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Advancing the Science of Quality Improvement | Quality Time with Dr. Schaal

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In this episode, Dr. Don M. Berwick, a foundational figure in health care quality improvement, shares his perspective on how far we've come in our pursuit to improve patient safety through the design of a safer health system — and how far we have left to go.

Expert: Dr. Don M. Berwick, president emeritus and senior fellow at the Institute for Health Care Improvement (IHI), which he co-founded in 1991 and led as its first CEO, former administrator of the Centers for Medicare and Medicaid Services and former faculty member at Harvard Medical School and the Harvard T.H. Chan School of Public Health.

Notable topics covered:

  • The development and adoption of the science of health care improvement
  • The goal to close the quality gap through research and education
  • The impact of a psychologically safe work environment on health outcomes

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DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist Leading Medicine podcast. I'm your host, Dr. Shlomit Schaal, a Clinician Scientist and a Retina Specialist. And I serve as the Chief Physician Executive of Houston Methodist, located in the world-renowned Texas Medical Center. I passionately believe that quality is the heart of healthcare, and a commitment to quality is essential for every healthcare system. Join us each month as we discuss the latest advancement in quality in healthcare with clinicians, researchers, physicians, industry experts, and thought leaders who are as passionate as I am. I am very pleased and honored to welcome to the podcast Dr. Don Berwick. He's the President Emeritus and Senior Fellow at the Institute for Healthcare Improvement, IHI, which he co-founded in 1991 and led as its first CEO. He served as Administrator of the Centers for Medicare & Medicaid Services, CMS, from 2010 to 2011, and has held faculty positions at both Harvard Medical School and the Harvard T.H. Chan School of Public Health. A pediatrician by training, Dr. Berwick has dedicated his career to advancing high quality, patient-centered care in the US and around the world. Welcome Dr. Berwick.

DR. DON BERWICK:

So pleased to be with you. Thank you so much.

DR. SCHAAL:

Before we start, I want to thank you for serving as our keynote speaker at our eighth annual System Quality and Patient Safety symposium in May. We were honored to have you and inspired by your message. Thank you.

DR. BERWICK:

It was a complete pleasure. I really enjoyed working with you and your many colleges.

DR. SCHAAL:

So, tell us a little bit about yourself. How did you become the famous Dr. Don Berwick?

DR. BERWICK:

I'm a pediatrician by training and practiced for 20 years. Always part time cause I also had an interest in healthcare leadership and management. I grew up in a really small town. My father was a GP, a general practitioner, and so, kind of got -- early on got impressed with the medical sensibility. But, you know, practicing pediatrics in a very good medical center, I still saw things go wrong all the time and I became curious about why that was and how come we weren't seeing the kind of continual improvement that actually has characterized so many other industries. We were sort of stuck at a level of performance that was good but not the best we could. And that led me to a journey. I was sponsored to visit other industries, I came to know manufacturing companies, hotel chains, importantly NASA, I spent time with NASA. Like, I started to see what it would be to manage quality itself, to actually focus on improving processes and services as a core strategy with a lot of science behind it. I discovered the sciences of improvement. And with several colleges in the United States started with a non-profit organization, The Institute for Healthcare Improvement, where I now am a senior fellow, and as you said, was the founding CEO until I went into the Obama administration. I think I was, A, bugged by what was wrong, and B, I saw the sciences that could help us do better if we used them.

DR. SCHAAL:

