|
I N T E R V I E W
B E R W I C K & G A L V I N
W E B E X C L U S I V E
12 January 2005
‘A Deficiency Of Will And Ambition’:
A Conversation With Donald Berwick
Responsibility for improving
U.S. health care lies not with
individual consumers but with the power centers,
where commitment has been lacking.
By Robert Galvin
ABSTRACT:
A leading champion of health care quality sees
the slow pace of improvement as evidence of a failure of provider leadership
and concludes that external pressure will be necessary to move the system toward
meaningful change. Donald Berwick, founder of the Institute for Healthcare
Improvement, supports performance incentives for hospitals and health systems.
But in this interview with Robert Galvin, director of global health care at
General Electric, Berwick expresses skepticism about the value of “pay-for-performance” schemes
for individual doctors and nurses and emphatically condemns increased patient
cost sharing as an appropriate tool for increasing the efficiency of the health
care system.
Robert Galvin: Don, since you have focused for
more than a decade on clinical quality improvement, what are your thoughts
about how the system is doing? Do you have a sense that we’re making
progress? And, if so, are we moving fast enough?
Donald Berwick: I think that the first stage in
progress is awareness. You can’t solve a problem you don’t know
about or don’t recognize. We’re making progress on that front.
The IOM [Institute of Medicine] has clearly been of immense national assistance
in this, and we now have a pedigreed acknowledgement of the degree to which
health care underperforms. So, high score for awareness.
The pace and improvement of care itself are still very
disappointing. Despite a lot of attention and push, and despite the presence
of a few organizations that are starting to really change care, it has not
become the mainstream agenda to change care properly yet. So we’ve still
got a long way to go.
Galvin: Within those few organizations that have really
taken on change, are you finding that they have what it takes to get that change
done?
Berwick: Different kinds of capacity are needed. Do
they have the physical and financial resources to make changes? We already
have a bloated system with tremendous excess capacity. So we don’t really
have a resource issue here, in my mind, with a few exceptions.
There’s workforce capacity or capability: Can people
in the workforce—doctors, nurses, receptionists, therapists—change
their own work? Are they capable of making innovations happen? The answer is,
No, they’re not. We’ve never trained the workforce to change its
work. So we have a capability-building agenda that’s really important.
And all the successful organizations are investing in retraining their own
staffs.
That is not a primary problem, though; it’s a secondary
problem. The capability that is key to the proper allocation of resources and
development of the proper workforce is leadership, and that’s where we
still lack traction. It’s not that we don’t have capable executives
and committed boards. It’s that the capable executives are still devoted
to maintaining the status quo. And the hospital boards—I don’t
know if this should appear in print—but they’re sort of out to
lunch. They’re good-hearted. They care about the organizations that they
are stewards of; they respect the managers and the doctors. But they don’t
understand that they have a duty to cause change. And without executive and
board leadership, I’m not sure we’re going to get off the dime.
Professional Education
Galvin: Let me take that response in a couple of directions.
First, I’ve always been impressed with how difficult it is to get the
medical education system to take on the task of creating leaders. Despite fifty
years’ worth of commissions working on various aspects of reforming medical
education, including quality and leadership, little uptake seems to occur once
these reports are disseminated. Do you have a sense of why it is so difficult
to effect educational reform and what it would take to change that?
Berwick: I agree with your observation. First, let’s
not confine it to medicine only. Although educating doctors is important, there
are nurses and health care administrators and paraprofessionals and therapy
professionals, all of which have the same issues. So I think it’s a mistake
to focus only on medicine.
It’s been a remarkably difficult arena to get changes
going in. Partly it has to do with the economics of education—and I don’t
mean the money. I mean the budgeting of time. You have a student in your hands
for a certain amount of time. And the way educational systems work is to regard
that time as if it were currency: It’s doled out among the various stakeholders.
There are no internal stakeholders for the processes of improvement
and change in the modern medical school. The stakeholders are in biochemistry
and physiology and pharmacology and surgery and medicine—in the traditional
buckets. So once you’ve taken all the time you’ve allocated out
to the buckets, there’s nothing left over for a course on safety or system
leadership or physician stewardship and change, often even ethics.
