FEBRUARY 2005FEBRUARY 2005

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“I’m losing mypatience”“I’m losing mypatience”

IHI CEO Dr. Don Berwickis creating a groundswellof support for healthcareimprovement

IHI CEO Dr. Don Berwickis creating a groundswellof support for healthcareimprovement

Politics are a very strange animal.The ve-hemence brought to the table by theextreme left and right—and just about

everyone in between, too—strikes me as bothfrightening and encouraging.

One on hand, the activism is heartening tosee, especially in the youth.More people cast aballot in 2004 than in any other Presidentialelection in the nation’s history, accounting fornearly 60% of eligible voters.

On the other hand, I read recently thatwhile all of the ballots haven’t been countedyet, 50% or more of the eligible populationvoted in Iraq’s first election—and every singlevote they cast was its own small victory.

American voters sometimes have to dealwith long lines and confusing instructions; Iraqivoters had to keep an eye out for suicidebombers and black sedans distributing leafletsthat promise death to every voter—not tomention the decapitation of their children.

I vote, but readily admit I wouldn’t have thecourage to vote if I had to do it under the pallof a death threat.Then again, if improvementsaren’t made in the U.S.healthcare system,pre-ventable errors will kill thousands of Americansas surely as any act of violence.

Dr.Don Berwick,CEO of the Cambridge,Mass.-based Institute for Healthcare Improve-ment (IHI), is trying to tap some politicalstrategies to create a groundswell of support formaking desperately needed changes.The sub-ject of this month’s Executive Profile (see page18),he has seen the healthcare system in actionfrom almost every perspective—practicingphysician, academic, activist and businessman—and he’s tired of strategies without deadlines.

“I’m losing my patience, not with the peo-ple in healthcare, but the system itself,” he saidduring his keynote address at IHI’s recent an-nual meeting in Orlando.He wants results, notpromises of vague improvements to beachieved by some unspecified date.Borrowinga motto from the political arena, he often says,“Some is not a number; soon is not a time.”

THE SAFETY IS IN THE DETAILSDr.Berwick wants to save 100,000 lives by 9a.m., June 14,2006, and he has identified sixspecific changes that will achieve that goal.When he outlined his plan to me,with all of itsdetails and very specific timelines, it was a gen-uinely moving experience.Looking at the ideasand deadlines in black and white made me be-lieve. In fact, his figures are admittedly conser-vative, assuming that only a third of U.S.hospitals will implement the changes, and thatthey will achieve a smaller success rate than es-tablished studies have shown to be possible.

This past year, I watched in fascination andhorror as intelligent people on both sides of thepolitical spectrum spewed vitriol at each otherover a pseudo-documentary by filmmakerMichael Moore.You could see the rage and ag-gression in their eyes, and in some cases, itlooked like barely controlled violence.

I understand the intensity to a certain ex-tent—it was a polarizing film, for certain—butwhere is that energy when it comes to ourhealthcare system? Someone, somewhere,probably suffered an adverse health eventwhile they were actually watching that filmand had to go to the hospital.Did the concernand apprehension they felt while watching themovie escalate as they were en route to ahealthcare facility? If not, perhaps it shouldhave; experts agree that hospitals aren’t as safeas they could and should be.

My guess is, though, that their moral andpolitical dander cooled after they left the the-ater, and that’s the first thing we should strive tochange.

We need, as Dr.Berwick is showing, to har-ness that activism and motivation to changehealthcare—not for some of us, but all of us—and we don’t need to do it soon,we need to doit today. MHE

Converting political fervor for the benefit of everyone

If Americans were half as adamantabout improving healthcare as they areabout partisan politics, we’d all be saferBY MICHAEL T. MCCUE

Mike McCue iseditor-in-chief of MANAGED

HEALTHCARE EXECUTIVE.He can be reached atmmccue@advanstar.com.

A S GEORGE BERNARD SHAWonce said,“Nothing is ever done in thisworld until men are prepared to kill

one another if it is not done.”While accidentalfatalities—even those caused by preventablemistakes and human errors—are a far cry frommurder, Don Berwick, MD, has seen enough

death. He’s also heard enoughrhetoric about ways to im-prove healthcare quality.

