In Conversation with…Donald M. Berwick, MD, MPP
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI). A pediatrician and professor at both Harvard Medical School and the Harvard School of Public Health, he is generally acknowledged as one of the foremost experts and leaders in health care quality and patient safety. He has published more than 100 articles and several books, has been the recipient of several major honors and awards, and was recently named an honorary Knight Commander of the British Empire by Queen Elizabeth II. In December 2004, he announced an IHI-led "Campaign to Save 100,000 Lives"—promoting the implementation of evidence-based interventions to improve patient safety and decrease mortality in six clinical areas. In less than a year, the campaign has already signed up nearly half the hospitals in the United States.
Dr. Robert Wachter, Editor, AHRQ WebM&M: Did you always want to be a doctor?
Dr. Donald Berwick: Oh yes, I never remember a time otherwise. I got very intrigued with public policy and government in college as well, and so I always wanted to have a foot in that camp. But my father was a horse-and-buggy GP [general practitioner] in a small Connecticut town, and I knew from my first moment of awareness that I wanted to be a doctor.
RW: What were you like as a kid?
DB: A bit of a geek, I'm sure. You know, very studious. I grew up in a farm town—a very small town where you knew absolutely everybody and everybody knew you—in a very tight social system that only rural America really has. I think the biggest city I visited probably in the first ten years of my life might have been Hartford, Connecticut, or occasional forays to visit relatives in New York. But small farming town kid, that's me.
RW: Your interest in medicine, I assume, at least in part came from watching your dad. How about your interest in social policy, justice, and equity—where did that come from?
DB: I don't really know. My mother, who died when I was young, was very politically active in the town. She was chairman of the school committee and always involved in community affairs. I guess, now that you ask me, that was possibly one of the sources. I also became really interested in high school in debating. I started what became a debating society in the school, joined the state debating network, and won the championship in our first year. I remember debate as being a really intriguing entree into thinking hard about public policy.
RW: Some people have looked at your work and seen in it both political and evangelical aspects. I wondered whether you ever thought about going into either politics or the clergy.
DB: Never the clergy. Politics, yes. I've always been interested in political science and government. When I was in medical school, although I did enjoy it, I got a little antsy because of my disconnection from social science. So I enrolled in the second-ever class of Masters of Public Policy students at Harvard's Kennedy School of Government and graduated with a joint degree in medicine and public policy. That was my attempt to satisfy that side of my needs.
RW: As you were doing that, did you envision that you would blend these together—that you would be a doctor part of the time and a policy person on the side?
DB: I never had a plan or a vision for it. I took it one step at a time. The critical transition probably was the mentorship of Howard Hiatt, who was then the new dean of the Harvard School of Public Health. In my residency, Howard approached me and offered me a chance to get involved with a new center he was setting up at the School of Public Health, which was attempting to bridge policy and clinical work. I couldn't have predicted that; it was almost an accident.
RW: You have an extraordinary ability to confront hard issues and yet to do it in a way that is so genial and non-confrontational that it works. You're confronting people with some harsh realities, and yet they always seem to leave feeling good and supported, and that their position had been understood. I think that's a very unusual skill.
DB: Well, it's nice of you to say. I've not thought about the sources of that, but it does make me think about three things. One is small town roots—you grew up in a city, Bob?
RW: I grew up in the suburbs, Long Island.
DB: Well, in small town, rural New England, you're part of a community and you have to respect other people. You're too tied to other people not to do that. There's something about growing up like that—when I fly over the United States and I look down from 30,000 feet and see all those farms in Kansas and Nebraska, I have this embarrassing feeling that I'm surprised that I don't know them. It's as if the small community part is there. A second is, I really love doctoring. I think that being a clinician is one of the great privileges in my life. Although I don't do clinical practice right now, I always loved it. The great teachers I remember—their message was to respect the patient. You know, you sit down and you listen. I don't think there's anything different in what I do now in my work from what I would try to do in my clinical role, which is respect the person you're trying to help. Everyone has their side of the story. I think the third, I must say again, is Howard Hiatt. I can't overstate the influence of that man on my career and my self-image. He defines graciousness, and I have always chosen him as a model of courageous and bold, but respectful, behavior. He's an immensely helpful guidepost for me developmentally.