It’s starting to change. The AAMC [Association of
American Medical Colleges] now has an internal unit on changing professional
education toward improvement. We have absolutely courageous leadership of ACGME
[Accreditation Council on Graduate Medical Education], and David Leach [ACGME’s
executive director] is defining new competencies in doctoring, which are very
related to system change. That’s really compelling. I don’t know
why it’s such a dense shell to crack here, but it’s very difficult.
Role Of The Industry And Its Leadership
Galvin: Outside the health care sector, boards have
played major roles in keeping organizations accountable. I have observed the
same thing you have in health care, which is that the best business people
in their communities join a hospital board and suddenly don’t ask the
questions they would ask in their own sector. They seem overwhelmed and intimidated
by the fact that they’re not technical experts in the field. However,
these same people serve on other boards outside their expertise and become
actively engaged. Do you have any thoughts about how to address this?
Berwick: There’s a deficiency of will and ambition
in the major centers of power in the delivery of health care in America. We
do not have a shared aim to raise the bar in performance. That’s the
problem. Where will one find will? Certainly from Leapfrog and public pressure
and outsiders who say, Come on, wake up and get this done. But you need insiders
also, and translators. And where would you go other than the board and the
senior executive suite? The observation is just as you say. Boards have tended
to be seats of honor, not stewardship. Board members are volunteers, so it’s
not their day job to be guiding the organization. They trust their doctors,
and they’re intimidated by the technology and the technical aspects of
care. As a result, they do not inspect the core performance characteristics
of the organization that they are stewards of, other than finance, and that’s
the problem.
Galvin: I agree. Let’s talk about other major
centers of power in health care delivery. Are you finding that organized medicine—whether
specialty societies, the AMA [American Medical Association], or others—have
been obstacles or assets, as you’ve been trying to improve quality?
Berwick: If I’m interested in change, I need three
things: the will to change; ideas, alternatives to the status quo; and the
management of change, as an ongoing process. With respect to will, the dues-paying
organizations—the ones that have members and depend on the core membership
to supply them with the resources to be an organization—always have to
play to the middle of the pack. They can’t push their members too hard—nor
would I, if I were running those organizations. So they have a lot of trouble
building the will for change. Most of the large associations, including specialty
groups, are arguing for further resources for the status quo, and that’s
not going to get us where we need to go.
We have occasional examples of the opposite. The Society
for Critical Care Medicine is an interesting case in point. So is the American
College of Cardiology. On the technical end, they are very forthcoming, saying, “Major
improvements are needed in our specialty area. Here’s how we can get
there; here are the protocols and guidelines we should be using.” They’ve
gone out in front of their membership a bit. But at the moment we still aren’t
able to turn to the core trade associations to develop the system of the future.
With ideas, it’s a little bit different. Once you
get into the guts of an organization, you find that there are tremendously
interesting things going on in the membership, and those who have looked and
asked who’s really doing something very inventive on nursing practice
or on safety have hit pay dirt.
I think that the AMA deserves a tremendous pat on the back
for its work getting the National Patient Safety Foundation going, which is
a national treasure. It’s a resource now for the exchange of good ideas
on safety. The late Jim Todd [former executive director] really caused that
to happen. Another bright light has been the Joint Commission [on Accreditation
of Healthcare Organizations]. I think that Dennis O’Leary [JCAHO executive
director] has been brilliant in his slow but steady navigation of that system
into one that is trying more and more to support improvement as a core feature
of the organizations it surveys, and I think we’re going to see more
progress in the future. The other commendation has got to be given to Steve
Jencks and his team at the CMS [Centers for Medicare and Medicaid Services],
who are not satisfied with the status quo. They’re really pushing the
envelope. Overall, though, I’m less and less sure that the will for change
is going to come from inside the industry. I just don’t think it’s
there.
External Influences
Galvin: You mentioned that the will for change may not
come from inside the industry, be it organized medicine, the education system,
or the governing boards of directors. In other sectors it is common for the
motivation to change to arise from external conditions. So I’m interested
in your thoughts on the impact of the Leapfrog Group, an effort organized by
the purchasers of health care, both private-sector employers and public purchasers.