So, you told a very powerful story of you taking care of a baby. You told it in the symposium. I'm wondering if you would mind sharing it with our listeners as well. DR. BERWICK: Yeah. It was one of the critical experiences for me. I was a young resident in pediatrics, in the middle of the night, doing an exchange transfusion on a little baby. Today, we don't do exchange transfusion in the United States. We don't need to, because we can prevent the blood incompatibility that causes the need for transfusion. But in those days, it was common. And so, the middle of the night, I -- you know I went through the motions of starting to transfuse a baby, and it all went sour. The baby got very, very sick right in front of me, and I didn't know what was going on. My fellow came in and figured out the problem. The problem was that the blood bank in that hospital, centrifuged blood when it got it from the donor and divided into two packets. One is a clear liquid plasma, and the other pack red blood cells. What you were supposed to do is when you received the blood from the blood bank, remix them so you got whole blood, which was the right material to transfuse the baby with. I didn't see the plasma packet, it was dangling down out of sight, and that procedure to centrifuge the blood from the donor wasn't the procedure at the other hospital that I worked at where I first was in pediatric intensive care. So, I was caught. I mean, baby got really sick, thank goodness survived, but it was a near miss that scarred me. I felt, at that time, I blamed myself. I mean, how could I be so stupid as not to have seen that other bag and not to know that procedure? And I still feel terrible about it, of course, but through the years, I began to see the systems issues behind it. I was trained in a different system, this is the middle of the night, it was very dark in the NICU. I don't know why the nurse didn't remind me to mix the blood, but maybe there was a hierarchy issue that stood in the way, or maybe she didn't see the bag of blood. Now, I could analyze that as a bad design and that improvement would require redesign. And that transition from blaming myself to seeing the system as error-prone was an important transition. Plenty of grist, plenty of episodes where things didn't go right. I think there and still now, you know, we train ourselves to try so hard and to feel so responsible that we turn to heroism as the answer. Just try harder, try harder, and things will go well, but. So, it dawns on me that, you know, the hero in healthcare has evolved, right, over the years, but still we have this image, at least as physicians, when we train and when we go out there that, you know, we are the heroes. And what you have tried to do with IHI and all the national and international effort is really to design systems to help us be successful. So, no matter if you are new or you're more experienced, no matter if you are a resident in training or, you know, you have practiced for many years. No matter if you practice in this hospital or that hospital, this state or that state, there is a system that will help you be successful. So, tell me more about those systems. Where did you get that idea? And then how is it implemented today in today's medicine?

DR. BERWICK:

The basic approaches to systems that you're talking about developed outside healthcare as organizations, especially at high-risk organizations like, you know, aviation or nuclear power, or aircraft carriers try to be reliable, they rapidly learn, they couldn't rely on individual heroism. People are trying as hard as they want and can already -- As they possible could, pilots don't want to crash, and people don't want things to go wrong. But problems have causes, and the sciences of improvement are trying to open our eyes to what those causes are, so we could change the processes so they're less prone to the defects. That's the science. It has deep roots. Quality improvement and healthcare has deep, deep roots in social sciences, and statistics, and engineering sciences, and cognitive psychology. But combining those sciences, and saying like you said, how could we build a system that is much less error-prone? Today, an airline or airplane has failure rates in the range of one part per ten million. One part per ten million. In healthcare, we have evidence that -- more recent -- the most recent evidence, about one in every four patients in a hospital is actually harmed by the care because of --

DR. SCHAAL:

So, this statistics, what does it show us? That we haven't learned? That we haven't implemented the science of improvement?

DR. BERWICK:

Not enough. We're making progress. And in fact, at Houston Methodist, in my visit, I saw the progress, I saw the commitment to making things more reliable. But it's a culture change. We come of a culture in which, you know, it's supposed to be like the doctor is the captain of the ship, and you try hard, you think it will be okay, and if something goes wrong, you didn't pay enough attention. We blame people. We put incident reports in nurse's charts, we criticize people and we make heroes of some. That's not a good plan. Healthcare is learning. There are many cases now over the past three decades or so where healthcare has made substantial progress. Hospital infection rates now are lower than they've ever been. Surgical mishaps are less common, patients are much less likely to get pressure sores from lying in their bed. All these because we've changed the processes to improve. But creating an overall culture of improvement where everybody, number one, has the skills, knows how to look at a process, which is team-based because we're smarter together than we are separately, and where there's complete transparency, when something goes wrong and we say it, we know it, we notice it. You can't fix what you don't see. And these properties, nonjudgmental, optimistic, trusting culture, a just culture is a much better one for making care what it needs to be. More recently, there have been other changes that I think are really important which is to give patients and families much more voice, much more power. I'd say the more control patients have, the more voice they have, the better the outcomes are gonna be.

DR. SCHAAL:

So, just, you know, to go back to IHI, when you started IHI in 1991, it was just on the heels of the publication,"To Err is Human," right? It was just published then --

DR. BERWICK:

It was actually ten years before "To Err is Human."

DR. SCHAAL:

Oh, ten years before? Okay.

