win the World Series. I intend to empty my email inbox before the Red Sox win the World Series.

So, in that spirit, I ask you here: Which will happen first, the health care we ought to have, or the Red Sox winning the World Series? Being a health care improvement fan and a Boston Red Sox fan do have something in common: playoffs, but no Series. Until recently, I would have bet on the Red Sox.

But, now, I'm not so sure. It's been a good year for the quality movement … a very good year. I think a real turning point was actually almost exactly one year ago, when Sister Mary Jean Ryan and her colleagues at SSM Health Care earned and won the Malcolm Baldrige National Quality Award. They met world-class quality standards with the best assessment criteria we have on the same playing field as other industries! Now we have the news that two more places have followed in SSM's steps: Baptist Hospital in Pensacola and St. Luke's in Kansas City just won the Baldrige, too.

The IHI had a good year. We launched our new IMPACT network—I call it “The Association for Change.” A new project supported by the Robert Wood Johnson Foundation, called Transforming Care at the Bedside, is part of IHI's growing focus on helping the nursing profession—something we just have to tackle as a top priority in American health care.

Our Pursuing Perfection project, also funded by the Robert Wood Johnson Foundation, has begun to show major gains in all thirteen sites—seven US and six European. Maybe best of all, I am now clearly seeing a small but increasing number of American health care organizations finally aiming for whole system change—what we've been waiting for: improvement as the core strategy. For example, Randy Linton and his colleagues at Luther Midelfort; John Toussaint and Scott Decker at ThedaCare; George Kerwin and Pete Knox at Bellin Health System in Wisconsin; Gary Kaplan at Virginia Mason in Seattle; Sister Mary Jean and SSM throughout the country; Leo Brideau at Columbia St. Mary's in Milwaukee; Mayo Clinic at all of its sites; Bill Corley at Community Hospitals in Indianapolis; and Doug Eby and his colleagues at the Southcentral Foundation and the Alaska Native Medical Center in Anchorage; to name only a few.

And, the improvement movement is now absolutely global. Sweden, Norway, the UK, the Netherlands, Australia, and New Zealand are only some of the bright spots. The UK improvements are soaring with the help of such leaders and IHI friends as Sir Liam Donaldson, Sir Brian Jarman, David Fillingham, and Helen Bevan. John Oldham, longtime friend, associate, and senior faculty member of the IHI, was knighted this year—he is now Sir John Oldham, but he lets me call him, simply, “Sir”—because of what he's done to improve the UK's primary care services. The IHI is now working with the World Health Organization to figure out how to expand our efforts into the fight against AIDS.

Federal agencies are also doing tons. Take a look at Medicare, with some bold, new programs to reward exceptional quality of care, led by Steve Jencks, Sean Tunis, Barbara Paul, and Michael McMullin; the Bureau of Primary Health Care in HRSA, showing massive improvements in access and chronic disease care in community health centers under the leadership of Sam Shekar; and the Veterans Health Administration, setting the pace in patient safety.

Trying to keep up with this pace of change, IHI's management team and staff have been working this year on a big redesign of the IHI itself. We've decided that we're going to focus all of our energies—that we'll judge ourselves—on what we are actually achieving on the Institute of Medicine's [IOM] six aims for improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. We are going to make IHI more results oriented than ever before.

We have rephrased the IOM's aims a little. Here are the results we want to get, and we want to get them with you:

No needless deathNo needless painNo helplessnessNo unwanted waitingNo waste

And we want those results for all—for everyone; that's the sixth IOM dimension: equity. That's what IHI exists to accomplish. That's how we'll measure our progress and yours. This clarifies our priorities. We will work on what helps get there, and we will turn down chances to work on things that don't.

So, with all of this, I'm bullish on improvement. It's a tight playoff series, but quality is pulling ahead by a game or two. Maybe, just maybe, the curse of the chasm—the health care quality chasm—will fall before the curse of the Bambino does. The trick now, just like for the Red Sox, is to put it all together.