The Leapfrog agenda has focused on transparency of clinical performance, benefit
incentives that engage consumers and patients in the quality and cost of care,
and payment reform so that reimbursement reflects performance. My question
is, What do you think is the potential for that agenda, and how do you think
it’s doing, in terms of being one of the external drivers for change?
Berwick: Well, Bob, it would be mistake to try to answer
without acknowledging your role in teaching me about this. My opinion on this
has shifted greatly, thanks to the time that you spent with me. Transparency
is a don’t-pass-go issue. I have completely lost faith in the concept
of confidentiality as an important asset in improvement. On the contrary, I
think that the more public we can be about performance, the more we’re
going to get serious about making changes. That’s not just about incentives,
it’s about learning. Until we have a country that is comfortable finding
out who’s the best at something so that we can all learn from them, we
can’t learn from them. So I think transparency is essential. It is difficult,
because you can oversimplify. You can be transparent about the wrong thing,
or claim that Measurement A actually is about a different phenomenon than it
really is. But we’ll get better and better about that. I’m totally
on the transparency wagon at this point.
Pay-for-performance at the entity level would be probably
a pretty good idea. It would be better for organizations that are safer and
more effective and more patient centered to find that that’s good for
their wallets. It is always a little bit troublesome to me, though, that we
have to dangle money before the system before it does the thing it was created
to do. There’s something a little off-center about pay-for-performance
as a fundamental strategy, and I think we should talk more about that. But
it’s probably going to be helpful.
It’s really crucial that anything we do with pay-for-performance
and incentives be linked strongly with a capability-building agenda. The average
hospital, the average doctor, cannot improve what they do, because they don’t
know how. That’s a big, big gap, and that part of the strategy has got
to be completed.
The one part of the plan that I am absolutely against at
the moment is the shifting of burden to individual patients. I do not believe
that making the individual American patient more “cost-sensitive” has
any rationale in science, ethics, or evidence. It will fail, and it will fail
miserably. It will result in a shifting of care away from the people who need
it the most. It is a displacement of responsibility for changing the system.
You know, if CalPERS or Xerox or GE can’t change care through using its
purchasing power, then I absolutely promise you that Mrs. Jones can’t.
The idea that she will now be more sensitive because she pays an extra ten
bucks out of pocket is, to me, nearly stupid. So I really disagree with that
element of the agenda.
Internationally, when one looks at high-performing systems
around the world—and ours is nowhere near the highest-performing one—it
is almost a routine characteristic of the best systems that they have first-dollar
coverage, and there is no attempt to make patients pay more when they’re
sick, which is a stupid thing to do.
Transparency And Pay-For-Performance
Galvin: On the transparency issue, I have followed your
work for a long time, and it is worth noting that your current view represents
a major change in your thinking.
Berwick: I used to think we had to privilege such information
so that people could use it to improve. In return for some privilege, the producers
of care would get serious about improving the care. And that has so utterly
not panned out that I no longer think it’s a bargain worth making. One
other comment: I don’t think transparency operates primarily because
it informs consumers. I think it operates primarily because it reaches the
superegos of the people who are involved.
Galvin: I agree that much of the effect of transparency
is exactly what you said: the knowledge that providers didn’t have before.
It’s the pride they take in their work. I would add that the implicit
threat of loss of business from scoring poorly is also a factor. Human nature
is complex: Pride and fear of loss of income are not mutually exclusive.
But let me move to where I think we disagree. Pay-for-performance
is a part of payment reform, and there are two distinct issues. The first is,
don’t punish quality. By that I mean, to the extent that any hospital
or provider is paid on a fee-for-service basis, and if the highest-quality
care means doing less service, then doing the right thing for the patient means
hurting the provider’s own income. That’s different from paying
more for or rewarding high performance. So let’s stop disincentives for
quality and then provide real incentives for quality. The conceptual basis
of this is—as unsettling as it may be to “dangle money” to
increase motivation—grounded in personality and motivation theory. In
private industry, we would simply call it understanding what makes people tick.
