Escape fire

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Escape Fire

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Donald M. Berwick

Introduction by Frank Davidoff, MD

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Escape Fire

Designs for the

Future of Health Care

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Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-Bass

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Library of Congress Cataloging-in-Publication Data

Berwick, Donald M. (Donald Mark), 1946–

Escape fire: designs for the future of health care / Donald M. Berwick; introduction

by FrankDavidoff.

p. ; cm.

Keynote speeches presented at the annual National Forum on Quality Improvement

in Health Care, 1992–2002.

Includes bibliographical references and index.

ISBN 0-7879-7217-7

1. Health care reform—United States. 2. Health services administration—United

States. 3. Medical care—United States—Quality control. 4. Patient advocacy—

United States.

[DNLM: 1. Delivery of Health Care—trends—United States—Collected Works.

2. Organizational Innovation—United States—Collected Works. 4. Quality of Health

Care—trends—United States—Collected Works. W 84 AA1 B49e 2004] I. Institute

for Healthcare Improvement. National Forum. II. Title

RA395.A3B47 2004

362.1'0425—dc22 2003021193

Printed in the United States of America

FIRST EDITION

HB Printing 10 9 8 7 6 5 4 3 2 1

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Contents

Preface ix

Acknowledgments xv

Introduction xix

Frank Davidoff, MD

1. Kevin Speaks 1

2. Buckling Down to Change 11

3. Quality Comes Home 43

4. Run to Space 61

5. Sauerkraut, Sobriety, and the 93

Spread of Change

6. Why the Vasa Sank 127

7. Eagles and Weasels 155

8. Escape Fire 177

9. Dirty Words and Magic Spells 211

10. Every Single One 239

11. Plenty 269

About the Author 297

About the Commentary Authors 299

Index 305

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To Ann, with thanks, for love and courage

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Preface .................................

To read these eleven speeches in one sitting, as I have now done,

makes me dizzy. They pass before me at a speed disrespectful of the

difficult decade they mark.

When I gave the first speech in this collection, “Kevin Speaks,”

in 1992 in front of sixteen hundred self-starting mavericks, the

Institute for Healthcare Improvement was a young organization

with a handful of employees, and health care had no quality move￾ment at all. Ben, my oldest child, was a high school junior, and Becca,

my youngest, was in first grade. (Ben is now a legislative aide on

Capitol Hill and Becca is a high school senior.) Hillary Clinton was

just about to try to rescue American health care. Avedis Donabedian

and W. Edwards Deming were alive and well. So was my father. My

family had not yet lived for a year in Alaska, or even imagined doing

so. We were all healthy. I ran twenty miles a week, and my wife’s two

years of devastating illness were far in the future. The European

Forum on Quality Improvement in Health Care and the Asia Pacific

Forum did not exist. The Institute of Medicine (IOM) had no

quality-of-care agenda on its screen. My hair was full and black.

Ten years later I gave the last speech in this collection, “Plenty,”

in a wholly different world. The National Forum on Quality Improve￾ment in Health Care now had four thousand participants. A quality

movement was expanding rapidly on at least three continents. The

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x PREFACE

Institute for Healthcare Improvement employed seventy people and

worked with more than four hundred faculty members worldwide.

The 8th European Forum on Quality Improvement in Health

Care—with one thousand participants from forty-three nations—

lay just ahead, and the 2nd Asia Pacific Forum—with seven hun￾dred people from twenty-three nations—lay just behind. So did

September 11. Harry Potter had met Voldemort, and my wife, Ann,

was in her long convalescence, walking and working again. Avedis

Donabedian, W. Edwards Deming, and Philip Berwick, my father,

had been laid to rest, each after a long and difficult illness full of

compassion from their caregivers and defects in their care. The IOM

had spoken, in To Err Is Human and Crossing the Quality Chasm:

“Between the health care we have and the health care we could

have lies not just a gap, but a chasm.” My right knee was totally

blown and my jogging days were over. My hair had thinned and

turned pure white.

With so much different, why do these speeches strike me as so

repetitive? Metaphor after metaphor, list after list, story after story—

but always the same. Year after year I can find only three messages

at the core: focus on the suffering, build and use knowledge, and coop￾erate. There is no other suggestion in these pages—all else is fluff

and padding, trying over and over again to make the signal com￾fortable enough to hear and eloquent enough to remember.

The words hide my impatience. Why is changing health care

so hard?

