Clinical Innovators | Donald M. Berwick, MD: Advancing Quality, Lowering Costs, and Improving Care
Donald M. Berwick, MD, is former administrator of the Centers for Medicare and Medicaid Services (CMS) and current gubernatorial candidate for the governorship of Massachusetts. Prior to his work in the administration, he was president and CEO of the Institute for Healthcare Improvement (IHI), a nonprofit organization dedicated to innovative health care improvement worldwide. Among IHI’s projects are multiple programs aimed at lowering the number of heart failure readmissions. Dr. Berwick has studied the management of health care systems, with emphasis on using scientific methods, evidence-based medicine, and comparative effectiveness research to improve patient quality, safety, and costs.
In this issue of CardioSource WorldNews, we interviewed Dr. Berwick about his role in health care reform and the future improvements in health care delivery that he anticipates.
You have had a remarkably varied career—transitioning from a practicing pediatrician to a national health care quality leader to the administrator of CMS. Can you describe your journey?
I grew up in a small rural town where, if someone’s car was stalled on the side of the road, you didn’t drive by. You stopped to help. It was a general idea that I grew up with: we’re all in this together and we help each other. My father was a doctor, making house calls miles away, helping everyone he could, and I wanted to follow in his footsteps. After medical school, I went on to become a pediatrician.
Public policy was always an interest of mine, and when the opportunity presented itself to receive my master of public policy degree from the John F. Kennedy School of Government while still in medical school, I jumped at it. I saw patients in a large group practice, and, like all clinicians, I experienced inefficiencies that hindered my ability to provide the best care to my patients. That drew my interest to health care quality. How do we do better? I became a student not just of health care, but of improvement. I began studying how large systems get better through modern approaches to continual quality improvement.
This interest led me to found with others the nonprofit Institute for Healthcare Improvement. Over the past 2 decades, the institute has brought together health care professionals from across the world together to optimize health care delivery. In 2010, President Obama called upon me to lead key aspects of the implementation of health care reform as the administrator of CMS. It was an opportunity to serve that I could not refuse.
Your term in Washington is often remembered for the rancorous debate surrounding your appointment to CMS Administrator. Close observers of that agency believe you indelibly transformed the agency for the better—noting your enhanced focus on “health” over merely processing claims. What were some of your greatest achievements in Washington?
My first rule in leading CMS was that we had to run the agency and conduct ourselves in the way that we wanted health care to be conducted. As you note, CMS had traditionally been focused on administering health care payment policies. I introduced to CMS the now-popular notion of the “triple aim” to re-orient the agency towards the goal of achieving better public health, higher-quality health care, and reduced costs—all at the same time.
I led the drafting of a first-ever mission statement calling for the agency to be a force for the continual improvement of health and health care for all Americans. I also focused squarely on the workforce and the people of the agency—we led improvement projects across the agency that empowered members of the workforce to find opportunities to improve service to the American people and remove waste. I wanted this attitude and capability to become part of the fabric of the agency. We launched several key initiatives under the Affordable Care Act (ACA), including the Center for Medicare and Medicaid Innovation, which will test new models of payment and care delivery; the Accountable Care Organization (ACO) model of care; and the $1 billion patient safety initiative, Partnership for Patients. The goals of the latter program were to reduce hospital-acquired conditions by 40% and readmissions by 20% over the next 3 years.
You co-authored a commentary this year in JAMA focusing on some of the limitations of the ACA.1 What do you see as the strengths and limitations of the legislation?
The ACA is very strong legislation that sets the country on the right path. It provides near-universal coverage and the foundations for significant health care delivery reform in the form of ACOs and other new models of payment and delivery.
There are always opportunities to improve. The JAMA editorial was not a general critique of the ACA; it focused very specifically on the availability of Medicare data for improvement work. Legislatively, there are some limitations on how Medicare data can be used to improve care and service delivery. I believe appropriate use of health care data—always thoroughly protecting patient privacy—can be a critical driver of improvement, and I believe that steps can be taken to enhance use of these data.
The British Prime Minister appointed you to lead quality transformation efforts in the National Health Service (NHS). What do you see as the greatest challenges in that system? What are the greatest opportunities?
Earlier this year, I was asked to do a short-term project advising the British government and other leaders on quality of care in the NHS. Faults are to be expected in any enterprise of the size and ambition of the NHS. Our report described some of those problems and suggested remedies. Among the problems we saw were: a partial loss of focus on quality and safety as primary aims; inadequate openness to the voices of patients and caregivers; insufficient skills in safety and improvement; inadequate staffing for patients’ needs; and very unhelpful complexity and lack of clarity and cooperation among regulatory agencies. I advised four guiding principles for reform:
- Place the quality and safety of patient care above all other aims for the NHS.
- Engage, empower, and hear patients and caregivers throughout the entire system, and at all times.
- Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work.
- Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.
You are now running for governor in Massachusetts. What fuels your motivation for this next step? If elected, will quality improvement feature in your agenda as governor?
I want to stay in the public sector. What governments can do is phenomenally important—if it is done right. By “right,” I mean governmental processes that are well-run, responsive to the public, and in good partnership with the private sector. I would like to be our state’s Governor to bring that kind of thinking about proper management, along with a firm commitment to the alleviation of poverty, total commitment to the well-being of children, and follow-through on reforming health care to achieve the “triple aim” of better care, better health, and lower cost.
Hubert Humphrey said, “The moral test of government is the way it cares for those in the dawn of life: the children; those in the twilight of life: the aged; and those in the shadows of life: the sick, the needy, and the handicapped.” I agree. As governor, I will call out that commitment loud and clear, and help Massachusetts become a state that never forgets the vulnerable among us.
1. Toussaint J, Berwick D. JAMA. 2013;310:29-30.
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