People respond to incentives. So part of the pay-for-performance movement is
based on this idea that clinicians are really no different than other people
and that they’ll respond to incentives.
Something else you said is that pay-for-performance isn’t
enough: You also need the capacity to improve. Proponents of performance-based
payment believe that the responsibility of the market is to deliver clear messages
about what services will result in more business. To the extent that performance
falls short, it is the responsibility of the supplier to say, “We’re
not where we need to be; let’s figure out how to improve, and therefore
let’s go find an IHI or a similar organization and figure out how to
get better.” Our belief is that when demand arises, supply follows.
Berwick: Well, maybe. It certainly will drive expensive
consultancies, and lots of money will change hands. But will care get better?
I think that care will get better much more quickly with a national commitment
to learning, putting knowledge about improvement in the public domain, and
developing appropriate information infrastructures. I don’t think that
the market will be sufficient to support the kind of national learning we need
about what care has to become. I just don’t trust it enough. I think
we’ll end up with gaming. When we got DRGs [diagnosis-related groups]
into place, we didn’t get this wave of learning about how to manage cases
better. We got a wave of learning about how to bill properly. I want to induce
real improvement, not games—that’s all. And I don’t trust
the market to do that the way you do. I think that improvement should be regarded
as a property of knowledge for the common good, somehow. We don’t have
a national policy that really does that.
With respect to your first point about pay-for-performance,
I would first draw a very dark line between the incentives that apply to organizations,
boards, executives, and the bottom line of a company, where I do want incentives
in place. I want it to be good for an organization to be safe, and I want it
to be good for an organization to manage chronic illness carefully or to put
patients in control.
As far as organizational incentive structures—I want
the kind of reforms you’re after, to the extent that we possibly can.
At the individual level, I don’t trust incentives at all. I do not think
it’s true that the way to get better doctoring and better nursing is
to put money on the table in front of doctors and nurses. I think that’s
a fundamental misunderstanding of human motivation. I think people respond
to joy and work and love and achievement and learning and appreciation and
gratitude—and a sense of a job well done. I think that it feels good
to be a good doctor and better to be a better doctor. When we begin to attach
dollar amounts to throughputs and to individual pay, we are playing with fire.
The first and most important effect of that may be to begin to dissociate people
from their work. That’s really where we’ve come to, and we’ve
done it by pay-for-performance in terms of throughput measurements and manipulating
payment schemes.
I think we need a national agenda to restore joy in work,
and I don’t see that as the direction we’re moving in right now.
Ninety-nine out of a hundred people would think that’s a naïve comment.
But they don’t think it’s naïve when they go to work. Because
they know when someone shows up and says, I’ll pay you ten bucks more
to do a good job, they feel not helped out, not incentivized. They feel insulted.
And they ought to feel insulted. When we have garbage—bad doctors, bad
nurses, bad hospitals—we ought to nail them, shut them down, throw them
out, fire them. That will make the system a tiny bit better. But I don’t
think we’re going to get to the heart of the problem in American medicine
by paying doctors to try harder.
Galvin: Well, I think the jury is out. I can tell you
that in the Bridges to Excellence initiative, we’re being very careful
to avoid the kind of negative consequences that you mentioned. It’s interesting,
I think, the difference between the theory that you talked about, about satisfaction
in joy and work, which clearly is a motivator, and what we heard from a majority
of physician leaders as we developed the Bridges to Excellence program with
them. Their message was that to motivate their practicing physicians, financial
rewards were part of the equation. More than three thousand doctors are participating
in this program, and their message has been, “Look, I could use some
of this money for improvement. I could use some of this money to put investments
into my practice. And to the extent that either I am doing well or I want to
improve, pay-for-performance seems okay to me.”
Berwick: Well, I’m glad you’re doing it.
Because if it’s an experiment and will prove me wrong, I welcome that.
