Catching Up With Don Berwick: Where Quality Improvement Is Going, and How Young People Are Leading the Way

Last month, The American Journal of Managed Care® spent time with former CMS Administrator Don Berwick, MD, MPP, the president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), when he spoke at the Patient-Centered Summit hosted by Horizon Blue Cross Blue Shield of New Jersey. Berwick is best known as the champion of the triple aim—the idea that remaking America’s healthcare system requires the pursuit of 3 goals: improving the experience of care, improving the health of populations, and reducing per capita costs.

Berwick criticized what he called efforts to undermine the Affordable Care Act (ACA); the conversation took place a week before President Donald Trump canceled cost-sharing reductions. However, Berwick brightened when he spoke of what he sees and hears in his work at IHI and during conversations with fellow champions of better care, particularly young leaders who will build the system of the future.

IHI and Berwick host a National Forum on Quality Improvement in Orlando, Florida, in December, which he said brings 2000 groups together to discuss the best new strategies. Below are excerpts from the interview with Berwick:

AJMC^®: What projects excite you today?Berwick: The most exciting one is called the IHI Leadership Alliance. We thought if we made a call out to the country for organizations, hospitals, physician groups, and health systems that want to achieve the Triple Aim, they might learn more together than separately. There’s now upwards of 30 organizations that meet regularly, virtually and in-person. It’s in its fourth year. They pick projects to learn together how to achieve better care and lower costs, or refocus on community care and wellbeing.

My favorite project they did recently was on cost reduction—we called it “Breaking the Rules for Better Care.”¹ Twenty-four of the organizations polled patients and staff to identify rules that appeared to impede care—these were silly, obstructive rules that could changed. We had over 350 rules nominated by the 24 organizations—and most turned out to be not regulations or laws, they were just habits. There were 4 categories: (1) habits; (2) administrative rules that could be changed; (3) myths, which were misinterpretations of statutes; and (4) statutes and regulations. So, over 80% of the “rules,” were, in fact, not actually rules or regulations.

Another project I love is the IHI Open School, which is about 8 years old. We had demand from young people who wanted to learn about quality, error reduction, and patient safety, but weren’t learning it in medical school or nursing school. So, we started IHI Open School, which is a computer environment in which young people—at no cost—can take courses, start local chapters, and engage in international projects. Right now, there’s about 550,000 young people all over the world networked together in the open school. They’ve downloaded more than 3 million courses. There are over 800 chapters in 80 countries. This is an international movement. We have another element of the open school called ICAN, which is an action project, in which young people can pick projects they want to do, such as population health.

When we originally did it, we knew there was a gap. We polled about 1700 students in all health professions—medicine, nursing, health administration, industrial engineering, pharmacy, respiratory therapy—and we asked them: do you want to learn how to change your care? And 85% said, “Yes.” Are you learning in your current school? And 85% said, “No.” Then we said, we’ll do one of two things, we’ll start different virtual schools—one for medicine, one for nursing, one for pharmacy—or we’ll just do one across all professions. Overwhelming the response was, we want to learn to work together. So, this is a highly multidisciplinary program. And I love it. I am sure the younger professionals are ready for the triple aim. Those of us who were trained in a different era—we elders—it’s our job is to make it possible.

AJMC^®: How is the quality movement penetrating the average healthcare system? Are we translating this excitement into the care that the average person receives?

Berwick: We have a long way to go. Awareness is very high now. It’s hard to find a hospital or a clinic, certainly in the United States, where people aren’t aware of problems in patient safety, patient-centered care, social determinants of health, reliability of scientific standardization. ... [But] the payment system still supports thinking in fragmented terms because it’s largely still a fee-for-service payment system. And so, if you if you interested in improvement you want a team working on more integrated care, and its hard. That said, come to the national forum this year, there will be over 6000 people from 2000 organizations in Orlando all there just to learn about improvements. I think it’s spreading. I wish it were faster.

AJMC^®: In the United States, what is the geographic distribution of health system delivery reform?

Berwick: You’ll find gems everywhere, In every region. If you name a problem I can probably name a hospital in some part of the country that’s doing well [in that area]. There is a tradition in quality in other industries that the Midwest has been a center—in the universities and organizations, because a lot of manufacturing was there. There’s an awful lot of interesting activity in the heartland, and also on the coasts. But in many ways the small, rural hospitals are just knocking their socks off with what they’re able to do, with a little bit less viscosity than you’d find in very large academic centers.

AJMC^®: We’re hearing a lot about financial crises in rural healthcare. How can we improve quality and keep the doors open?

Berwick: There comes a level of budgetary stress that makes it hard for any organization to work on improvement—they’re so busy getting through the day they don’t have time to learn and change. It’s just like a child who is stressed all day is not going to be a very good learner. The other more serious part is the current political environment is reducing the available resources, especially for the care of vulnerable people, for Medicaid, for people of marginal incomes, for the lower middle class, for poor people, for hungry people. To me, the erosion of the federal commitment to the safety net is a very dire and serious threat to improvement, because those are the places that most need to work on improvement.

AJMC^®: What is the uncertainty in the current healthcare climate doing to efforts to improve quality?