RW: Let's turn now to the campaign. I'm sure that, once you decided to launch a national campaign to save 100,000 Lives, it was soon clear that this would be bigger and more audacious than anything you'd done before. What about it kept you up at night before it launched?
DB: Well, at first there were a few key questions. One was, the IHI is an organization with a global mission: to help accelerate improvement of health care throughout the world. But the business plan of the Institute is to remain very small. We currently have 90 employees and don't want to get any bigger than that. So the general idea is to use leverage to change the world. When you use that strategy, selectivity becomes crucial because you cannot ask 90 people to do everything. You have to do only the things that must be done. In its early days, the campaign was vying for attention from our core staff with other opportunities. We struggled with the opportunity costs—what wouldn't we do if we did the campaign. That tradeoff was what I was losing sleep about.
That related to a second losing-sleep issue, which was the alignment of the campaign with our strategic plan. I knew we had to set it up in such a way that the campaign would be an integrating, instead of a disintegrating, force for the organization. The third losing-sleep issue was leadership. At that point, we did not have the people on board to lead the campaign. We ended up selecting Joe McCannon to run the campaign, which was a very wise move. But until we had Joe in position, I wasn't sure how we were going to manage it.
RW: I know you've said that the campaign became something very different than what you had planned, as these things always do. In what way?
DB: We struck oil. The amount of resonance, will, energy level, graciousness, and enrollees—they're an order of magnitude higher than I ever expected. It occurred first at the level of the leadership groups that I asked to help. The minute we knew we were going to do this, I started getting on the phone to the Joint Commission, to the American Medical Association, to the American Nurses Association, to all of the leadership groups in the country that I could think of, and said, "We want to do this, do you think you could help? Is there some way you could contribute to this or help the work?" And instead of meeting anything like resistance or skepticism, it was, "Where do we show up?" I could not get over the generosity of the senior people in these organizations. Many of them then had to walk the idea through their own boards. So that was amazing to me. And second, in parallel with that, was the field. We initially estimated that a thousand hospitals might sign up if we were really lucky. We have 2,800 signed up as of today. And the emotionality of the doctors and nurses and managers around signing up has absolutely stunned me. By January, very shortly after my announcement of the campaign at our National Forum, we suddenly realized we had a tiger by the tail.
RW: Let me ask you to try to do something that's hard, which is to take off your Don Berwick hat and pretend you're an outside observer. Okay, now analyze the things that made the campaign resonate so deeply and more vigorously than perhaps anybody had expected.
DB: I guess a couple of thoughts. One is that so much of trying to work in health care today is working under outside pressure. CMS [Centers for Medicare and Medicaid Services] is telling you to do this, then the Joint Commission [JCAHO], the public, the payers; everyone is going to work in the morning and taking unwelcome instruction from the environment. And I know the leaders of these organizations. I know they don't intend harm, but they do create this outside pressure. This demotivates the work force and demotivates people. It's the opposite of intrinsic motivation. The campaign appears to be a form of dialogue or conversation that is internally driven. It's about intrinsic motivation—I'm going to take this on because I want to do it. It's more connected directly to purpose in life than external pressures are. It happens also to align with external pressures. And when Dennis O'Leary [of JCAHO] or John Nelson of the AMA say "We really like this," then people say, "Oh my goodness, I found the sweet spot, it's something I really do want to do."
The other common message we get from the field is a kind of thank you for the focus, which is "I knew things weren't right. I know we've got troubles. I understand the six aims [of the IOM]. I understand pressures. But I didn't know what to do. And now the campaign has shown up and has given me something to do." The concreteness of the campaign agenda and the changes themselves, compared with the vague stomach rumbling that things aren't right, this is night and day. People want a task, and this gives them one that really counts.