However, I don’t care so much what the doctors say. I care what the patients
say. The results we’re after are more expansive than the adherence to
a small set of criteria, which get them paid a little more. It’s an experiment
worth doing, and I’m glad you’re undertaking it. But in the end,
you’re going to have sick and troubled and suffering people meeting people
who want to help them. We’ve got to support the culture, clinical care,
and underlying system that make healing, not scoring, the objective. Of course,
when you’re talking money to the doctors, they’re going to talk
money to you. You say that we’re playing baseball, and they’ll
play baseball. But you’ve got to make sure it’s baseball you want
to play. That’s what we’ve got to keep our eye on.
The problem with pay-for-performance is not that it doesn’t
mold behavior. The problem is that it does mold behavior. You get exactly what
you’re paying for, which might not, in the end, when you’re finally
on your deathbed, be exactly what you wish you’d gotten.
Influence Of Government
Galvin: We’ve been talking about the role of external
influences but still within the health sector. Let’s move more externally
and talk about the influence of government in driving the quality agenda. The
election results were just in [two months ago], and a majority of the electorate,
by several million votes, have spoken in favor of a Republican agenda, of less
government and lower taxes. So given what the electorate is saying it wants,
how large of a role do you think government should play in the pursuit of better
quality? And do you think government can do it differently than they’re
doing it today?
Berwick: I don’t agree with the interpretation
of what happened [in the 2004 election]. I think that the public voted for
a party that has an agenda of less government and less taxes, but the reasons
why they made that vote may have more to do with morality and issues that have
nothing to do with less government and lower taxes. Try to take away Medicare
and see what happens. So I don’t think the public made that vote. I think
the Republicans have that agenda.
That notwithstanding, government is an extraordinarily
important player in the American health care scene, and it has inescapable
duties with respect to improvement of care, or we’re not going to get
improved care. Here’s some of what really counts: Government remains
a major purchaser. It’s much bigger than GE. So as CMS goes and as Medicaid
goes, so goes the system. CMS needs to continue to develop to be the best and
possible purchaser of care, on behalf of its beneficiaries. To do that through
giving more choice to individuals, as I said earlier, is a very weak lead.
To do it as an aggregate purchaser, demanding performance, is a very strong
lead.
Number two is research. AHRQ [the Agency for Healthcare
Research and Quality] does a great job, but with an embarrassingly small budget.
We spend less than a fraction of 1 percent of the money on understanding how
to configure care systems as we do on providing the pipeline of biotechnology
that those care systems supposedly deliver. That’s a misallocation
of resources. It would be as if GE worked only components and not products.
So, as we said in the IOM Quality Chasm committee, we need to billionize AHRQ
and create an aggressive and well-supported national agenda for public research
on better health care systems. That would be really a big win.
With respect to the transparency agenda, much data exists
in the hands of government—largely Medicare and also Medicaid—and
we should be using the data to improve transparency. I think that government
has an essential role in supporting the education of professionals and should
be helping to mold that education to create professionals who are better able
to help improve care.
I have an opinion about the issue that you and I touched
on a little bit, which is technical assistance. Where should a hospital or
group practice turn for support to improve its work? We can make that a private-sector
issue, and you have to find the right consulting firm. But I am biased toward
thinking of knowledge about improvement of care as a public good. I like the
idea of an agriculture extension service analogue in the government that will
help especially small and rural hospitals and physician practices improve their
work—as a national investment, not as a consulting gig.
We are beginning to do that with information technology,
and it’s crucially important for the work that David Brailer [national
health information technology coordinator] has now launched to be heavily supported
by government funding. I don’t think we need to put a lot of capital
into the system. That’s a part I disagree with. But to have the norm
set and the vision set and the architecture offered as a matter of public good
is a terrific idea, and David’s the right leader for that.
Biomedical Innovation
Galvin: Let me move to another issue, and that is the
explosion that’s about to play out in biomedical innovation. If you talk
to patients, as much as they are in favor of the IOM aims, they are also interested
in innovations that can cure them or their loved ones. They speak about it
with pride and passion, and it’s something that I think they consider
an essential aim of the system. I think that it represents a separate value
and that we should add this as an additional aim for our health care system.
At the very least, we need to be sure that in the process of getting
to the goals of timeliness, patient-centeredness, and so on, we incorporate
this factor, which is also something that we do exceptionally well in this
country. I’m interested in your thoughts about this.
