Reinventing health care

A conversation with Donald Berwick

WEDNESDAY, JULY 2, 2008

President and CEO of the Institute for Healthcare Improvement, Donald Berwick, MD is one of the leading thinkers in health care and a champion of quality improvement and innovation. Here are highlights of a recent conversation.

How Kaiser Permanente stands apart from other health care organizations: 
KP's integration of care, at its very best, is second to none in the country. It has phenomenal cutting-edge information technology that is only going to get better over time. Its Labor Management Partnership is probably unique for an organization of that size in health care.

On Kaiser Permanente's position in a changing economy: 
Kaiser Permanente - given its size - is in the bull's eye of modern social issues in health care. This demands change. It forces everybody in health care, including Kaiser Permanente, to rethink how it does what it does. The good news is that because it's an integrated system, Kaiser Permanente can deal with issues and construct remedies that the rest of health care - disaggregated, fragmented, nonintegrated, not thinking in terms of populations - just can't do. So the challenges are immense, and the opportunities are just as big.

On competition with other health care providers: 
Kaiser Permanente's under a lot of pressure from competitors. It's especially vulnerable in some ways because of its immense size, with millions and millions of members. Kaiser Permanente has to hold itself to a higher standard of performance because every defect is going to be noticed. The standards for excellence at Kaiser Permanente have to be higher than the standards in an organization of smaller size.

On a new model of labor management relations: 
The silos that we build in health care - physicians, nurses, therapists, managers, the worker and the executive - are dysfunctional. They don't help get patients what they really want and need. If we want to optimize a system, it's going to be around teams and teamwork, and it's going to cut across hierarchies and professional norms. Unit based teams and much better relationships between those who organize systems and those who work in the systems are going to be essential to any real remedy.

People don't go to work to do wrong. They go to work to do right. And they don't go to work to waste things. They go to work to use resources well.

On quality and efficiency: 
Cost containment and quality improvement go together....The waste in American health care...is well over 30% of the total bill. Most of America can't extract that waste. KP can. And the guideline has to be never hurt a single patient as you do that.

Waste is everywhere in health care: Duplication of effort. Scrap. Things we make and throw out, doing things for patients that don't help patients. Nonsense that entered our work through history. Habits that don't have any functions. Who knows the waste? The people who do the work. They see it every day.

Unit based teams - an empowered workforce that's capable of changing its work - is one of the best waste-extraction mechanisms you could ever have....Kaiser Permanente has a chance here to do something very good for Kaiser Permanente as well as for its patients, which is to make care better and more affordable at the same time.

If Kaiser Permanente gets really serious about using quality as a strategic lever, it's going to find itself to be the most attractive health care system in the nation....It's a formula for success, for competitive success, moral success and mission success. It'll also be a better place to work. The workforce that gets trapped in waste and defect is unhappy to that extent. People don't go to work to do wrong. They go to work to do right. And they don't go to work to waste things. They go to work to use resources well.

The future of health care:
If Kaiser Permanente is going to reinvent care the way America needs care reinvented, it's going to have to break the habits and traditions, the assumptions that are prevalent in American health care....You're in an organization that can do things nobody else can do....You can show Americans the kind of health care that they wish they could have everywhere.