RW: The Rapid Response Team is a fairly new initiative. I think some people have looked at the state of the evidence both before and since and wondered whether it's robust enough to promote it so vigorously. Can you talk about Rapid Response Teams specifically, and then broaden the discussion to the tension between waiting for perfect evidence vs. a more commonsensical approach that promotes practices that seem like the right thing to do. How do you balance those two?
DB: Well, first, the campaign is strongly evidence based, and that includes Rapid Response Teams. We had extremely strong case study–level evidence out of Australia early in the Rapid Response Team work. And we also had the experience of IHI, with our IMPACT Network and our colleagues in the Pursuing Perfection project—many had implemented Rapid Response Teams over time in a large number of hospitals and had demonstrated, through the use of run charts and time series statistics, profound changes. So from my personal viewpoint, the evidence is secure that, properly introduced, some way to detect that a patient is deteriorating before their heart stops is a life-saving, life-preserving maneuver. I agree that the evidence base is not extremely broad in a classical sense. The one randomized trial from Australia that came out recently in The Lancet—we've been tracking this study right along, we work with those investigators all the time. We know a ton about that work. In fact, on our Web site we've done a very careful analysis of why they did get a negative result compared with the kind of results we think are possible.
I think that improvement work ought to proceed on the basis of evidence, but that the forms of evidence that are relevant to the PDSA cycles of improvement are different from those that are classically honored in evaluating clinical trials. You know more than you can prove through clinical trials and we need to use all the knowledge we can. That's the basis of the campaign. We encourage local innovation. In terms of Rapid Response Teams, the real hard problem here is not whether it's a good idea to spot a patient who is deteriorating before his heart stops. I'm not sure we need a tremendous amount of evidence to shore up that idea. It's how you do that locally. What do the specific mechanics of rapid response look like from hospital to hospital, place by place? How does it work in a 30-bed rural hospital? How does it work in an academic medical center? At that adaptation level, we're at a different set of scientific issues, something like constant formative evaluation. How are we going to do this? What did we just learn? What's the next step that we can take? And I think that's science also.
RW: I've had the pleasure of being in your headquarters. Most of the people who read this will not have been. Can you describe what it feels like in IHI headquarters? I don't mean where people are sitting and that they have computers, but, rather, what's the buzz? What's the culture?
DB: We have a set of values that we try to use here that guide the operational culture of the organization. The cultural issues of honesty and openness, of course, are important. But I think, hopefully, you'd see here in action a set of values that we really want to carry forward. The values are of boundarylessness, which means everyone connects to everyone else and you don't own data or competence or knowledge. We want to move everything around. I wanted to build an office—my metaphor has always been the newsroom of a newspaper—where the walls are low, or there are no walls at all; you could yell across the window or yell across the corridor when you've discovered something that somebody else needs to know. Boundarylessness. Speed and agility are values, which are to keep up with the industry, keep up with the needs, to shift when we have to shift, and to change when we've done something wrong. Honesty is a value, but means here not honesty in the ethical sense, but we mean we want to tell about our failures as loudly as we tell about our successes, so that we can learn from the things that don't work as well as well as the things that do. We value our volunteers. Most of the energy of the Institute comes from people who don't get paid anything. They just show up to do the work, hundreds and maybe even thousands of people like you, Bob, who I can call and say, "Could you help?" and they always say yes. We need to make interacting with the Institute the most fun part of anyone's professional life. We have a value of 100% customer satisfaction. So when we do something like an event or a product, the customer is always right. End of story. Everyone here is coached that way, and we have processes in place to try to make that the case. We have a value on orderliness, and that's something we're working on very hard this year. We have a value called Celebration and Thankfulness, which is to just keep pausing as an Institute, and look backward and have a party and do something that makes everybody able to feel proud of and happy with the work they do. I think hopefully the answer to your question is you'd be able to note it, you'd be able to create that list over time if you'd live with us for a week and be able to see the way we're approaching our work. I really want a place that has transparency embedded in it. We built an office in which everyone sees outside. There's nobody who can't look out a window, because I want daylight to be a characteristic of the organization, so that's what we're trying to do.
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