The New Health Dialogue

Over the summer, Bob Wachter wrote about "the non-scalability of charisma," how hard it is to make change for the better in health care, even relatively simple and proven steps such as implementing a checklist to reduce infection. We followed up with some thoughts about why it might not be quite so bleak -- because health reform is changing some of the incentives (not as many as we would have liked, but some), states are stepping up reporting requirements and transparency, and CMS is in very good quality-inspiring hands these days.

But Katherine Garrett, a New York based health quality expert, who happens to be one of  blog editor Joanne Kenen's oldest friends (and who if Joanne's memory serves was the first person many years ago to tell her about this interesting doc up in Cambridge named Don Berwick,) is more skeptical about the performance reporting elements of quality improvement. We asked her to guest post. Also if you identify with Garrett's comment about the "roller coaster" quality improvement ride, click back to this post on "The hype cycle," a term Joanne heard at an IHI conference).

Joanne Kenen’s recent post on the infection-charisma complex (great job on the title, by the way) led to a longer, off-line discussion between the two of us on whether optimism is warranted. I’ve been working in health care quality improvement since 1991 and I describe this work to my graduate students as an extended roller coaster ride: a rush of excitement--usually caused by a policy change, or a new commission, or a new IHI initiative--that a commitment to quality really will take hold and grow, followed by the stark reality described by Bob Wachter that, in fact, no, it won’t. I too doubt that the performance reporting initiatives you list are going to do the trick.

Why the pessimism? As usual, the person who explains it best is Don Berwick, this time through an interview last November with Phil Galewitz of Kaiser Health News (republished when he was nominated to CMS). Berwick notes that transparency about performance conceivably might lead to improvement in three ways:

1. Through patient choice: patients will choose higher-performing providers and market forces will therefore push most providers to higher performance. I think there’s not much evidence that this occurs; Berwick says outright that he “do(es)n’t think that’s the way it happens.”

2. By tapping into the super-egos of providers. No provider (physician, clinic or hospital) wants to be on the bottom, so those at the bottom will strive to do better on the elements that are measured. While Berwick calls this a “tremendously powerful lever,” the question for me is how widespread the commitment to improvement then becomes in the organization, and how sustainable this commitment is.

3. Through learning. Public reporting shows who's doing well so, in the best case, other providers can go and learn how the systems work at the high-performing places, and bring that learning back to their own organizations. Berwick calls learning the “strongest lever.” To me, in the long run, this is the only thing that really works. Improvement requires serious leadership and staff commitment to the concept of learning, of willingness to change and try new ways of work, of recognizing that even failure can provide valuable knowledge for the next try. The hard truth is that this commitment doesn't exist very many places even now, in spite of initiatives like IHI’s Five Million Lives Campaign or Michigan’s Keystone Project on central line infections.