Don Berwick, CEO of the Institute for Healthcare Improvement, spoke with HealthBlawg last week, as IHI comes close to wrapping up its 5 Million Lives Campaign.
IHI sponsors an impressive array of collaborative health care improvement programs, offering programmatic support and creating a network of like-minded institutions and leaders who provide feedback to each other on improvements to their local systems. The 5 Million Lives Campaign is the latest in a long line of successful campaigns.
I asked Berwick about the plethora of health care indicators used in P4P and pay-for-reporting plans, and he suggested that the 1,000 measures in use today could be whittled down to far fewer, that the "cacophony" could be eliminated, with better results for patients. The 5 Million Lives Campaign, for example, is built on twelve "planks," ranging from reduction in infections and med errors to board engagement -- the latter, a critical measure not often cited in connection with patient care process and outcome measurement. He also noted that NQF will be making an announcement in the near future identifying six key predictive measures.
IHI uses these indicators to "pull" health care providers into improved quality, according to Berwick; payors use them to "push" providers along.
Berwick estimates that 30% of costs in the U.S. health care system are "pure waste" -- excess administrative costs and medical expenses, where variation is based on habit, not evidence. The current economic climate brings greater urgency to the need to bring these costs under control.
While cautioning that information technology "isn't magic," Berwick emphasized that he has been calling for widespread implementation of EHRs for 30 years, so long as the EHR roll-out doesn't simply transfer paper processes to the computer but, rather, serves as an opportunity to redesign patient care and administrative processes.
Another opportunity for improvement lies in improving coordination of care across traditional boundaries -- e.g., primary care to acute care to chronic care. Berwick used the "M" word to describe the mechanism most likely to help in this arena: managed care: "not the evil managed care, not the mutant managed care, but the good managed care," that could really help patients, e.g., through a chronic illness.
In discussing future policy directions post-election, Berwick stressed that the U.S.needs to join the rest of the industrialized world and recognize health care as a right. It seems clear that if that were to happen, many other changes in the health care system would need to be made as well -- finance, delivery system, health care provider training and supply -- all topics worth further examination another day.
Interview of Donald Berwick, CEO of the Institute for Healthcare Improvement
October 28, 2008
David Harlow: This is David Harlow of HealthBlawg, and I have with me today Don Berwick, CEO of the Institute for Healthcare Improvement. Good morning, Dr. Berwick.
Don Berwick: Good morning.
David Harlow: Thank you for joining us today. I wonder, for starters -- though I’m sure many folks are familiar with your organization -- if you could give us a snapshot description of what your organization does and its mission.
Don Berwick: Sure. The Institute for Healthcare Improvement, IHI, is a non-profit organization started in 1991 by a group of colleagues around the United States. Our mission is to help accelerate the improvement of healthcare system all over the world. We have projects mostly in the US and Canada but also in Europe, the Pacific and South Africa now and several developing countries. So our basic work is research and development first. We try to identify or create prototypes that really perform current designs in healthcare for better safety and effectiveness and patient-centeredness and lower cost. We then try to test those prototypes with colleague organizations around the country or around the world, hospitals or clinics or practices that are willing to try new designs and see if they work and debug them. And then we have lots of activities to spread the innovations we can find that are helpful. We do this through large meetings. We have our big national conference coming up in December which will have about 6,000 people there and 15,000 on satellite. We have a website. It’s open to everyone, ihi.org. And in the past four years, we sponsored major national campaigns, the 100,000 Lives Campaign and the 5 Million Lives Campaign, which are intended to get literally thousands of hospitals to adopt a focused set of changes that make patients safer and reduce unnecessary harm and mortality.
David Harlow: Yes. And I understand that through the 5 Million Lives Campaign that something on the order of 80% of US hospital beds are now in institutions that have signed on, if you will, to this campaign.
Don Berwick: And the response has been amazing. We proposed twelve changes in care processeses and governance in hospitals to make patients safer. And I think the last number was 4,030 hospitals have signed up in the United States alone, and there’s spinoff campaigns being run by colleagues and friends in eight or nine other countries. So the response has been pretty dramatic. I’m sure but not all of the places are actually seriously changing process but many of them are, and we have been seeing phenomenal results in some.
David Harlow: Well government payors, CMS, and private payors as well have been tracking particular care processes or care outcomes – I’d actually been interested to hear your perspective on that -- and have been using as the basis for pay-for-performance programs. Now my understanding is that the programs that you’re describing are not necessarily tied to any payors but rather to care improvement in a more general sense. Is that a fair statement?
