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President Obama, Don Berwick, and the 17.3% Solution

17 May, 10 | by David Stevens

I hear something new every time I listen to Don Berwick—CEO of the Institute for Healthcare Improvement—speak. He is consistently able to adapt innovative ideas to a listener’s context—providing fresh meaning and insight.

Several weeks ago President Obama nominated Don to head the US Centers for Medicare and Medicaid. This position directs a federal agency with a massive budget for the care of the US elderly and poor—$453 Billion for Medicare and $290 Billion for Medicaid in 2010. It’s a considered move with the potential to assert new strategies for healthcare improvement and reduction of waste in a country where fully 17.3% of the gross domestic product went to healthcare in 2009. In spite of this financial commitment, the data show that US healthcare outcomes frequently underachieve when compared to many other countries that spend far less.

But first there’s a political reality. The President has to gain formal approval of Don’s appointment from a US Senate that is deeply divided over the Obama healthcare initiatives.

The culture, context and prior assumptions that go into hearing a speech, or—for that matter—improving healthcare, are very complex. Don’s quotes are making the rounds in newspapers and blogs. One of my favorites recently made it into Robert Pear’s New York Times article about the appointment: “’Health care has no intrinsic value at all, none,’ Dr. Berwick said. ‘Health does. Joy does. Peace does.’” I recall these words when they brought the IHI National Forum audience—6000 strong—to their feet in his plenary last December.

Unfortunately, I can only guess at the ways this comment will be heard in the many contexts where healthcare reform is being debated in the US. Health? Joy? Peace? In the politics of US healthcare, the context itself increasingly seems to shape the news, creating new interpretations of old statements to fit the spirit of the audience.

But, the data arrive wrapped in their own context. Let’s have a show of hands for those who don’t think that 17.3% of the US gross domestic product is a monumental opportunity for better and safer healthcare—plus a whole lot more. Now that’s the context for a discussion I’d like to hear.

Epistemology of improvement and the measurement of volcanic ash

23 Apr, 10 | by David Stevens

I spent last week at Cliveden House, near London, at the Health Foundation-sponsored International Colloquium on the Epistemology of Improving Quality—30 scholars who reflected perspectives from 9 countries and over a dozen academic disciplines. These colleagues sought to gain clarity regarding the epistemology of healthcare improvement—how we know what we know about making patients’ health and healthcare better and safer. One of their bold aims was to explore the fundamental differences among the diverse communities of thought that have, as the conveners said, “at best tolerated or ignored each other, at worst fought each other for the high ground (usually from the foothills of the pages of a journal).” The theory that underpinned such an assault on academic tribalism was simple but radical: advancing to the common ground of scholarship, pedagogy and practice might indeed hasten the realization of better health and healthcare.
Experience dictates that this would have to be more about listening than talking, the search for drivers rather than barriers, and the framing of models of success instead of recitations of failures. The Colloquium achieved all this and more. It led to a set of transparent initiatives that I cannot possibly summarize in this small space, but keep an eye open for an array of forthcoming initiatives and calls to action. They’ll embrace words like, “context, integration, complexity and confluence,” in addition to the more familiar, “change, innovation, science, and spread.”
All the participants returned to Earth (actually, London) from these epistemological heights to discover greater clarity regarding who is the real driver and who is passenger on this planet. All air travel in the UK and much of northern Europe was grounded by the ash cloud that drifted east and south from the Egjafjallajokull volcano in Iceland. We accessed online news sources, airline websites, and the shared opinions of dinner conversations, as dirty laundry grew and bank accounts shrank. We tracked and shared the daily measurements. Volcanologists, transport CEOs, air traffic control officials and government policy makers discussed the size, surface and shape of particles, the thickness of clouds and the temperature of jet engines. They measured the things they could. Today planes are flying again. Presumably the two–the measurements and the decision to fly–are related. Paul Batalden made the observation at breakfast this morning that—as with decisions regarding what measures are likely to lead to reliable and valid healthcare improvement—finding things to measure in most challenging circumstances is generally the easy bit. Knowing which measurements are truly useful is clearly another matter.

Fresh and Ambitious Look at the Epistemology of Healthcare Improvement

10 Apr, 10 | by David Stevens

Welcome to the new Quality and Safety in Health Care blog. Does the medical blogosphere need yet another blog? That of course is for you to decide. Suffice to say, my goal will be to convey what’s new and innovative in the scholarly healthcare improvement community and to try to make it worth your valuable time.
I’m about to leave Boston en route to Heathrow to participate in the International Colloquium on the Epistemology of Improving Quality. A couple dozen colleagues will gather north of London with the support of The Health Foundation. Co-conveners Paul Batalden, Paul Bate, and Dale Webb have invited healthcare improvement and patient safety scholars from a myriad of scholarly disciplines to probe critically the epistemology of improvement – how we know what we know about making healthcare better and safer for patients.
The conveners have taken one of their cues from C. P. Snow who coined the term, Two Cultures, for his Rede Lecture at Cambridge University in 1959. A scientist and novelist, he focused on how the breakdown in communication between science and the humanities created a barrier to more effective advances for the benefit of society. Harvard’s Jerome Kagan reframed this thesis in his recent book, The Three Cultures, adding a third “culture,” the social sciences – disciplines such as sociology, anthropology, and economics.
The conveners selected representatives from numerous and diverse disciplines—spread among the three cultures—to work together to craft the epistemological footings of healthcare improvement. Audacious as this task may seem, their careful preparation for this work holds great promise for bridging disciplines and research methods to advance these fields. I for one am optimistic about where this might lead. I’ll report here as it unfolds.

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