Decades ago, there began a rigorous effort to tackle health care problems by focusing on science, improvement and measurement. A prominent driver of all things related to practice betterment has been The Institute of Healthcare Improvement, or IHI. Led by pediatrician Don Berwick and colleagues, IHI’s siren song has been “Plan, Do, Study and Act” to seek out and resolve practice variation, poor performers, and waste. They promulgate the Triple Aim, and have annual conferences where one of many highlights is Berwick’s annual address.
The IHI website says: Although the problems are big and daunting, we resolve to approach them with optimism grounded in rigorous science, hard work, and a relentless drive for results.
And now, a pivot of importance. Don Berwick, also formerly head of the Centers for Medicare and Medicaid Services, says it’s time for a new Era in Medicine. In his keynote at the December 2015 IHI Forum, he noted a wide gap between what health care is and should be. His views were just published in JAMA, Era 3 for Medicine and Healthcare.
He talks about Era 1 – where doctors serve as trusted and proud professionals, and inquiry takes hold. Era 2 zeroes in on measurement, using incentives to drive behavior change, and the odd siblings of accountability and uncertainty. Yet things really get interesting, when the father of measurement improvement says it’s time to move into Era 3, remarking,
Let’s now pause and think about our belief system. Let’s step away from era 1 and 2
He now feels healthcare has to “back down” in several areas, especially stopping excessive measurement. He points to Robert Wachter’s New York Times editorial, How measurement fails doctors and teachers. He says “doctors and nurses are going crazy” and cites the need to modify Meaningful Use, abandon complex payment incentives and commit to full transparency. He even wonders if we can “get our mind off of the money for a minute?”
His YouTube video gets really fascinating. At 4:25 minutes, he wants to get away from doctor as the boss and know-it-all. He wants Era 3 to be about patient centeredness Taken To The Full Limit. (I can see it now…Eagles’ Randy Meisner singing at a #WalkingGallery meet up). Watch it and see what you think. You’ll hear “Patients should be in governance and be in control” which is an IHI pivot that the Society can help bring about.
We all know that it has to be more than a conversation. Patients, families, advocates must be active participants in Era 3. Berwick’s vision of Era 3 will only be achieved if healthcare and medicine Let Patients Help!
A summary of Era 3 goals:
1. Reduce Mandatory Measurement
Reduce by 50% in 3 years ( and by 75% in 6 years) the volume and cost of measurements being done and enforced. Measure only what matters, and mainly for learning.
2. Stop Complex Individual Incentives
Declare a moratorium on complex incentive programs for individual clinicians, which are confusing, unstable, and invite gaming. CMS should confine value-based payment models for clinicians to large groups.
3. Shift the Business Strategy From Revenue to Quality
Master the theory and methods of improvement as a core competence for health care leaders. Unlink incomes from metrics, such as “relative value units” for specialists’ incomes, which are not associated with quality and drive volume constantly upward.
4. Give Up Professional Prerogative When It Hurts the Whole
The most important question a modern professional can ask is not “What do I do?” but “What am I part of?” Young professionals should be redirected from prerogative to citizenship. Physician guilds should reconsider their self-protective rhetoric and policies.
5. Use Improvement Science
Academicians should make mastery of improvement sciences part of the core curriculum for the preparation of clinicians and managers.
6. Ensure Complete Transparency
Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens. Professional societies and clinicians should abandon traditional opposition to absolute transparency.
7. Protect Civility
Medicine should not, as happens too often in Washington, DC, substitute accusation for conversation. Proponents of era 3 should heed the advice of Waller, who noted, “Everything possible begins in civility”
8. Hear the Voices of the People Served
Clinicians, and those who train them, should learn how to ask less, “What is the matter with you?” and more, “What matters to you?” “Coproduction,” “co-design,” and “person-centered care” are among the new watchwords, and professionals, and those who train them, should master those ideas and embrace the transfer of control over people’s lives to the people. That includes paying special attention to the needs of the poor, the disadvantaged, and the marginalized, and firmly defending health care as a universal human right.
9. Reject Greed
Professional organizations and, importantly, academic medical centers should articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care.
Sue Woods MD, MPH (LinkedIn) is a former Board member of our Society. A long-time advocate of health IT and patient data rights, she works with the VA Health System and is associate professor at OHSU, the famously patient-centered Oregon Health & Science University.