Don Berwick: Yeah. IHI is one player in the changing landscape in healthcare that has both elements of push and elements of pull. The pull is what IHI deals with; we’re working with hospitals and clinics and clinicians and leaders all over the world and appealing, I think, to their intentions to do well. They want to be proud of their work and they’re interested in how to make changes and they’re being helped by transparency by turning the lights on and much better able to measure patients’ injuries or mortality or patient satisfaction for example to where we’ve ever been before. So there’s a side here that reflects ambition, aspirations, kind of a spirit in the work force. And I think that’s what IHI basically works with…but it’s no surprise. There’s push also from the society at large, the payors like the government payors and private payors, the public at large represented through consumer groups, Consumers’ Union, AARP and so on, and the employers who are paying the bills upstream for their employees. Those outsiders to healthcare want healthcare to be quite accountable. And once it becomes evident that certain kinds of complications or extra cost or overuse or risks are reducible or in some cases can be eliminated, there’s no surprise that the environment, the payor community, the patients have wondered or are really asking and I guess, in some cases demanding that the changes be made. There’s push and pull.
David Harlow: I understand that yesterday IHI ran a national learning network event and I imagine a number of ideas along these lines were showcased. I wonder if you could speak to a couple of them and maybe observations on where some of the successes are and what you see as some current trends.
Don Berwick: Sure. The National Network Day which was yesterday is one of the big national events we’ve been running in the campaign period of now four years of campaigning. I should say first that the campaign that IHI is supported by philanthropy so that, for example the Blue Cross Blue Shield Association and Blue Cross Blue Shield plans around the United States have donated considerable amounts to IHI and to local entities that help spread changes. Cardinal Health has helped. Other foundations have helped. So everything in the campaign is free. There’s no cost to hospitals that want to get access to it. So the campaign team has been funding different vehicles to give access to anyone that wants information on how to make changes and especially reports from places that have done so.
So yesterday was a day of sharing in which after some introductory remarks by among others, Richard Umbdenstock, the president of the American Hospital Association. We ran, all day long, virtual workshops on the phone and internet and web in which hospitals can report in on things they are proud of doing or lessons they’ve been learning. We had hospitals that have gone a year or two or in one case four years without a single ventilator pneumonia. We have the central line bundle which causes reduction of bacteremia in patients with central lines -- they don’t get septic -- which we developed a number of years ago. It has been expanded in the keystone project in Michigan. And they did a workshop on prevention of bacteremia. We have hospitals that are just making tremendous gains even in some cases hospitals that have reduced mortality rates measurably, dramatically in some cases. So they’re sharing how they did it and then curious teams and hospital leaders who wanted to understand how others have done it can get that information. We have about 200 mentor hospitals in the campaign. These are the hospitals that we track major results reduction or pressure sores or improvement of heart attack care or reduction of infection and they sort of donate their knowledge back into the pool of knowledge. And they also were available on this National Network Day.
We had through the day, I’m told, over 2,400 phone lines were open at one point or another to get these information. At the peak we had something like 460 or 470 phone lines open with ten or twenty people at each phone line. That’s thousands of people getting information from each other.
David Harlow: That’s terrific. And it’s very encouraging just to see the level of engagement in this sort of activity. You mentioned earlier twelve changes in care processes that were to be undertaken and I’m wondering how you would compare these processes or how these processes are selected because I’m comparing that to the many -- in some cases, dozens and dozens of processes or indicators that are collected and reported on to various payors including government payors. I guess the question is as hospitals are involved in dealing of a number of different payors and required to report on many different indicators, has your work shown that there is a small pool of indicators that would really work as proxies for all these others in terms of institutional level of quality of care.
Don Berwick: Well, David, first you’re absolutely right about the cacophony of indicators and measures. Hospitals today have, I think, quite literally over 1,000 variables they have to report on somewhere about their own performance. It really makes them crazy and it doesn’t allow for the kind of focus that we really need nationally. And we don’t yet have a national agenda of prioritized improvements, what are the most important ones to make. I think soon some will emerge with the National Quality Forum which is this public-private partnership group that’s going to articulate some goals.
In fact there is a press conference November 17th by NQF that’s going to lay out six goals for American care which I’m pretty excited about. But the IHI’s campaign planks, we call them, the twelve planks, were picked because we had great evidence from the scientific literature, our own prior work, or the work of others, that these changes could be made by hospitals that they would result in reductions in harm and in some cases mortality and were not expensive to do. So they’re a selected group. They do overlap quite consciously with a lot of the indicators you’re referring to. We have a matrix -- you can see it on our website -- that shows how if you’re on board the twelve campaign planks at the moment you’re really hitting a lot of other requirements from the Joint Commission and CMS and payors and so on. So there’s some crosswalk. There are also logical ones. There are ones where everyone knows we can really make progress. A number of them bear on infection: like reduction of surgical site infections, reduction of central line infections, reduction of ventilator pneumonias, reduction of methicillin-resistant staph infections. There’s one on pressure sores, an avoidable complication that we know can be reduced dramatically within hospitals. We’re focused on cardiac care, which is an enormous area for hospital work: both acute heart attack care, making that very reliable, and the same for congestive heart failure which is the most common reason for admission in Medicare.
