Dr. Don Berwick MD a professor of Healthcare policy, pediatrician and cofounder of Institute for Healthcare Improvement, and also a former administrator of CMS, is one of the first voices to call for quality improvement in healthcare system. A few years ago, after his wife was treated with a serious disease, his work gained a new sense of urgency. He says his experience speaks of the short-coming of the current system as, ‘enormously costly and with huge gaps between what was need and what they got’. In his plenary address at Institute for Healthcare Improvement’s 11th Annual National Forum on Quality Improvement in Healthcare in 1999, he spoke about the problems with healthcare system such as, medical errors are a norm, inconsistent and confusing medical information, and lack of patient safety. He didn’t hesitate to say, that providers are aware of such practices, whether pharmacists, physicians or any others, but are not ready to speak out.
He sketches-out an ambitious plan for reforms, based on a firefighting Montana hillside Mann Gulch Fire Tragedy of 1949. This catastrophe took lives of 13 young men and forever changed the way firefighting was managed. The leader Wag Dodge, devised a creative technique at the time, when facing a quickly moving grass fire; in which he deliberately burnt a patch of land to provide a refuge from encroaching blaze. His team refused to join him, and most of them perished in the fire. Dodge survived because of his brilliant idea, now popularly called Escape fire. Berwick mentions we can apply lessons learned at the tragedy to transform and bring fundamental change in US Healthcare system with revolutionary new design, to make the system more robust.
Berwick said, in the current healthcare system, people are working hard, but the system isn’t. The important decisions stay embedded in nursing notes, irrational decisions occur due to complexity of data and labelling patients as ‘difficult patients’, chaotic attention, un-timely care; missing follow-up in continuity of care; disarray in business operations; lack of communication. Such an environment in healthcare is like gulch blaze. He quoted a paper, Collapse in Sense Making in Organizations by Karl E. Weick from University of Michigan, who analyses organizations under stress or High Reliability Organizations (HRO), which carry-out tough tasks in harsh conditions. The author asks two questions on Mann Gulch tragedy: Why do organizations unravel? and How can organizations be made more resilient? Karl reasons organizations play key roles is sense making, without little or no preexisting sense. In other words, organizations don’t discover sense, its created by act of independence. A sudden ‘cosmology episode’ can panic-group orderliness, interrelationships, and tools provided by organizations; and its sense making will collapse. Berwick feels same is happening in healthcare, its sense making is collapsing, but its within our reach at the same time.
The paper further states, organizations can forestall deterioration by equipping them with four elements for resilience. First is, ‘improvisation’ the ability to invent when old formula fails; Second is ‘virtual role systems’, ability to carry social structure in their heads, even in situations where it’s not apparent. Third is ‘attitude of wisdom’, means in changing times organizations should show curiosity, openness and complex sensing. And lastly, ‘respectful interaction’, means if trust, honesty and self-respect are more developed in a system, new options are created.
Loss of sense-making is a powerful vocabulary for interpreting current healthcare crisis. The sense making of healthcare must change at two levels: preconditions and designs. The preconditions, are a set of shared assumptions to tackle an issue, and making sense possible. There are five preconditions: First the toughest, ‘face reality’ to state with courage the magnitude of problems without marginalizing truth teller or demoralizing good people working in bad systems; Second ‘drop the Pulaski’ means healthcare’s backpack is full of useless old repeated assumptions; Third is ‘stay in formation’ to have virtual role models, and to consider all stakeholders in any solutions and to align business, and financial success with patient care; Fourth is procedural ‘talk to each other and listen’, conversation and open dialogue is an enterprise of interdependency and success; Last is the ‘leadership’ effective leaders in HRO leaves sense making intact by exhibiting certain skills-clearly defining tasks, demonstrating own competence, disavowing perfection to encourage openness and team building. These five preconditions, sets the stage for sense making in health.
He proposed the future healthcare should have three primary design elements, ‘access’ a system that promises, ‘we are with you’ without processes and assumptions of rationing and control on access to appointments and authorizations. Thus, summarizing into uncompromising healing relationships with ‘24/7/365’ total access with, emphasis on self-care, access to scientific information, physicians reachable through emails. Such access supports compliance. The second element is ‘science’, means to standardize actions based on knowledge, such as ‘promise to deliver, reliably and without error, all care that will help and only the care that will help’ as adopted by Dr. James Reinertsen’s foundation. Third is, ‘relationships or interactions’, time spent on educating patients in self-care, is care.
Care is not about doctors, nurses, hospitals, computers, books, rules or medicines. These are inert. Care is interaction among our assets, and between assets and patients. Four properties of interactions are an investment for continual improvement: to regard information transfer as key form of care, ‘nothing about me without me’ is a formula of idealized interaction and access. Second interactions should be tailored to patient needs, ‘every patient is the only patient’ and third interactions, ‘the patient is the source of all control’ care begins in the hands of people we serve; and finally, ‘interactions we nurture should be transparent’ with no secrets but should be confidential.
In the new system, old tools won’t work, rather it will open new sense making routes for escape through invention and opportunity. As trust blooms in an open environment.
‘Escape fire: Future of Healthcare’ is an excerpt from the plenary address of Dr. Don Berwick, and is in continuation of my reflection to contribute to Vibrant Healthy Communities! Would love to hear your thoughts on healthcare reforms.