Zeev Neuwirth, Senior Medical Director of Population Health at Carolinas Healthcare System Medical Group, and an old friend and former colleague, launched a weekly podcast last August entitled, Creating a New Healthcare. I love the recurrent introduction that Zeev gives at the start of each of his podcasts:
Hello, I’m Zeev Neuwirth, and welcome to “Creating a New Healthcare,” a podcast series for healthcare leaders who are interested in fresh perspectives, new ideas, bold solutions, and a renewed sense of meaning and purpose in their journey to advance patient centered, customer oriented value based healthcare.
Last November Zeev sat down with Don Berwick, a man who needs no introduction, and together they recorded a podcast that is a remarkable conversation about Era 3 in Medicine. When Don was the Administrator of CMS I visited him in at his office in Washington. During the visit he pointed out the quotation by Hubert Humphrey that is carved into the wall of the building that houses Health and Human Services and CMS.
It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.
I think that you will learn from the conversation between Don and Zeev that what Don calls “Era 3” in Medicine is an attempt to move closer to the spirit of Humphrey’s statement. Please click on the link above to hear all or at least part of their conversation. Below is my attempt to give you the “CliffsNotes.”
Zeev began the conversation with a discussion of the nine items Don identified as needing change as we moved into the future of healthcare, what he has called, the “moral era, or Era 3.
- Stop Excessive Measurement
- Abandon Complex Incentives
- Decrease Focus on Finance
- Avoid Professional Prerogative at the Expense of the Whole
- Recommit to Improvement Science
- Embrace Transparency
- Protect Civility
- Listen. Really Listen
- Reject Greed
Zeev asked Don about the thought process that produced the list. Don said he was thinking about how conversations about what to do next, or debates about the future of healthcare always seemed to have the tone of a fight. He wondered, “What are we fighting about?” The answer is complex, but what he settled on emerged from his framing of two previous eras that were in conflict with each other, and now are in conflict with a better future.
Era 1 was about professionalism. Doctors have knowledge that others cannot access. In Era 1 doctors self regulate. They use science. The culture and attitudes go back more than a thousand years. Don’s father was a doctor in a small town where he was treated as if he were “quite royal and had special privileges.” I entered medicine in the twilight of this era, and I was trained by doctors who were wonderful examples of all of its virtues. It was an era when the patient “sat at the feet of a standing doctor in a white coat,” and listened to the diagnosis and accepted the prescribed treatment without questions that challenged the doctor’s authority. There was little transparency. The profession governed and judged itself. In many ways the best of the attitudes of Era 1 are still valuable, and are still palpable in our times.
Era 2 really bloomed in the eighties along with data about our performance. We became aware of variation in practice along with the troublesome data about the cost and safety of healthcare. Don’s work, and the work of others like Jack Wennberg at Dartmouth, startled all of us with evidence of the unwanted variation and other defects in our care as Era 1 collided with Era 2. Hard feelings and conflicts emerged as we began to compare our methods and outcomes. We went from being unquestioned on our pedestals to feeling like defendants in a criminal investigation. What occurred was “control” with conversations and arguments about accountability and pay for performance. We still suffer with intensive measurement, attempts at gaming, and the associated increases in waste and cost.
Don imagined Era 3 by asking what lay beyond the conflict between Era1 and Era 2. He imagined that the “foundational charter” would include a “respectful account” of the important parts of professionalism, transparency, proper payment, and econometrics, but added, “…it does not stop there.” It moves forward to a vision of a much better system that arises out of the combination of the two previous eras tempered by what we have learned is important, but has been largely ignored, which is the importance of how we view our relationship with the patient.
He called the list of nine principles a “first draft’ that was an attempt to describe a change in “mindset” and priorities that would lead to a much better system that would converge on the interests of patients, families, and communities. Era 1 thinking would support measurement that promoted learning. The measurements of Era 2 were about “accountability, incentive, reward and punishment, and its just ballooned” with an “insane amount of metrics that impedes work.” His conclusion: let’s put measurement on a diet and use it for learning and improvement and not as a tool in combat or compensation. Era 3 is a course correction.
When asked by Zeev about “the reason, the problem we are trying to solve” Don responded that we were here to relieve suffering and to try to prevent it. Our purpose was all about patients, families and communities. The Triple Aim is the best answer to “what are we about.”: better care for individuals, better health, and lower costs. Costs need to be controlled because cost “confiscates resources.” “It [healthcare] is such an important and charismatic endeavor that when it wants money, it gets money.” That money “comes from somewhere… other government investments like housing,…,education, and criminal justice…a third of what we are spending on healthcare is waste.”