There are are a number focused on drug errors, medication reconciliation when patients move from one place to another that’s one. And another is a specific focus on high-alert medication -- that’s insulin, sedatives, narcotics, and anticoagulants -- which explain over half the serious injuries that patients get from medication errors in hospitals.
The twelfth plank is unusual and that’s not about a condition, it’s about governance. We call it Boards on Board and that reflects the need, really the imperative, that hospital governance and executive leaders take, in this case, patient safety firmly under their stewardship. This improvement in safety that we can achieve is not achieved without leadership from the boardroom and the executive suite. So plank twelve, Boards on Board, it coaches hospital boards on how to take cognizance and really be helpful to the improvement of patient safety. It’s kind of a rational set. It doesn’t do everything. There are other areas that we will be getting into. In fact IHI, after this December meeting, December National Forum, we’re going to be articulating a set of entirely expanded set of goals and aims that are even more related to what’s happening in the environment right now.
David Harlow: Great! Are those would tie in with some of the other standards or goals that are being articulated by NQF and others?
Don Berwick: Yeah. We’re going to try to make sense of the cacophony so it won’t be just repeating a bunch of, a long, long list of standards but trying to come up with this real serious leverage. And by the way, incorporating cost reduction -- because among the improvements you can achieve with really conscientious process management is reduce cost while helping increase the experience, improve the experience of patients and the staff so you’re going to see a number of initiatives on our part that are strongly focus on wise reduction and cost because we badly need those as well.
In the end, that’s where we’re headed for our hospitals -- because this campaign is focus on hospitals right now -- hospitals that function at a completely new level of reliability and patient-centeredness and lower cost. And that’s what we’re going to try to accumulate and plan for over the coming months.
David Harlow: Do you have a view on expanding some of this work to non-hospital settings as much of healthcare is moving -- ?
Don Berwick: Oh yes for sure. IHI has perhaps, well now close to half our work in the non-hospital settings. Next March, just as we have our National Forum in the December, we have, I think, our tenth annual meeting called On Improving Office Practices and that focuses on ambulatory care, care across the continuum. We currently have a grant from the Commonwealth Fund to work at the level of states on reduction of unnecessary hospitalization through improvement of care for chronic illness across the continuum. We have a wonderful project with the Indian Health Service now which is focused on chronic disease care in the Indian Health Service which is almost completely an outpatient issue, not an inpatient issue. We also have a major research and demonstration project now underway called the Triple Aim project which deals with population-based care, dealing even beyond care into issues of prevention of illness and the total per capita cost of healthcare in a population. As of now, we have over forty organizations, most in the US but not all, working on innovations and new designs to improve care at the population level. So we’re doing a lot more than just hospital care, but a lot of hazards lie in hospitals and so we’re going to keep the spotlight there as well.
David Harlow: Yes. You’ve mentioned cost control and cost management. Do you see a focus on that increasing in the minds of hospital administrators given the current economic crunch or is this a long-standing issue that’s just being worked on now?
Don Berwick: Access cost has been a problem in the US healthcare for three decades at least so it’s a chronic problem of high severity. We’re at a great disadvantage economically as a country because of what we pour in to healthcare -- close to 17% of the GDP. And since IHI is a global organization we work with and see systems in Europe and elsewhere that function at half our cost per capita and get results every bit as good as ours and, if you read the Commonwealth Fund’s research, in most cases a lot better.
We’re at the bottom of some lists that you’d expect that we’d be on top of given our expenditures so it’s chronic. I think the latest financial crisis only adds fuel to that fire and I think converts a chronic crisis into something pretty close to an economic emergency. And I’m sure hospitals are making major adjustments now as all organizations have to in our country and worldwide.
From IHI’s point of view, this is about waste. It’s not about cutting back on things people need. It has to do with getting very smart about what it is that we do that doesn’t help anybody and getting that out of the system. My own estimate through the years has been that at least 30% of American healthcare costs are in that pot. They don’t help anyone. They’re just pure waste. They’re administrative cost and excess care that can’t help, unscientific care, variation based on habit, not fact. And conscientious professional leadership, conscientious organizational stewardship, and good public policy ought to be able to identify that overuse, that waste, and remove it from the system thus saving a lot of money without harming a single patient and advancing the health of communities.