Berwick: I think you’re right. Innovation is absolutely
crucial, and I don’t think we should slow down our investment in the
development of innovations and better ways to care for people and better technologies.
I do think this: We have a learning disability in this
country with respect to the difference between technologies that really do
help and technologies that are only adding money to the margins of the companies
that make them, without essentially paying their way in value. One of the drivers
of low value in health care today is the continuous entrance of new technologies,
devices, and drugs that add no value to care. If we had strong national policy,
it would allow us to know the difference, and I would more fully support what
I think you’re correctly proposing, which is an innovations value. We
need to help the public know the difference. There’s a big agenda here,
possibly for government, to help create a public awareness that more is not
necessarily better. Frequently it’s worse. So we can be smart about what
we buy and what we choose not to buy.
Efficiency, Quality, And Equity
Galvin: Many of us on the purchaser side see radically
improving the efficiency of the system as a way to free up capital to cover
the uninsured and to fund innovation. How do you think efficiency fits into
the quality agenda?
Berwick: Let’s define efficiency as
making sure that every dollar you spend gets a dollar of value back, so that
efficiency is the opposite of waste. It is absolutely essential to the IHI
agenda. Right from the start, it has been one of the great illusions in the
reign of quality that quality and cost go in opposite directions. There remains
very little evidence of that. There may be some innovations that raise cost
while raising quality, but many, many improvements reduce costs.
I have said before, and I’ll stand behind it, that
the waste level in American medicine approaches 50 percent. It’s certainly
in double digits, and this has to be absolutely pasted onto the quality agenda.
There is no difference between quality and efficiency. It’s the same
thing looked at with the same crystal, through a different facet.
What puzzles me is how to access efficiency as a social
agenda in health care. There are couple of problems. The first is that a lot
of people make a lot of money on inefficiency—on production of things
that have no value. So the minute you try to become truly efficient, you’re
going to run into stakeholders who are going to tell you that you’re
harming care, and the knee-jerk reactions of doctors and others will be to
reinforce that idea. And they include you. I mean, GE pays out of one pocket
and then makes money on products and services that do not add real value.
Galvin: GE’s CEO, Jeff Immelt, has said that profiting
from the inefficiency of the system is not a winning strategy in the long run.
But that being said, many of the programs my health care management group has
sponsored have not been uniformly popular in GE’s Healthcare business.
There are days when I’m not a popular figure in that business.
Berwick: I’ll bet you’re not. It’s
a tough issue. It will not come out of the supplier sector to get that kind
of efficiency. It will have to come out of very demanding purchasers.
Galvin: It’s got to come out of the buy side.
Despite your reservations about pay-for-performance and incentivizing consumers,
getting employees financially engaged [as health care consumers] is one of
the few levers we have to drive efficiency, and it has proved to be very effective.
Berwick: I don’t think that incenting individual
consumers is a lever of efficiency. I think what it drives is inequity. Sick
people are poor, and poor people are sick. That’s the fundamental problem
of the economics of health care.
Galvin: There’s a threshold issue with most purchasers
when you talk about getting a patient financially engaged. That is that no
one ends up paying more because they’re sick. The only option would be
to pay less.
Let me give you an example: Many employer-sponsored benefit
plans across the country have hospital copays as part of their cost sharing.
This means that that there is a fee of a hundred or several hundred dollars
when one is admitted to a hospital. In these benefit designs, while most people
have pretty free choice of what hospital they go to, going to the one that
objective data demonstrate is of superior quality and efficiency would result
in a waiver of the copay.
Berwick: Well, I can be an empiricist about it. Go ahead
and try it. I shudder to think about what may happen, because in the end, that
sick patient arriving at that hospital is in the absolutely weakest position
at that particular point to decide, “Aha, I’m going to save a hundred
dollars and go elsewhere.” That person is more likely to be poor, more
likely to be black, more likely to be a low-wage earner. I think it’s
regressive social policy, and I predict that it won’t work. It’s
a displacement of responsibility from the stewards who actually have the job
of crafting systems to meet the needs of the people who come to them for help.
