Daniela Levi 2010 1

“every single one” Don Berwick

“in its deepest core, the pursuit of perfection is to forget no one. And to forget no one is to pursue justice…”

Daniela Levi 2010 2

IOM report on HC quality

• Need major systemic effort to overhaul how – Deliver care– Educate and train clinicians– Assess and improve quality

Daniela Levi 2010 3

3 quality problems:

• Overuse of procedures and interventions

• Underuse of treatments that are known scientifically to be helpful

• Misuse- errors in execution

Daniela Levi 2010 4

6 aims for improvement

• Safety• Effectiveness• Patient- centered

• Timeliness• Efficiency• Equity

Daniela Levi 2010 5

The problem is design- 4 segments of HC

• Level 1- patient and community– Purpose– Aims– Quality is defined here

• Level 2- The microsystem– Encounters the suffering, need and tries to heal

• Level 3- organizational context– Information, financing, architecture, rules, personnel

• Level 4- environmental context– HC financing, regulations, accreditations, tort,

education, market

Daniela Levi 2010 6

Microsystem redesign- 10 rules

• Base care in healing not visits

• Customize to individual

• Patient in control• Share knowledge• Evidence –based

decisions

• Safety as a system property

• Transparent• Anticipate not react• Reduce waste• Foster cooperation

Daniela Levi 2010 7

Berwick’s famous quotes

• Whom do we serve?

• Fundamental assumptions

• Every defect is a treasure

• Medicine as a social act

• Never-ever loose sight of the patient

• Becoming something we are not today

Daniela Levi 2010 8

“Learn how to heal systems”

• Open access• Health information• Patient decisions• 24/7 visiting for ICUs• Patient and family advisory councils• Community members on patient safety committee• Sharing clinical pathways with patients• Reduce unwanted and ineffective medical procedures at

the end of life• Consolidate high- technology services into regional and

community-wide centers

Daniela Levi 2010 9

Berwick’s on innovation:

• “Change agents often have a deep understanding of the system they wish to change”

• “People who lead change must usually leave their current environment in order to grasp what others cannot see”

Daniela Levi 2010 10

Quality improvement:

• Tenacity and tension needs to be applied today to:– Insisting on better outcomes– Insisting on more dignity in care– Insisting on less waste– Insisting on more safety– Insisting on more listening