David Harlow: Do you see some of the new information technology tools as being particularly useful or more helpful in trying to move organizations into an evidence-based medicine mind set? You and others have been talking for years about certain lean management principles, but as you’ve said there’s still a tremendous amount of excess cost in the system. Do you see an opportunity with expansion of information technology in this area?
Don Berwick: Yeah. I’m of two minds on information technology and on the one hand, it’s kind of falling off a log to say we need it. I mean, for Pete’s sake, we’re still not even in 20th century, let alone 21st century information technology in most of healthcare and it’s time to go there. Our care would be more reliable. The flow would be smoother. Patients would be remembered. Chronic disease care would be integrated. Finance could be better managed if we have better information. And so we definitely need to modernize healthcare information technologies and the underlying infrastructures and rule base for that. There’s no question that would be helpful. It’s time to have an electronic medical record and I was part of the Institute of Medicine committee thirty years ago that said that.
On the other hand, I don’t think we should expect information technology to be magic. It isn’t magic. In fact, the big mistake would be that we could introduce information technology and not change processes and then we’d just be automating the current inefficiencies and defects and it would be easy to that. We have to do two things which are modernize information and change care and the combination would be extraordinarily powerful. Is it necessary to modernize information in order to change care? I don’t know. At some level, no. I think it’s possible for a local unit or clinic or hospital to do quite a bit with whatever information they happen to have, but it certainly would be helpful that we can get synergy between information management and improvement.
In some organizations we’re seeing that. There are recent breakthrough, for example Kaiser Permanente which has invested literally billions of dollars on modernizing its information platform but they are also beginning to harvest from that important new forms of redesign, such as making home the hub for care. That’s one of their slogans and it really is real. And they’re going to exploit opportunities for better care with better information and I think could give us a good head ups on what’s possible. They are not alone and so we need to be tracking these very progressive redesign projects.
David Harlow: Sounds great. So in sort of wrapping up, I’m wondering if there’s any other areas or any other advice that you might offer to healthcare organizations as we face both the economic crisis and a new administration in Washington, and also what you might have to say to a new administration in Washington, areas of emphasis that you would like to see from a federal policy perspective.
Don Berwick: Well, let me start with policy and then I’ll talk about organizations. At the policy level, in our country, the most important leadership we need governmentally to me is back in the domain of ethics and human rights. I mean, healthcare is in almost every other country in the world -- and certainly in every other developed country -- clearly a human right. And they don’t negotiate on that point. They then figure out how to make it so and struggle through the difficulties of doing that. We haven’t done that in this country and I’m looking for congressional, presidential leadership that finally crosses that bridge and says it’s just not right to be a wealthy, first world country, and have anyone be denied healthcare that they need. A big important form of that and also related to policy is to close the gap between rich and poor and black and white in our country. The worst [sic] predictor of your health status today in America is the color of your skin and we need to end that as a fact. It has to be changed, and so I think that is also a matter of public commitment and federal policy and governmental leadership.
At the more technical level, we need government leadership to modernize information technology, that’s clear. We also need to reconfigure the role of government, especially as payor, to help us integrate care across boundaries. We’re very fragmented in the way we pay for care even from the federal government level and we need better chronic disease care, especially, in this country. And that’s going to involve new forms of integrated payment that return us to if I dare say the best kind of managed care not the evil managed care, not the mutant managed care, but the good managed care, that really means I’m helped in my journey through my chronic illness. I think we need to focus on wise cost reduction and we need federal policy that supports that. And we need to research on that so we understand what costs can be reduced without harming people. We need much more voice for patients. CMS and others have been very good in helping patients speak up through proper data and surveys and reporting requirements. And I think we need even more of that.
On the organizational side, I would guess the two most important lessons I’ve been learning are first, it does take leadership. Until executives, heads of boards, the lay executives, clinical executives, nursing leaders, physician leaders, own improvement of care as their job, it’s very hard for the workforce to get organized to make care better and we really need executives alert and at the helm to make care better. It’s got to become part of the job, and every way we can do that will help. The other good side of that lesson is, I think, executives who do that are going to find a workforce -- doctors, nurses, pharmacists, receptionists, therapists, and middle managers -- they’re going to find a work force ready to really help. I mean IHI’s 5 Million Lives Campaign is uncovering this enormous amount of goodwill on the workforce to make care better. It’s there. And executives and boards that realize it and go for it are going to find it available and I think that’s a piece of good news that I want them to hear.
David Harlow: That is a piece of good news. And I thank you for joining us today. I’ve been speaking with Don Berwick. This is David Harlow on HealthBlawg. And Dr. Berwick, thank you again for joining us. I appreciate it and enjoyed our time speaking together.
Don Berwick: Thank you, David. It’s been my pleasure.