Berwick: We haven’t seen an articulation from this administration of a quality agenda that is scientifically grounded. And so, those who have been invested in safer, better care haven’t received a signal about what’s going to be supported. The insurance markets, of course, are under tremendous stress right now because of both direct and indirect threats to certainty. We don’t know what’s going to happen with cost-sharing reduction subsidies, we don’t know what’s going to happen with efforts to stabilize the exchanges, we don’t know what’s going to happen to Medicaid—payment levels and support, and rules—and so, there’s a panoply of policy changes which either are taking resources from improvement or are making everyone wonder what’s going to happen. … It’s hard to be neutral about the uncertainty about whether we’re going to adequately fund Medicaid. To me there’s only one wise answer—we’ve got to get healthcare to the people who are the most vulnerable.

In the ACA there were quite a few initiatives to help care change and evolve—to become more team oriented, more based in the community, to help people transition from institutions to home, to work on patient safety, to give more transparency, to give voice to patients—all of these initiatives came under threat, of course, with the repeal and replace effort. And they’re still under threat administratively. I am worried about back-pedaling on commitments to better care.

AJMC^®: What are your thoughts on administrative proposals to make changes to the Center for Medicare and Medicaid Innovation (CMMI)?

Berwick: I can’t sort the rhetoric from the reality right now. CMMI has been a major source of innovation and energy in the country since it was set up. It’s supported state innovation grants, very informative experiments on new ways to pay for care, more team-based care. It supported the largest national effort ever—in any nation—on patient safety; there’s documented success in safer care. It supported transitions for institutions to home. All were tests of new models of care. Some worked, and some didn’t, but that’s what we want—investments in change. The rhetoric in the [Request for Proposal] right now is talking about more local control, that answers don’t come from Washington. It’s a little confusing to me because the whole idea of CMMI was the release of a tremendous amount of local innovative energy. I hope we don’t lose that.

AJMC^®: How can health systems continue to innovate amid all the uncertainty from Washington?

Berwick: They always have, and they always will. One of the strengths of IHI is to discover these gems around the country. I can name you individuals who in one medical center invented ways to reduce waiting times or improve asthma care, or reduce Cesarean sections, or improve cardiac surgery. Ideas come from one place and then spread. The system wants to innovate.

Right now, in the payment environment, they’re being driven a little crazy because of the mixed payment system—at 10 o’clock they get paid fee-for-service and at 11 o’clock they get paid under this contract. … It’s a mixture of payments and it’s very hard to know how to survive. Healthcare organizations need to have global budgets as much as they can, so they can do what they want to do which is take better care of populations. When you have a budget like that, you can innovate more. You don’t have to stay on the gerbil cage constantly. So, this general trend toward value-based payment, and global payments and bundled payments is healthy support for innovative energies.

AJMC^®: Where do you see digital health and telemedicine fitting into the picture?

Berwick: I think there’s tremendous promise in information technology, telemedicine, remote monitoring, predictive analytics, and big data and artificial intelligence. We’re not there yet—right now we’re in an adolescent stage. We don’t have the mechanisms in place to sort the truly value-added technologies from the ones that are just shiny. But we will get there, and the energy I see is amazing. The number of 20-something entrepreneurs who have a bright idea about how to cure diabetes is thrilling, and out of that will emerge some real breakthroughs. These breakthroughs, by the way, have the property of empowering patients—they really give patients, communities, and families much more control, better care, and wellbeing, which changes the game. For the healthcare organizations, they’re going to have to adapt to this. The model that says, “The best bed’s a full bed,” that’s goes away—the best bed’s an empty bed. That’s going involve changes in finance, in payment, and in culture.

The other changes are a little less technological, and this involves roles in healthcare. I hope we’re at the threshold of a new way to think about the healthcare team—a new way to empower healthcare professionals other than physicians, to work at the top of their licenses, to do things for patients that doctors would never do. So, team-based care and innovative ways to think about the workforce are really important. And the biggest workforce are the patients and families themselves—we’re putting tools in their hands to sense their own possibilities and act on that to their full potential. They should lower costs dramatically. As the care gets more local, it should get less costly.

AJMC^®: What brought you to Horizon’s Patient-Centered Care Summit?

Berwick: I think what Horizon’s trying to do to build better bridges to the delivery of care, not just organizations but doctors and nurses, is important. We’ve built chasms where we need bridges. We’ve separated finance from delivery. Assuming that proper care is the product of negotiation is not correct. It’s the product of cooperation. So, I’m intrigued by what’s going on here is the conscious attempt to pull in especially providers and clinicians. And invite them to share ideas. The most important questions for an [entity] like Horizon to ask is, “How are we doing?” They need to ask that of patients and they need to ask that of clinicians. That’s what I think is happening. I think some of Horizon’s thoughts and experiences will offer future ground for truly innovative payment to support team-based, community-based, population-centered, prevention-oriented care. Nobody’s cracked that code yet, but I think we need places like Horizon to be thinking it through.

Reference

1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017; 317(21):2161-2162. doi:10.1001/jama.2017.4703.