“I’m losing my patience,”he said during his openingspeech at the 2004 annualmeeting of the Institute forHealthcare Improvement(IHI) in Orlando, “not withthe people in healthcare, butthe system itself. Healthcareprofessionals are doing somany things so well; they’reputting actual transformation

within reach. Now we need to grab it. Theclock is a tyrant, and if you spend too muchtime ‘getting ready,’ you’re going to lose.”

Dr. Berwick, founder of the Cambridge,Mass.-based IHI, has fought this battle on justabout every possible front. He’s been a provider(pediatrics), an academic (current faculty mem-ber at Harvard Medical School), businessman(CEO of IHI), and quality improvement vi-sionary (IHI leads many cutting-edge programsthat aim to move the industry beyond the sta-

tus quo; one example is Pursuing Perfection, a$21-million initiative of the Robert WoodJohnson Foundation).

He’s listened to patients relate heartbreak-ing tales of tragedy, and even though he’s heardhis share of inspirational success stories as well,he wants the industry as a whole to stop talkingand start doing.

He has recently started borrowing a politicalmaxim:“Some is not a number; soon is not atime.” During his opening presentation at IHI’s2003 meeting, he asked attendees which wouldhappen first:Americans get the healthcare sys-tem they need and deserve, or the Red Soxwin the World Series?

“I bet against Boston,” says the avowedmember of Red Sox Nation. “My mistake.What I should have done is set a deadline forfixing healthcare.”

A man who rarely makes the same mistaketwice, he now has a very specific, time-sensitiveplan: to save 100,000 lives by 9 a.m., June 14,2006. It will be accomplished by launchingIHI’s “100,000 Lives Campaign,” which aimsto incorporate six changes into 1,600 U.S. hos-pitals within the next year and a half.The words“some” and “soon” don’t appear anywhere inhis game plan.

THE BIG SIXThe Campaign’s six change initiatives are:

■ The creation of Rapid Response Teams to

Dr. Don Berwick, CEO of theInstitute for HealthcareImprovement, has a plan tostop the rhetoric and startthe improvementsstory | Michael T. McCuephotographs | Sameer A. Khan

“I’m losing mypatience”

intercept unexpected deterioration ofinpatients;

■ Developing reliable, evidence-based care for acute myocardial infarc-tion (AMI) to reduce mortality due toheart attack;

■ Increased use of the so-called ven-tilator bundle, a set of scientifically val-idated processes used for managementof ventilated patients to prevent venti-lator-acquired pneumonia;

■ Increased use of the central linebundle to keep indwelling venouscatheters from becoming infected;

■ Prevention of surgical site infec-tions, largely by reliable use of appropri-ately chosen and appropriately timedperioperative antibiotics; and

■ Prevention of severe adverse drugevents through the use of so-calledmedication reconciliation procedures.

“The problem now is very clear:The buck stops not with the work-force, but with governance and senior

leadership,” Dr. Berwick says. “The improve-ments will happen because of senior leader-ship, or not at all.The front-line workers areready, willing and able to implement the sixchanges we need to meet that goal of 100,000lives saved.

“But the attention of the strategic leadersin healthcare has not been focused on the im-provement of care.The strategic objectives havefocused on more traditional goals such asgrowth, marketing and capital development.We need leaders to create a new future, not de-fend the status quo.”

His goals are aggressive, but Dr. Berwick isnot asking those leaders to fly blind.The sixinitiatives he identified are proven to be suc-cessful. Rapid Response Teams, for example,have demonstrated their worth in real-worldhealthcare settings. In a 1999 article published inthe Australian Medical Journal, authors reported a27% decrease in hospital mortality rates fromthis single intervention alone.

BUNDLING IS BETTERWhen speaking with Dr. Berwick, the conceptof “bundling” comes up frequently. Getting

medical facilities to adopt this concept won’tbe easy, however, because it’s much harder onresults than the current system.

For example, it is widely accepted that thereare specific things that should happen when apatient presents with AMI:

1) early administration of beta-blockers andaspirin,

2) beta-blockers and aspirin at discharge,3) an ACE inhibitor or angiotensin receptor

blocker at discharge if they have systolic dys-function,

4) timely reperfusion, and5) smoking cessation counseling.If 100 patients with AMI came into a hospi-

tal and 90 of them received beta-blockers atadmission, compliance would be 90% for thatintervention, according to standard methodol-ogy.“Currently, we score our reliability for thoseinterventions as a list of numbers, one for eachitem—90% for beta-blockers at admission, 95%for aspirin at discharge, and so on,” Dr. Berwicksays.

