Über die Autorin bzw. den Autor

Donald M. Berwick, MD, MPP, is president, CEO, and cofounder of the Institute for Healthcare Improvement in Boston, Massachusetts. Dr. Berwick is a clinical professor of pediatrics and health care policy at the Harvard Medical School, and a pediatrician. An associate in pediatrics at Boston’s Children’s Hospital, he is also a consultant in pediatrics at Massachusetts General Hospital. Dr. Berwick is the coauthor of the books, Curing Health Care and New Rules, also available from Jossey-Bass.

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"Why Is Changing Health Care So Hard?"

In this provocative and much-needed book, health care expert Dr. Donald Berwick shares eleven of his most compelling speeches. These unforgettable speeches (which were delivered at the Institute for Healthcare Improvement s annual National Forum on Quality Improvement in Health Care from 1992 to 2002) dramatically show that we need to create a new system that guarantees that every patient has the benefit of care drawn from the best scientific knowledge available. No mere diatribe, Berwick s vision for change includes practical suggestions and tools that can truly transform our broken system and puts the patient at the center of the health care system.

"In this vibrant book, Don Berwick speaks about one of the most vexing issues of our time with compelling competence, penetrating clarity, relentless honesty, and heart-warming humor. In an era when so many public voices lack these qualities, Berwick gives us reason to hope that our most difficult social problems have solutions that are within reach. We are the solution, of course if we are willing to emulate the intellectual and moral courage modeled by leaders like Don Berwick."
Parker J. Palmer, author, The Courage to Teach and Let Your Life Speak

"[Berwick s] target is a health care system that has evolved primarily to serve the needs and interests of those who work in the system doctors, nurses, administrators, payors, insurers rather than the needs and interests of patients."
from the Introduction by Frank Davidoff

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"Why Is Changing Health Care So Hard?"

In this provocative and much-needed book, health care expert Dr. Donald Berwick shares eleven of his most compelling speeches. These unforgettable speeches (which were delivered at the Institute for Healthcare Improvement’s annual National Forum on Quality Improvement in Health Care from 1992 to 2002) dramatically show that we need to create a new system that guarantees that every patient has the benefit of care drawn from the best scientific knowledge available. No mere diatribe, Berwick’s vision for change includes practical suggestions and tools that can truly transform our broken system and puts the patient at the center of the health care system.

"In this vibrant book, Don Berwick speaks about one of the most vexing issues of our time with compelling competence, penetrating clarity, relentless honesty, and heart-warming humor. In an era when so many public voices lack these qualities, Berwick gives us reason to hope that our most difficult social problems have solutions that are within reach. We are the solution, of course–if we are willing to emulate the intellectual and moral courage modeled by leaders like Don Berwick."
–Parker J. Palmer, author, The Courage to Teach and Let Your Life Speak

"[Berwick’s] target is a health care system that has evolved primarily to serve the needs and interests of those who work in the system–doctors, nurses, administrators, payors, insurers–rather than the needs and interests of patients."
–from the Introduction by Frank Davidoff

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Escape Fire

Jossey-Bass

Preface

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 movement 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 Improvement in Health Care now had four thousand participants. A quality movement was expanding rapidly on at least three continents. The 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 hundred 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 cooperate. There is no other suggestion in these pages-all else is fluff and padding, trying over and over again to make the signal comfortable 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'tre 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 little 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 knowledge and actual practice, the commitment to 'appropriateness,' 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 available anywhere."

Why do we continue trying to make great health care out of disconnected, 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 admonition, "The pace of change is majestic." From that higher perspective, 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 provocateurs, 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 contracting, making quality of care begin to seem like a serious business issue. Health care quality is now a major theme in medical literature, and both the Joint Commission Journal and the British Medical Journal Publishing Group's journal Quality and Safety in Health Care are completely devoted to the issue. Training and residency programs are beginning to include quality and improvement in their required curricula for medical students. The National Health Service 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 improvement of care at the center of their government-sponsored systems. The World Health Organization now has a chartering policy statement 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 single 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...