He recommends pursuing the goals of the Triple Aim through improvement science. Era 2 choses accountability and incentives. Era 1 choses “professional heroism.” Neither heroism or accountability hold the “keys to the Triple Aim.” The Triple Aim is a “shared enterprise of redesign.”
Zeev asked, “How do we put metrics on a diet,…how do we course correct?” Don’s response was that the answers are “leadership dependent.” If we are going to get better, “You kinda have to know how you are doing.” The key is to establish a leadership commitment to approach the improvement of complex systems scientifically. The solution requires “clarity of aim,” a “whole new way to engage the workforce in spirit and intent, through joy and growth, and development and respect for their motivations.” Then “hire measurement, it’s your servant.” He points out that in Era 2 we put the measures in the forefront and then “everybody sits around talking about how do we measure, and do we have the reports?… it’s very wasteful.”
Deming said that if leaders want to make things change there are four areas or disciplines they must master. First, master the nature and dynamics of systems. Second, understand variation through an understanding of statistics. Third, understand psychology as it explains individual motivation and group process, human perception, and adult learning. Fourth, master the plan, do, study, act cycle, PDSA that is built on how to continually learn in a complex system. It is an exercise in epistemology.
Leaders who don’t have these skills will “get themselves confused” because they will not understand systems, will misinterpret variation and motivation, and they will not support testing. After observing leaders for forty years, Don believes Deming is right. At corporate retreats, and visits with leaders in their institutions, he doubts that many of them use these skills. They are looking for silver bullets, quick solutions. They misuse Lean and Six Sigma by failing to recognize the need for their own mastery and transformation. In Era 3 leaders “get back to school” in complexity, variation, psychology, and the science of continuous improvement to enable them to lead toward improved care in a systematic and sustainable way.
Zeev asked what Don would tell Leaders and boards as a “call to action.” Don said that they must employ the basics principles of scientific improvement. They must have a “clarity of aim,” a “constancy of purpose for improvement.” He asks, “What are they there for?” He suggests that they “pick the stuff that they really want to make better.” Asking critical questions is their job, and asking will point them in the right direction.
Once the Triple Aim is your goal, then method matters. There are only two parts to the quality journey, “aim and method.” He had two pieces of advice on method. First, really, really listen to the patients. Get the voice of the people you serve into the room all the time, at every level. Secondly, embrace interdependency. Heroes never were the solution. The solutions are found in dialog. You can’t get a great system by everyone focusing on their part in isolation. .
A question from Zeev initiated a conversation about asking patients, “What matters to you?” rather than “What is the matter with you?” The PREMS and PROMS metrics are important to Don. PREMS are patient reported experience metrics, and PROMS are patient reported outcomes measures. Don said that if he were leading an organization now, he would get everyone into the “What matters to you?” mode.
Zeev asked for specific examples that illustrated Era 3 thinking. Don responded with several stories that moved the conversation from the theoretical to proven practicality. At one point he commented, “The new era is not an imaginary place. It does exist. It just doesn’t exist everywhere.”
Late in the conversation they tackled the huge problem of the second leg of the Triple Aim, better health for the community. Hospitals and medical practices rarely define it as their concern, although Don was able to give examples of institutions that did recognize that it was. Care offered in hospitals and the doctor’s office is a minor contributor in the overall endeavor to improve health. No one owns the health of the community, and the resources are slim. Era 3 acknowledges that reality. Don challenges us to lead in organizing the efforts to improve the social determinants of health. The IHI has organized a “Leadership Alliance” to begin to make a difference. Don gives kudos to Cincinnati Children’s Hospital, Bellin Health in Wisconsin, and Kaiser.
Zeev closed by asking if there was anything left unsaid. Don said he was optimistic about the future, but we must work together using scientific methods that help us deal with complexity and systems. He said, “If you are feeling lost, maybe you are trying the wrong way.” He then said that he “personally had to take cognizance of the political environment.” He said:
I can not imagine an American society that is healing without a commitment to care of the vulnerable, protection of the disadvantaged, the pursuit of social justice and equity, the repair of our criminal justice system, a whole bunch of what I regard as progressive policies which are currently under a very dark cloud given the national ethos and our national leadership today. It’s not OK. I just can’t help making a plea to the professionals who are listening to you in this podcast to be active in restoring a sense of social justice as a primary foundation for our nation. And if the politicians currently in charge won’t do it, and they won’t, then I think professionals have a duty, just as they do to the improvement of the system. They have a duty to the improvement of the moral foundations of the nation, and that for me is a part of Era 3, as well. So, excuse the political excursion here, but it is a time to speak up because what is going on is not OK.