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Berwick Pushes for Quality

 |  By jsimmons@healthleadersmedia.com  
   September 16, 2010

Prior to taking over as administrator of the Centers for Medicare & Medicaid Services (CMS) two months ago, Donald Berwick's name was fairly synonymous with the word "quality." The list of accomplishments for the founder, past president and CEO of the Institute for Healthcare Improvement have made him an international figure when it comes to examining the delivery of quality care. So the next big question is: what emphasis on quality improvement is he bringing to his new job?

Berwick made his first public speech this week to attendees at America's Health Insurance Plans (AHIP's) Medicare and Medicaid conference in Washington. Threaded throughout the talk—beyond examining the implementation of the Affordable Care Act—were references to quality and healthcare that will likely be highlighted during his term.

He said that "as we say in the world of quality improvement, 'Every system is perfectly designed to achieve exactly the results it gets.' If we want new results—and we do—we need a new system. All improvement is change." Here are some of those changes he is proposing.

The Triple Aim. To get started on his journey, Berwick referred to the roadmap that he would like to see "healthcare rally around"—"The Triple Aim"—which he first wrote about two years ago on how to improve care in the United States. The Triple Aim, he noted, refers to three goals at once:

  • Better care for individuals, as described by all six dimensions of quality in the 2001 Institute of Medicine report on Crossing the Quality Chasm: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
  • Better health for populations in relation to the upstream causes of ill health, such as poor nutrition, physical inactivity, substance abuse, and unwise behavioral choices, violence, and economic disparities.
  • Reducing per capita costs by eliminating waste.

For the last item, Berwick specified—in light of previous comments that have come under scrutiny—that this meant "not by withholding from us or our neighbors any care that helps them— specifically not by harming a hair on any patient's head."

Acute care. One of his "strategic priority" areas is to make "the quality of care in hospitals and outpatient clinical settings better—much better—everywhere and for everyone," Berwick said. 

One of the top areas that he is focusing on: safety. He noted that the IOM's report on patient safety—To Err Is Human—is now over 10 years old. "We still lack the firm national commitment to make the safest care the standard care everywhere—no matter where an American patient goes," he said.

He called for a "rededication to safe care," with an aim for "a major and immediate reduction in medical injuries to patients in hospitals.

Integrated care. Substantial and prompt progress is needed toward better-integrated care—"care that makes sense to patients and families, so that they don't feel lost and forgotten and confused as they make their way through our complex systems," Berwick said. "We owe them journeys—not fragments."

Fragmented, disorganized care is still relatively common in today's healthcare system, he noted. It's where patients have to tell their name and address and story again and again to everyone you see, and where no one seems to talk to each other and records are forgotten or unavailable.

He cited the example of the fragmented car—one that would use the best of every vehicle—such as the brakes from a Jaguar, the door from a Volvo, the fuel system from a Camaro, or the suspension of a BMW. 

But instead of the best car in the world, it would be a car that wouldn't work because the parts don't fit together. "A car isn't just a collection of parts; it is a system of interacting parts.  That's why cars need designs, and that's why healthcare needs design, too," Berwick said. "'Everyone does their best" is a bad plan. The right plan is, 'Everyone does their best together.'"

Community-based prevention. Rather than wait for problems, actions should be taken to prevent them, Berwick said. That means addressing the causes of illness where they lie—in communities—by looking at daily habits, social supports, and everyday choices.

Moving in these directions will not work with a "top-down, national project," he said. Instead, any successful redesign of healthcare will be a community-by-community task. "That's technically and morally correct, because, in the end, each local community—and only each local community—has the knowledge and skills to define and deliver what is locally right."

America is "seriously underinvested" in using what is known about preventing illnesses such as heart disease, asthma, and depression, he said. "Prevention, if we get serious about it, is a big, big bargain."

So will this quality vision honed over years of working with healthcare providers work? "None of this will be easy." Berwick admitted. "All of us will have to change the way we do business. And there's plenty of work ahead."

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.

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