Why don’t we yet remember more reliably that our work has no

other raison d’être than to relieve pain? In “Kevin Speaks” I wrote,

“We are not here so that our organizations survive; we are here so

that Kevin survives.” Ten years later, recounting the story of a lit￾tle girl, Alicia, who had cystic fibrosis, and her tireless father, Jim,

I wrote, “We are here today for exactly—one reason—the same as

Jim’s—to make Alicia’s senior prom night romantic.”

Why are science and practice still so far apart? In 1993 I wrote,

“The commitment to improving the match between scientific

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knowledge and actual practice, the commitment to ‘appropriate￾ness,’ must come from the professionals whose actions constitute

care”; and in 2001, “We need to get serious about promising every

patient the benefit of care that draws on the best knowledge avail￾able anywhere.”

Why do we continue trying to make great health care out of dis￾connected, separately perfected fragments instead of weaving the

fabric of experience that our patients need from us? Kevin asked in

1992, “Do you ever talk to each other?” And a decade later I echoed

him in my exhortation, “Cooperation is the highest professional

value of all.”

Though frustrated, I do find comfort in Joseph Juran’s admoni￾tion, “The pace of change is majestic.” From that higher perspec￾tive, improved results for the vast majority of patients still seem

elusive; but the optimist in me thinks that something momentous—

something substantial, meaningful, and rational—may have, after

all, begun. I do sense a movement—not fast enough yet, but maybe

a little “majestic.” From a fringe collection of oddly placed provo￾cateurs, the advocates of fundamentally changed health care have

joined the mainstream. The IOM reports—To Err Is Human and

Crossing the Quality Chasm—have chartered a whole new wave

of scientifically grounded efforts to improve. A federal agency,

the Agency for Healthcare Research and Quality (AHRQ), has

changed its name to include “quality” and doubled its budget in

pursuit of that aim. Big federal programs such as the Veterans

Health Administration, the Bureau of Primary Health Care in

the Health Resources and Services Administration, and Medicare

have led the nation in embracing quality improvement aims.

Patient safety, the cutting edge of quality, has front-page status. The

Leapfrog Group—a progressive purchaser consortium in the United

States—is trying to put quality criteria into health care contract￾ing, making quality of care begin to seem like a serious business

issue. Health care quality is now a major theme in medical litera￾ture, and both the Joint Commission Journal and the British Medical

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xii PREFACE

Journal Publishing Group’s journal Quality and Safety in Health Care

are completely devoted to the issue. Training and residency pro￾grams are beginning to include quality and improvement in their

required curricula for medical students. The National Health Ser￾vice in the United Kingdom has established the Modernisation

Agency, which now has eight hundred employees and massive

improvement agendas, and is in the midst of the largest single-system

improvement effort ever undertaken in any industry. Australia, New

Zealand, and much of Scandinavia have all begun to place improve￾ment of care at the center of their government-sponsored systems.

The World Health Organization now has a chartering policy state￾ment on patient safety from its 2002 World Health Assembly.

The change is preadolescent but massive. These eleven speeches

punctuate a decade of stage setting, a getting-ready-to-change that

in 1992 I could not even have begun to imagine. It would have

seemed crazy even to hope for it.

Eleven National Forum speeches from now, how different will

the message be? Now I can hope even more, without feeling crazy.

The pedal point will be the same, of course: help people—every sin￾gle person; use knowledge—all the knowledge; work together—

cooperate, above all else. But maybe our hard work on these themes

will at last have paid off so that new themes can also emerge out of

results won, problems solved, and sensemaking returned.

In 2012—twenty years after “Kevin Speaks”—will a National

Forum keynote speaker be fortunate enough to say that millions

upon millions of patients—Kevin’s successors—are safer, in less

pain, more honored in their values and choices, wasting less time

and money, and more confident in the reliability and gentleness of

their care? Will we live longer and die less lonely and less afraid?

Will we be able to celebrate that our health care remembers us in

continuity, through our lives and across our communities, achiev￾ing well-being for populations as its measure of success rather than

counting fragments and calling that “productivity”? Will we have

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replaced nineteenth-century information systems with twenty-first￾century ones? Will we have restored joy in work for all professionals

and staff, and be unembarrassed to say so? Will our young people,

learning their craft, feel the highest sense of honor and delight in

their choice of profession? Will we have come to think truly glob￾ally about the health we seek—for everyone—for all races, for all

regions, for all nations?

Eleven speeches . . . a decade of change . . . a challenge defined

. . . a movement well begun. Now, I’d say, things get really interesting.

September 2003 Donald M. Berwick, MD, MPP

Boston, Massachusetts

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