DR. BERWICK:

"To Err is Human" came out in 1999, and"Crossing The Quality Chasm," these two, really benchmark --

DR. SCHAAL:

Oh, I thought it's 1990. So, 1999 "To Err is Human?" Okay, that's fantastic. So you, you know, you were before your time. So, tell me how it was back then and what was the goal, and how it evolved to today.

DR. BERWICK:

It was really amazing. IHI began with a grant from the John A. Hartford Foundation as a kind of little trial if we took these lessons learned from other industries and tried to bring them into the hands of hospitals, of clinicians would -- what would happen? What happened was enormous excitement. The people that signed up to join our -- our courses or teaching opportunities, or improvement projects, they were like -- I don't know, they were mavericks. They didn't represent the mainstream of healthcare. Mainstream of healthcare was still waiting and watching, but they were -- I can't tell you how exciting it was. And I have many friends from those years who we still enjoy our company and still are at it. You know, we're still trying to make things better. So, there were these pioneers around the United States, and more and more worldwide in many countries around the world, they kinda caught fire, and IHI became kind of a international partner trying to bring scientific improvement into healthcare. When those National Academy of Medicine reports came out,"To Err is Human," in 1999, 2000, and then"Crossing The Quality Chasm," which was a much more comprehensive report, not just on patient safety, but on all the dimensions of quality, then things really took off. That was a very trusted organization coming forward with very dramatic findings about how much improvement we need.

DR. SCHAAL:

So, what IHI is doing for our listeners who might be in different stages in their career? What is IHI? How can you reach out to IHI? How can you learn from IHI? DR. BERWICK: A lot. I'm now a senior fellow there. It's -- I guess almost 40 years old. It has a number of activities. For the general audience, people that really want to get involved, you can just go to IHI.org and you'll see on the web all sorts of opportunities. The one that's my favorite in a way is the IHI Open School. What we did was we realized we just couldn't keep offering courses at a fast enough rate to teach those sciences of improvement. And so, we began a web-based educational system, a school, the Open School. Originally, it was for students in medicine, nursing, health administration, pharmacy, any discipline students could take it. But more and more others are signing up, other organizations are getting licensing -- getting licensed to use it. But that's a really easy way. And I think there's over 30 courses you can take now on IHI.org in the Open School. We have large meetings. I just came back from Utrecht in the Netherlands, where with the British Medical Journal, we had our annual International Forum on Quality in Healthcare. There were, I think, over 2,500 people there from 60 countries. And it was, you know, four days of just courses, and workshops, and celebrations as -- we say, "All teach, all learn." And so, everybody's sharing what they're doing. There actually are, I think, five or six forums now. The biggest one is in the United States. This year it will be in Anaheim, California in December. And on IHI.org, you can find it. That'll be many thousands of people together learning, and celebrating, and working together. Most importantly, I think in ways, leaders, executives, leading physicians and nurses so that their learning how to lead improvement. We now have meetings, there will be one in Singapore and in August there will be one in Australia coming up. They'll have one in Latin America, and in the Middle East. So, practically every continent's covered by these for -- we call them forums. And then there are more intensive opportunities. IHI can train you to be a very high-level technical expert on improvement in flagship courses called the IA, improvement advisor, and it's an emerging course. It's four weeks so it's very intensive training on how to master skills of improvement. So, you have Open School courses, you have large forums, and then you have, really, immersion courses for people who want to become specialized.

DR. BERWICK:

We also have networks. That's really important. A big part of my work is with the leadership alliance, which is a network in the United States of 60 organizations that stay together, they meet together, both in person and virtually. And they're -- it's like this very active and buoyant club in a way of organizations that really work. And the organizations are variable. They include hospitals, group practices, some dental practices. Even some insurers are members of the leadership alliance. We have its cousin in Europe, the Health Improvement Alliance, Europe, which is another 50 or 60 organizations from a number of European countries that come together.

DR. SCHAAL:

So, I see that this is really an effort that is encompassing the entire world. Do we know what's the safest country, you know, to get care? Is there -- are we measuring something like that?

DR. BERWICK:

We don't have -- I mean the World health Organization publishes its own opinions of performance. I think France is currently rated as the highest performing health system. Not just with respect to safety. This has to do with access, and equity, and quality overall, you know? Are you following the science? Outcomes, do patients actually do better? So, there are higher rated systems than ours by far --

DR. SCHAAL:

Really?

