Health Systems Improvement Necessary for Good Health Care Reform, Says Berwick

Health care reform may do more harm than good unless attention is paid to improving health “systems,” according to Donald Berwick, president and CEO of the Institute for Healthcare Improvement and professor in the HSPH Department of Health Policy and Management, who gave the annual Dr. Herbert Sherman Memorial Lecture on October 13 in the Kresge cafeteria. The event was sponsored by the Office of the Dean.

 

“The idea of a system is neither a frill nor a fine point if we are to get reform right,” said Berwick. “It lies at the very center of the scientific and political challenges that stand between us and the care we seek. With a proper understanding of systems, authentic health care redesign is feasible and socially productive. Without that understanding, ‘reform’ will likely do more harm than good.”

Berwick said that paying attention to each individual part of the nation’s health care system — cost, quality and coverage — will not be enough if all the parts do not work together to produce an intended result. “The performance of a system — its achievement of its aims — depends as much on the interactions among elements as on the elements themselves,” he said.

He lamented the fact that, during their training, medical students rarely train with nurses and that often different departments within a hospital jealously guard their own resources and rarely meet to identify how they might work together to provide the best possible care for patients.

“Health care reform without attention to the nature and nurture of health care as a system is doomed,” Berwick said. “It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it.”

In its groundbreaking report, Crossing the Quality Chasm, Berwick noted that the Institute of Medicine designated six aims for improvement. These included: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

“The improvement of health and health care depends on systems thinking and systems redesign,” Berwick said. “ ‘Reform’ without systems thinking isn’t reform at all. Those who lead, fund and work in American health care were not trained to think in systems terms; indeed, they were in some cases trained specifically not to. For that reason, between us and effective health care redesign lies a gamut of changes in culture, belief, and norms.”

He said challenges include placing a renewed emphasis on the interdependence among all stakeholders involved in the health care system; making sure processes are centered around the needs of patients, not providers; taking pains to do a better job of sharing knowledge; reducing waste; supporting multidisciplinary research and development; providing more training in systems science; and redesigning institutional arrangements.

“Reform, if it is to reduce the chances of failure, will have to mean change of the care itself,” he said. “Changing contexts can help, such as removing the toxicity of fragmented payment, assuring universal access to care, ending senseless regulatory bars and administrative nonsense, and improving transparency about performance,” he concluded. “But these just set the stage. The patient depends not on the context, but on the care.”

During a question-and-answer session, Berwick decried the “culture of blame” that seeks to identify individuals for making mistakes rather than viewing mistakes as errors in the system as a whole. Improving quality “is still in the backseat,” he said, and more research is needed to move it forward.

Regarding the costs of reform, he estimated that at least 30 percent of all money spent on healthcare is wasted and said that eliminating that waste could solve many problems that are at the heart of the current health care reform debate.

But, he said, that will be difficult if the numerous stakeholders in the health care system are all pursuing their own self interests.

— Michael Lasalandra. Photo by Suzanne Camarata