“What we at IHI want to do is grade health-care on a pass/fail basis on the whole bundleof interventions.A hospital would get a ‘yes’ if itdid everything it was supposed to do for a pa-tient, and a ‘no’ if anything—even one ofthem—was left out.We at IHI call the bundledscoring system ‘raising the bar on performance.’”

As with the Rapid Response Teams, thereis hard scientific evidence to back Dr. Berwick’sclaims on reliable AMI care. Hackensack Uni-versity Hospital (Hackensack, N.J.) and McLeodRegional Medical Center (Florence, S.C.) aretwo organizations that were willing to adoptthe more stringent system, and had to makenumerous changes to accomplish it: using stan-dard protocols for care, providing reminder sys-tems and changing job designs.They achieved a50% reduction in inpatient AMI mortality ratesin less than a year.

CRUNCHING THE NUMBERSWhen a 500-bed hospital implements all sixstrategies, here’s what Dr. Berwick believeswould happen:

■ If the Rapid Response Teams were ableto reduce hospital deaths by 10%—less thanhalf of the 27% achieved in the Australian facil-

DR. DON BERWICK

“The problem now is very clear: The buckstops not with theworkforce, but withgovernance and seniorleadership.”

ity cited in the original study—it would saveapproximately 120 lives.

■ If all patients received the proper AMIcare, it would cut mortality 50%, saving ap-proximately 50 lives.

■ An 80% reduction in ventilator-associatedpneumonia and lethal drug errors would eachprevent about 10 deaths.

■ An 80% reduction in surgical site infec-tions would save 30 lives.

■ Proper prevention of central line infec-tions would prevent 10 deaths.

The grand total: implementing those six in-terventions in a 500-bed hospital would save230 lives per year.

“Let’s be more conservative with that num-

ber,” Dr. Berwick says. “Let’s say we achievedabout half of that … 125 lives per year.That’sone life per four beds in that hospital. If that’sour estimate, to prevent (or at least delay) 100,000deaths in a year, we would need to implementthose six improvements in 400,000 hospital beds.

“There’s our hard count: six interventions,1,600 hospitals, 400,000 beds,100,000 lives saved.”

Some is not a number.

NO TIME LIKE THE PRESENTDr. Berwick is mobilizing the 100,000 LivesCampaign with a few tricks he picked up fromhis son Dan, a veteran in the world of politics.

“Campaigns have field operations—so dowe,” Dr. Berwick says.“If an average-sized hos-pital has 250 beds, that means we’ll need to get1,600 of them—about one third of the total inthe United States—to achieve our goal.

“Campaigns have message discipline, so weneed to impart our message in such a way thatit can help where it’s needed.We must meeteach hospital on its own terms. If making allsix changes is too much, how about three? Howabout one?

“Campaigns have motivation.We created aseries of seven videos, supported by the RobertWood Johnson Foundation, based on the manylessons we learned during our Pursuing Per-fection Initiative. IHI is now making them avail-able for purchase to anyone who wants to seethem, and I encourage everyone to do so.

“In our campaign, I don’t even hope thatthe majority of healthcare organizations areready to make improvements in their core strat-egy. But I deeply sense that a substantial andimportant minority is.That’s the group we’retrying to appeal to.

“When all is said and done, maybe you aren’tone of the hospitals we need to target,” he con-cludes.“Maybe you’re already there. Still, I haveone minor request: Please check your own dataand progress.Are you raising the bar, or merelyat the bar?

“If you’re sure you are already performingat the highest level, then help the others get tothe same place. Be a mentor. Join our campaignstaff. Every life saved counts, even if it’s in anorganization other than your own.”

Soon is not a time. MHE

DR. DON BERWICK

“We must meet eachhospital on its ownterms. If making all sixchanges is too much,how about three? Howabout one?”

HEADQUARTERSCambridge, Mass.

YEAR FOUNDED 1991

STAFF 75

MISSION STATEMENTTo improve the lives of patients, thehealth of communities, and the joy ofthe healthcare workforce.

GOALSTo work with healthcare providersand others to accelerate themeasurable and continual progressof healthcare systems throughoutthe world toward: safety,effectiveness, patient-centeredness,timeliness, efficiency, and equity.

AT A GLANCE

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