DR. BERWICK:

We're more in the 20s or something among nations in ranking of our health system performance. My own -- I have my own favorites. One is Sweden, which is doing a terrific job. And Sweden organizes its healthcare by regions or counties. And one partner county that we have is called Jönköping county, just west of Stockholm. And oh man, they're amazing. The whole region is organized around improving healthcare continually and redesigning. It's quite stunning. There are terrific examples of the systems within the Netherlands. There's a great system run by nurses that involves outreach into homes to help people stay healthy and well and help people with chronic illness do well.

DR. SCHAAL:

So, does it have to do with how the healthcare systems and specifically payers are designed in that country? Does it, you know, as quality actually stems from the infrastructure of this entire county of how healthcare is tackled?

DR. BERWICK:

Yes. I mean, it has to do with a sense of responsibility. Let's say that waiting times are too long. Is there someone in the country or region that could say,"Waiting times are too long and we're gonna work on it, and here's the plan." So, there's a sort of leadership backbone that can focus on what needs to be done and assure that resources are getting to the people, the clinicians and others who actually can make the changes. So, I think that it's a leadership issue, and the Untied States, we don't have that. There's no real minister of health or, you know. For example, look at our terrible substance abuse problem in this country taking, you know, tens of thousands of lives. Who's in charge? Who's responsible for saying,"Okay, we're gonna get organized now, everyone. Please help. Here's some resources and approaches that we're gonna use and keep at it." That's rare in the U.S. unfortunately 'cause we're so fragmented. Other countries where yes, if there's a national level payment system like in the UK, and in Scotland, and England, and Wales, and northern Ireland, they can get organized. Right now, they're having big troubles, all countries are. But in the UK, there's a long history of a decision to focus on whatever the issue that's on their minds right now, waiting times, or worker morale, or cardiac care outcomes, so, leadership. Payment systems can be variable. We have very -- the highest rated system, France. It's a mixed payment system. But profiteering and profit- driven payment are much less present in those countries. In the United States, the dollar has kind of taken over and profit-seeking I think has reduced the amount of investment going into -- going into quality of care. No country has it perfect but we sure can learn from others. I learn -- every time I travel, I learn.

DR. SCHAAL:

So, you know, you encourage us to go to these forums and learn from other people from other countries, listen to what they're doing and maybe try to adopt some of them. I'm curious to hear if we are actually teaching this in medical schools today or in residency programs today.

DR. BERWICK:

Not much, but some. And I think that patient safety and methods of improvement are more and more making their way into the curriculum. We've got a ways to go, but there are schools that are in the lead, and I really believe that students will eventually demand it. When we started the IHI Open School, it was in response to student demand. We polled 1,700 students in all health professions, and we said, "Do you want to learn about improvement?" And the answer was overwhelmingly yes. And, "Are you learning it on your campus?" And the answer was overwhelmingly no. So, there's a great need out there. Some school are using the IHI Open School. They're actually taking those online courses and mapping them into their curriculum. That's not uncommon now.

DR. SCHAAL:

Yeah. You know here at Houston Methodist, we are envisioning a Quality and Patient Safety Institute for that same reason because we feel that the people we hire and put into, you know, clinician roles, they were not trained enough in quality and patient safety. And because we lead with quality, you know, our kind of motto is, "Safety, quality, service, and innovation," safety and quality are first. We found out that we need to invest and we want to start that institute here so everybody can -- actually will be required to take some courses to enhance their basic knowledge. But what we find when we go to donors, you know, it's always something that needs to be supported by philanthropy is that donors don't really see, you know, what -- why is it important? It's not exciting when we say the science of improvement. It's not that inspiring. So, how might we learn from Dr. Don Berwick and inspire our donors to give to that cause?

