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Saturday, December 01, 2007

Half Way There

It is my distinct impression (though I can’t know for sure) that when the Institute for Healthcare Improvement was founded in 1991, its then and current CEO Don Berwick believed that if doctors and hospitals were taught how to improve the quality and safety of care, they would do it.

The intervening years of frustratingly slow progress have apparently convinced him otherwise. Together with colleague Steven Spear of the MIT faculty, Berwick authored an op-ed piece in the November 23, 2007 issue of the Boston Globe, titled “A new design for healthcare delivery.” It points out that the structure of healthcare delivery as it evolved over 50 years ago is based on professional specialty, with resulting “silos” of surgeons, nurses, cardiologists, pharmacists, etc. That arrangement served the needs of its time, but is no longer suitable now that effective health care depends less on individuals and more on the systems and processes that cross specialty lines and that have been found so difficult to manage.

They give examples of spectacular results achieved by hospitals that have made serious efforts to manage care. They put the onus of responsibility for undertaking such efforts where it belongs – on institutions; i.e., hospitals, nursing homes, dialysis units, ambulatory surgery centers, and physicians’ offices, as well as on programs of education in the health professions. Significantly, they make no mention of the medical profession as such (which has historically had jurisdiction over matters of quality) and deprecate the usefulness of “dramatic legislative, regulatory, and fiscal flourishes.”

They recognize that, instead, improvement requires “diffuse work” at the local level and leaders willing to get into the “nitty-gritty of patient care” and confront “professional norms.”

Perhaps in a future article they will address some of the cultural and practical barriers that stand in the way of carrying out their recommendations.

That would be good, but if it is true that you can’t solve a problem until you recognize it, we can at least take some comfort now from being halfway there.

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