Donald Berwick: Curing the Healthcare System

How Dr. Donald Berwick and the Institute for Healthcare Improvement apply business best practicesfrom lean manufacturing to innovation

People go to the hospital to get well. Yet every year, some 15 million patients at U.S. hospitals are harmed—by surgical errors, bed sores, hospital-acquired infections, or other complications. Such avoidable conditions add tens of thousands of dollars to the cost of a patient's hospital stay, and an estimated 100,000 people die as a result, according to the Centers for Disease Control & Prevention.

These sobering facts were the inspiration behind the 5 Million Lives Campaign, a two-year initiative that urges hospitals to adopt 12 specific goals to avoid causing unnecessary harm. The campaign was launched in December 2006 by the Institute for Healthcare Improvement (IHI), a Cambridge (Mass.) nonprofit that was founded in 1991 by Dr. Donald Berwick, to apply business best practices —from lean manufacturing to innovation strategy—to health care.

"Other industries had long ago started managing for continual improvement in products, services, cost structures," says Dr. Berwick, who toured Bell Labs, NASA, and Toyota (TM) in the late '80s to see how those organizations approached quality control. "I soon realized that there was a need for this knowledge on a national level."

Leading Figure in Health-Care Innovation

IHI, which is funded through a combination of membership fees and foundation support, develops software tools to help health-care centers track their performance. It works with partner hospitals to test new methods, essentially running an industrywide innovation department. And it publishes case studies to help health-care providers improve their service and reduce costs at the same time. IHI now employs 118 people, and Dr. Berwick, as its founder, is widely respected as a leading figure in health-care innovation, able to synthesize and apply diverse management practices to an increasingly complex industry.

Consider the problem of how to move patients through a hospital efficiently, from patient admission to the emergency room through surgery and recovery to discharge. ERs in the U.S. are typically operating beyond their capacity, and hospitals often respond by expanding the ER to accommodate more patients. But this worsens the problem by bringing more patients into the system (who will ultimately need more operating rooms or in-patient beds) and adds to hospital costs because more patients end up "parked" in expensive ER beds as they wait to be transferred.

To solve the problem, IHI studied how hotels manage patient flow and found that the answer lay in eliminating unnecessary fluctuations in demand. For instance, hospitals might not be able to control when patients show up, but they can identify and schedule patients to be discharged, just as hotels have a check-out time. Thanks to these insights, published in IHI's 2003 report "Optimizing Flow," Kaiser Permanente doctors now do rounds at 11:30 a.m. to identify patients who can go home the next day and start the discharge process. This helps the staff prioritize patient visits in the morning, and helps housekeeping know when a room will be ready to turn over.

Spreading the World

Through IHI, Dr. Berwick has created an innovation network of hospitals to test new approaches, using a 90-day R&D process that IHI based on the practices of companies such as Procter & Gamble (PG) and 3M (MMM).

IHI analyzes the data to identify the method that has the biggest impact on patient outcomes and publishes the results for free on its Web site for any hospital to adopt.

To further spread its findings, IHI launched the 5 Million Lives Campaign, which 4,000 hospitals joined, meaning that they adopted at least one of the 12 goals and promised to report the results. Even after the campaign ends next month, any hospital can still adopt the goals. Dr. Berwick thinks many probably will, because the goals—and the specific recommendations to reach them—save lives and prevent harm, and they often cut costs.

For instance, patients on a ventilator are susceptible to an often-deadly pneumonia. Every case adds an estimated $40,000 to the cost of a typical hospital stay. One of the four IHI-recommended approaches to preventing the infection is to ensure that a patient's head is elevated at least 30 degrees.

To prevent the head from falling below that, IHI suggested drawing a line on the wall beneath which the bed shouldn't drop and instructing nurses, housekeepers, family members, and anyone else to alert the nurse if the line became visible. It's simple but effective, and it's the same story for the other 11 goals. "Each complication, if not prevented, would have resulted in thousands of dollars of extra care, medication, and prolonged hospitalization," says Louise Liang, the senior vice-president of quality and clinical systems support at Kaiser Foundation Health Plan & Hospitals.

"A Personal Hero"

Dr. Berwick, a former pediatrician, has won myriad awards for his work, but when it comes to measuring his impact, the proof is in the data. Dominican Hospital in Santa Cruz, Calif., reduced the rate of hospital-acquired infections to near-zero after adopting IHI's methods. At Missouri Baptist Hospital in St Louis, the April 2004 introduction of an IHI-tested innovation led to 31 fewer cardiac arrests than the previous year. And Albany Memorial Hospital reduced its mortality rate by 15% in 2006. Hundreds of doctors and nurses and health-care administrators deserve credit for these achievements, but Dr. Berwick's role in developing, testing, and spreading these innovations is unparalleled.

"Dr. Berwick is the single most influential worldwide leader and driver of health-care process, practice, and clinical outcome improvement," says Dominican Vice-President Lee Vanderpool, "He's a personal hero of mine."

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