DR. BERWICK:

Well Dr. Schaal, first I'm really excited by what Houston Methodist is gonna do. Remember, with nine hospitals, you already have a learning system possible among all of them, but I think you could be real leaders, and I'm so excited about your launching this institute. I think the energy lies in the stories. It's in the faces and voices of people. Patients who have hopes and dreams that we need to step up to, people who have been injured. You know, finding patients in your wonderful system who still suffered from problems in -- errors in their care, or safety issues, and having them speak. The voices of the communities we serve and the patients are the most powerful windows we have on what really needs to happen. And you're right, the wonky, you know, quality science or process thinking or statistics, that's not -- they're really crucial, but that's not where the heart is. The heart's in the faces and the voices. So, I'd encourage you to more and more to tell the story through the experience of patients. And I think patients could give energy to this by themselves, joining in the effort. The institute should be one in which patients, families, communities actually have, not just voice, but power, you know, in governance. And they're the ones when they go out and tell their stories to potential donors, I think those donors will say,"Uh-huh, now I get it." The other thing is the problems in quality in healthcare, despite the excellence we have in many ways, the problems in quality are pervasive, which means almost everybody has experienced them. And in the donor community, if you can connect to those experiences, you remember your friend got an infection that they didn't have to get. You remember that kid who had surgery and suddenly a serious complication of that surgery. Do you remember that member of your family who got diagnosed too late and died because it was from a preventable disease? Connect to the experience of people and I think they're gonna step up and help.

DR. SCHAAL:

So, one of my team member, Pavithra Bora, who is actually sitting here right next to me and listening. She shared a wonderful quote from you saying that the work that we are doing is actually with -- you know, it's not seen, but it's seen in people that attend graduation, that attend weddings, that grandma that can see her children. You know, things like that. So, that was very inspiring to me, you know. If we don't do our job correctly and there are errors, it really destroys lives. DR. BERWICK: It does. And the problem here is it is with all prevention, this is a form of prevention as that quote said, the names of the people helped are not known. They're people to whom the problem did not happen… Right.

DR. BERWICK:

The complication did not happen, so we can't count them the same way, but they still have faces, they're still names out there, and I think it has to begin with looking at what goes wrong with courage, and transparency, and not blame but honesty.

DR. SCHAAL:

So, we always track and report to the board serious safety events that happen in our system, and we grade them. And you know when I started in my role, I said, "You know, we need to hear more of those, not less. We need to hear more reports of things that actually went wrong in different levels. We don't hear enough. And so, one of our board members, a very respectable judge said,"Well, if we hear more and we report more, how do we know that we're actually getting better?" What would be your response to that?

DR. BERWICK:

It's a great question, but you're absolutely right. If a hospital tells me tells me they look for serious safety events and don't find any, that's a hospital that's not doing it right, because it's everywhere. It's everywhere. So, the first thing is to realize that. As for your board member's question, there are two answers, one is for specific targets. For example, now we know how to prevent central venous line bacteremia infections. It can be zero. You can count those. And so, there are certain indicator conditions which we ought to be working on, certain kinds of surgical complications. So, yeah and no one has yet come up with an overall safety metric. That would be hard to do and probably inaccurate because there's no particular way to do it. But you can identify certain kinds of them and certain kinds of defects in care and count those, that's one. The second is the culture, and that's crucial. In a safety culture, a just culture, a culture of quality, the staff know it. They will say, if you ask a staff person,"If something goes wrong, can you report it and expect to be noticed and not blamed? Are you allowed to contribute to the design and redesign of the work you do? Does the system demand of you work that you know is waste, but you have to waste your time on it?" And there now very good culture surveys, but I -- if I had to pick one answer to the judge's question, it would be here's how we know. Every month, we go out there and we talk to our wonderful doctors and nurses, and we ask them about the water they're swimming in, and are we, the board and the executives creating a culture which supports honesty, safe reporting, participative teamwork on improving processes, learning, learning about how to improve. And that cultural index would be a really important answer.

DR. SCHAAL:

So, you know one of the things that we are doing here at Houston Methodist is the Joy in Medicine Initiative, which we fondly call JIMI. JIMI, Joy in Medicine Initiative. And we have a JIMI tour, and we are just gonna conclude this year, this year's tour a week from now. And in those tours, we go and ask our physicians,"What brings you joy?" And in 100% of the rooms that I was in, and these are dozens of rooms across the system where many dozens of physicians come in and talk about what brings them joy and what hinders joy. In a 100% of those rooms, people stood up and said,"What brings me joy is the ability to provide high quality of care to my patients." And I think we hear it, not only from physicians, but from nurses and anybody that works in the healthcare system. If you feel that you can provide high quality of care, it brings you joy. Can you talk a little bit about that because I heard you mention the word joy and I was overjoyed to hear you mention the word joy.

