ORLANDO, Fla.—Healthcare is not meeting the social needs of its patients and it is not accomplishing the goals of the Triple Aim to provide higher quality care and improve population health while lowering costs.
Indeed, healthcare is in trouble, Don Berwick, M.D., president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), told the 5,500 attendees at the conclusion of the organization’s 29th annual National Forum on Quality Improvement in Healthcare.
And it will never accomplish the goals of the Triple Aim or the Quadruple Aim, which adds the goal of finding joy and meaning in work., if the industry continues to bet on competition as the remedy to the problem, he said.
“Competition is not the answer,” he said. “It is the problem.”
Berwick contends that healthcare leaders and their teams must learn to act and think in a fundamentally different way. And it requires cooperation, which may be difficult for some healthcare professionals to do in such a competitive industry.
But it is possible. He used the example of the near-death experience of his younger brother David this year and the life-saving skills of the ICU team at Beth Israel Deaconess Hospital in Boston to illustrate his point.
Within hours of developing a fever, David had a raging case of sepsis from Legionnaires' disease and suffered multiple organ failures. He was taken to the ICU and put on life support.
Berwick said his family was sure they would lose him, as the death rate for his condition was so high. By day five and six it seemed hopeless.
But slowly David began to improve. By day nine his breathing tube was removed and he opened his eyes. Day 11 he was moved out of ICU and by the 20th day he was at rehab. He was home on day 40.
“He beat the odds,” Berwick said.
The reason he survived was due in part to machines and technology and the antibiotics developed to treat his condition, Berwick said. But most of all it was because of the dozens of healthcare professionals in the ICU, as well as the people the Berwick family never met who work in the back offices of the hospital, laboratory, stock room, pharmacy and up to the supply chain.
Most of all, Berwick said, it was because the ICU team talked with one another, talked to the family and worked together to find a way to save his brother.
“This was a ballet more complex than any dancer ever danced,” he said. “Amazingly they included me and David’s family. They asked ‘did we have any questions? Did we have any ideas?’ We, the people who loved David were not watching the team, we were on the team. Everyone had a voice.”
And every member of the team mattered. Berwick recalled at one point a respiratory therapist questioned something his boss, the medical resident, said. And the resident thanked him for the correction.
“I have focused on quality and healthcare for four decades now,” Berwick said “But this chapter I saw was care that I dreamed of. How do you thank someone for your brother’s life? Because of them, David had a lobster roll on a birthday we thought he’d never see.”
The message that everyone on the ICU team understood was that it took each one to save his brother’s life, Berwick said. No individual could have done it alone. Their glue was purpose.
“All together or not at all,” he said.
Local success stories spur a movement
Berwick mentioned other success stories, such as the work that M. Justin Coffey M.D. and C. Edward Coffey, M.D., did at the Henry Ford Health System to achieve a goal of zero suicides within a high-risk group of chronically ill patients. They accomplished it in two years and their strategies have been adopted across the world.
It's become an international movement, Berwick said. And the work that the Indian Health Services did to decrease end stage renal disease among a population that had high diabetes rates became a national effort. It involved patient education, public health nurses, primary care, pharmacists and tribal leaders, working together to achieve tangible results.
Berwick brought Jennifer Walthall, M.D., on stage to talk about the work she led to redesign the public health system to stop an outbreak of HIV cases in Scott County, Indiana. In January 2015 there was an outbreak of a cluster of 11 HIV cases, something no one had seen before. They learned that in the rural community there was a generational use of needle sharing to inject a prescription opioid, Opana. All of the cases were due to the injection of the drug.
“We realized this was not a chronic disease. We were looking at something more like a natural disease pandemic,” she said, adding they called on the Centers for Disease Control and Prevention and disease specialists in 10 states to help. Together, they built integrated space that is a one-stop shop for care and includes a syringe exchange program, where dirty needles can be exchanged for clean ones.
One patient who tested positive for HIV in a mobile health clinic was able to come to the shop and leave with a driver’s license, birth certificate, healthcare insurance card, a doctor’s appointment, a substance use appointment and all his immunizations were brought up to date.
That experience, Walthall said, left him with hope that things would be better the next day and he wasn’t handed a death sentence after all.
Berwick said all of these stories show it’s possible for humans to cooperate on a massive scale. And that cooperation is necessary to create a fundamentally different health system that can improve the social determinants of health, provide insurance security and reduce soaring healthcare costs. Working harder, incentives to payment systems to force changes, measures and regulations won’t fix the broken system.
The current approach of win or lose plans and market competition as a driver of excellence won’t spur improvements, he said. And, Berwick noted, he feels a sense of weariness for that approach within the industry. Instead, he looks for healthcare professionals to pursue a common purpose with the glue being the aim. Along with shared action, a community can succeed, he said.