I think it’s a bad, bad policy, and I don’t see it playing out
productively in other countries, either.
We need a little copay, and we’ve got it already.
That’s in the RAND Health Insurance Experiment, it’s in the system—that’s
enough. Now let’s make the organizational leaders responsible to produce
organizations to give us the care we’re paying for.
One of the big things that Health Affairs ought
to be featuring more is international study and comparison. We underperform
laughably compared with what is going on in Europe and to some extent in Asia,
New Zealand, Australia, and other settings. Why are we not a nation willing
to study the lessons learned in other forms of financing organization of care
that produce care of fundamentally higher value than ours? The stakes are absolutely
enormous. That is a conversation that has been unable to even get started in
America, and it’s very much against our interests not to be globally
curious in this regard. The answer always is that we’re different: America’s
different, we’re not Sweden, we’re not England. Or you hear mythological
views of how bad those other systems are against the available evidence. One
thing we would not discover is making individual patients more accountable
for the cost of their care. It’s not in the plan for the successful systems.
Galvin: But those systems are facing cost pressures
similar to ours. Let me say a little more about how private purchasers in the
United States are looking at incentives. If we really believe in what we’ve
seen in our early forays into this, what actually happens with these patient
incentives is that people aren’t moving nearly as much as provider organizations
are. Facilities are worried that people will move, and that gets them motivated.
It’s an example of “prospect theory,” which won the Nobel
prize [in economics] a couple years ago, which showed that concern about even
very small losses creates incentives and behavior far in excess of the effects
of those losses.
You’re saying that it makes you uncomfortable and
you don’t like it as policy to use financial incentives at the patient-consumer
level, to drive motivation for providers. I accept that we disagree on this
issue, but given that costs are rising in countries outside the United States
generally as fast as they’re rising here and that internal efforts at
improvement are not moving fast enough, I would not be surprised to see other
countries begin to experiment with patient incentives.
Berwick: What you’re saying is that you’re
not serious about it, but you’d like to create that illusion. Maybe I’ll
be illusionist with you. The thing that I do believe—remember, I’m
a fan of transparency—is that we could embarrass the heck out of systems
and create tremendous motivation by being transparent. I think if we say, “Hospital
X, we’re going to tell Mrs. Jones how good you are,” we’ve
got 98 percent of the wallop that you want.
Personal Reflections
Galvin: Last question, Don. Through this tremendous
work that you’ve done in the health care system, what have you learned
about being a change agent, and if you were to start this phase of your career
again, would you do anything differently?
Berwick: The reservoir—the latent will in the
workforce to do better—is absolutely overwhelming. It’s like drilling
for oil. There is so much pent-up need in the health care workforce—and
I include here not just doctors, but nurses, pharmacists, respiratory therapists,
managers—to really do better. It’s so easy to get there once you
decide to. It’s a constant source of energy to find that people want
to be better at what they do. Once you give them an authentic invitation to
do that, it’s so much fun and so inspiring. So that’s probably
the biggest lesson.
The other thing is that the power of the scientifically
based redesign is extraordinary. Five years ago I would have thought that you
could get lower mortality and shorter wage and lower cost with changes. I would
have suspected it. Now, I absolutely know it, and it’s dramatic, dramatic
potential. Those are two of the lessons so far.
Things I would change? I would get directly to patients
much sooner. The voice of the patient—not the money exchange, but the
eloquence of the patient to speak up about what they need and want—is
so powerful. We haven’t invited patients to speak up enough.
I’d build an IHI that was a megaphone for the patients. It’s storytelling;
it’s hearing that this patient was in my hospital and this is what they
went through. We need to create a space for patients to talk about things like
that. Because, sooner or later, it’s going to be me or my child.
Don Berwick (dberwick{at}ihi.org)
is president and chief executive officer of the Institute for Healthcare Improvement
(IHI) in Boston, Massachusetts. Bob Galvin (robert.galvin{at}corporate.ge.com)
is director; Global Health Care, at the General Electric Company in Fairfield,
Connecticut.
DOI:
10.1377/hlthaff.w5.1
©2004 Project HOPE–The People-to-People Health
Foundation, Inc.
|
