No one should have been surprised when Dr. Donald Berwick, MD, Interim Administrator for the federal Centers for Medicare and Medicaid Services (CMS) announced that he will be stepping down a week from today. To be appointed permanent Administrator, he needed U.S. Senate confirmation and 42 Senate Republicans had already signed a letter committing to oppose him.
So. Is this a big deal? Yes. For Berwick, obviously, and for the rest of us, not so obviously, though even more so.
When the history of American medicine since, say, 1910 (around the time, it is suggested, the chance that an encounter with a physician would help more than harm a patient, surpassed 50/50) is written, Berwick will be recognized as one of our most important and influential physicians. What has he done to deserve that?
Back in the 1980s, Berwick was a pediatrician at the Kenmore Center of the Harvard Community Health Plan in Boston, and in charge of "quality assurance" for the plan. His intellectual curiosity led him to wonder how non-medical parts of U.S. society addressed quality, a heretical notion in the snobby, clubby world of organized U.S. medicine.
In his search, Berwick stumbled onto a fast moving and worldwide intellectual revolution in industry and manufacturing. A key thought leader was another former heretic named W. Edwards Deming who taught the Japanese in the 1950s and the US in the 1970s and '80s that the path to economic success required a relentless focus on customer satisfaction and quality improvement, and that better quality -- doing the right thing and doing it right -- was a way to save money by eliminating rework. The term of art was "total quality management."
In 1989, Berwick wrote a seminal article for the New England Journal of Medicine called "Continuous Improvement as an Ideal in Health Care," and set off an intellectual revolution in American, and eventually, global medicine. Prior to Berwick, "quality" had been linked with the word "assurance" with the cavalier and false assumption that quality already existed, and all that was needed was adequate policing to root out "bad apples." Every hospital was required to have a "quality assurance" department that looked out for quality; everybody else just did their jobs.
More than anyone, Berwick changed the word from "assurance" to "improvement" with new assumptions: quality must be an essential part of everyone's job; no matter how good or how bad you think you and your organization are, every day, you have multiple opportunities to improve; and the key to quality improvement (QI) is the elimination of errors and waste, along with the empowerment of workers. Berwick did more than just establish an idea, he created an organization, the Institute for Healthcare Improvement (IHI), to advance and actualize it. Under his leadership, IHI has become the worldwide home for QI through training, teaching, learning, collaborating, advocating, and more.
In the mid-1990s, he had a new revelation. Up until then, he and IHI focused on teaching a toolbox of process improvement methods (i.e.: the plan-do-check-act or PDCA cycle) to anyone and everyone, as though learning the tools was all we needed to cure health care. Then he met a TQM thinker named Tom Nolan who convinced him that the tools were just like a carpenter's hammer and saw, not an end in itself, a means. The first and most important question must be, what are you trying to build? What are you trying to accomplish.
That insight led Berwick to shift his focus to health system change. Still at IHI, he became centrally involved in two landmark reports from the Institute of Medicine, To Err Is Human in 1998 (affirming for the first time that at least 100,000 Americans lose their lives every year due to medical errors) and Crossing the Quality Chasm in 2001 (defining the scope and breadth of quality deficiencies in the US health system and charting a path toward improvement). In 2003, focusing on his wife's life threatening illness, he wrote his own personal account of exposure to poor quality, Escape Fire.
At IHI, Berwick developed the national 100,000 Lives Campaign which organized hospitals across the nation in an unprecedented way to undertake a series of QI measures to save that number of lives through systemic, coordinated quality improvement. (While the campaign generated sizable momentum, the final result is disputed.) More campaigns followed, including the Triple Aim campaign to improve patient care, cut health care costs, and fix population health needs. Berwick brought the Triple Aim to CMS, though the lawyers demanded a name adjustment to "Three Part Aim." The CMS-HHS Partnership for Patients is now working to reduce hospital acquired infections and complications.
For the nation's quality improvement movement (make no mistake, this is a movement), it was a thrilling moment when it became clear that Berwick had been selected by President-elect Barack Obama and the new Secretary of Health & Human Services, Tom Daschle, to run the federal Centers for Medicare and Medicaid Services. Finally, the key U.S. health agency would be headed by a physician thoroughly committed to fundamental quality and system improvement, as well as patient empowerment. It was a heady -- and short-lived -- moment.
In late January 2009, Daschle's nomination blew up over his unpaid taxes. Berwick's nomination -- which would have sailed through an easy confirmation in early 2009 -- was held aside while a successor was recruited, and then the Administration began looking at other names. The health reform legislative campaign provided another reason to delay, and so it was not until April, 2010 that the President nominated Berwick. By that time, anything health-related from the Obama Administration had become anathema to Congressional Republicans; even health savvy Republicans such as Utah's Orrin Hatch denounced the man they had once openly admired.
So President Obama named Berwick as a temporary 18-month recess appointment in the summer of 2010 hoping temperatures would cool along the way and make a permanent appointment possible by late 2011. No such luck. Instead, Obama is nominating Berwick's savvy first deputy at CMS, Marilyn Tavenner, to take the slot. She is a decent and respectable choice who should do a fine job. Still, it is difficult not to mourn the loss of this visionary man from this vital position at this crucial moment in U.S. health policy history.
A favorite quote of mine is from the Book of Proverbs: "Where this is no vision, the people perish." If U.S. health care is to survive, it will be because of the vision of folks such as Don Berwick.
It also needs to be noted, this is a moment of meaningful disrespect by the Congress to the U.S. quality improvement movement. It is evidence that, in spite of all the lip-service paid by the Congress to the movement, the community doesn't matter and has no political juice. One of the movement's most distinguished leaders and voices got mugged by partisan Republicans who know better and who got away with it without a scratch.
That's a shame and it demands some soul-searching within the movement.
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