Dr. Bray Links

Wednesday, March 2, 2016

CMS administrator believes that relationships will be the foundation on which the next phase of health care

Former Administrator of the Centers for Medicare and Medicaid Services (CMS). Former President and Chief Executive Officer of the Institute for Healthcare Improvement a not-for-profit organization. Berwick graduated with a B.A. from Harvard College, where he graduated summa cum laude. Berwick earned both an M.D. cum laude from Harvard Medical School and an M.P.P. from John F. Kennedy School of Government in 1972. He completed his medical residency in pediatrics at Children's Hospital Boston.

Berwick offered health care leaders nine steps they can take to begin moving into this new age, which he tentatively dubbed as “the moral era”. Here they are, in his own words:

  1. Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find Sean in that glare. I vote for a 50 percent reduction in all metrics currently being used.
  2. Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
  3. Decrease focus on finance: This could be impossible. I feel na├»ve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? … If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
  4. Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
  5. Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
  6. Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
  7. Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient — these are not funny.
  8. Listen. Really listen: These terms — coproduction, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
  9. Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.

There’s a lot more I, as the reporter, could say about what was a wonderful, wonderful speech, probably the best I’ve seen in my four short years covering health care conferences, but I’ll leave it at that. Berwick closed by relating a tip from one chief nursing officer that’s resonated with him. Every time a baby was born, she would ask herself, “Is this a president?” Berwick says the sentiment of that small encounter has stuck with him, and he thinks it’s important that health care workers carry the thought behind that question into all that they do. Relationships will be the foundation of the health care’s new age, he believes.

“That’s Era 3,” he said. “The quest is clear. It’s not power or accountability or reward or punishment or score sheets or metrics or profit for its own sake. It’s a search for meaning in the value of the person who has come to honor us with his or her quest for some help. And we think to ourselves, is this a president? Is this a hero? Is this a mother? Is this a father? An artist? A craftsman? An honest laborer? A climber of hills? A singer of songs? Who is this person who honors me with their presence, and what can I do to help them?”


Writing for the New York Times, Dr. Bob Watcher argues that, “Two of our most vital industries, health care, and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point …”

The drive to performance measurement, he says, started “innocently enough” as “evidence mounted that both fields were producing mediocre outcomes at unsustainable costs.” Now, though “the measurement fad has spun out of control.  There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100,’ ‘honor roll,’ grade ‘A’ or ‘best’ hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.  Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?”

He’s not the only Dr. Bob who is anxious about performance measures.  Dr. Bob Berenson, who has for years played a key role in influencing Medicare payment policies as a former vice chair of the Medicare Payment Advisory Commission and, in the 1990s, as acting administrator of CMS, takes on the “myth” that W. Edwards Deming, the famed quality improvement guru, said that “if something cannot be measured, it cannot be improved” — the justification offered by many for the proliferation of performance measures.   According to Dr. Berneson, Deming actually wrote the opposite, “It is wrong to suppose that if you can’t measure it, you can’t manage it — a costly myth.”

Dr. Berenson continues: “The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by Deming, other management experts, or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.”


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