DR. BERWICK:

So happy to hear about your work on this. You know, everybody, not just doctors and nurse, everybody. The person on the street repairing the street wants to have pride and joy in their work. People feel better in their lives when they're connected to the meaning and mission of their work and are allowed to celebrate it together. For us privileged to be in healthcare, it's even better. I mean, it's such a noble undertaking we're engaged in, and the public that we help is so grateful for what we do. So, we start off with a full deck of cards to try to have joy in our work. Unfortunately, sometimes the managerial and executive climate, the environment of payment and surveillance, the belief systems take it away. They suppress the joy. They tell people,"Just do your job." Or if something goes wrong, they blame the person instead of saying,"Well, how can we understand this better?" They don't invest in the growth and development of staff. It's just get to work and do your job. And sooner or later, the staff lose their sense of meaning and purpose in the work, and they lose their joy. That is squandering. It's just squandering because the amount of that resource, as I'm sure you're discovering in your tours and your JIMI project, that amount of energy is phenomenal. You couldn't pay for it. You couldn't possibly buy it, but it's there.

DR. SCHAAL:

I always say it's priceless, it's priceless.

DR. BERWICK:

It is priceless. And leaders smart enough to call on it and to say,"I know you're committed to helping people, thank you. What are we doing to get in your way? What are the pebbles in your shoes that we're putting there, making it harder for you to do? What are the ideas you have how to make your work even better? Where are we, the board, the managers preventing you from feeling that joy?" And then get to work on it. That kind of teamwork and respect between the management and governance structures in the workforce that can open up this tremendous resource. I get sad when I find organizations that aren't doing that. When they're blaming or you're fretting, putting up barriers to communication or to understanding. That's sad.

DR. SCHAAL:

Yeah, so I think the premise there is that if you have an engaged, happy worker, clinician, then it will translate to higher quality of care to our patients. And so that's -- you know, that's the why, to invest in the joy of the people who work for our healthcare systems.

DR. BERWICK:

And then they'll be the first people to step up to help make things even better if you have the mechanisms of improvement at work where they can all participate and help.

DR. SCHAAL:

So, you've been a pioneer, and you actually were before, even the science of quality took the mainstream in healthcare. And you've seen a lot of changes over the years. And now we are in a, you know, in a phase which is very exciting and very frightening at the same time, where we have artificial intelligence, and all these smart platforms, ChatGPT, bots that can talk to human beings. What do you see as a potential for really improving in this one to four ratio that you mentioned. Can we get better with the help of technology?

DR. BERWICK:

No question, yes. I think that first, as I said in my keynote speech last week, a lot is changing that we need to keep up with. The whole idea of quality has changed. So where, before in the early days, it was a technical question. Did we get the -- did we prevent the infection? Did we get the surgery right? Did we get the medications right? That's all still important but now they're -- I think that now we're realizing there's a bigger thing here, which is are we a healing place? Are we a kind place? Are we a place where every human being is valued? Where what matters to the patient is what we do. That's more expansive, and I think we can make progress there. Can AI and the new world help? Absolutely yes. I don't think we've yet discovered how big that opportunity is, or discovered all the risk. But early on, we already know, and I believe this is true at your organization that ambient listening systems where the AI can produce the note that the doctor would otherwise be spending pajama time on that night trying to write. And those notes are just as good and even better than the ones the doctor would produce. We have AI assistants and diagnostics now in radiology soon in other domains where I, as a doctor, can have this AI assistant sitting on my shoulder, you know, helping me, giving me advice that I can take or leave. That's really great. I think our diagnostic accuracy should improve with AI.

DR. SCHAAL:

Yeah, so -- DR. BERWICK: And I think -- Last year, we did our JIMI tour in primary care. And because we heard about the burden of pajama time, documenting after hours, and actually, we could see it. We can log into Epic, there is a module there called, "Signal" that you can see actually how many hours our physicians are working at night just to complete the work of that same day. And so, we as leadership, we committed that now, today I can tell you 100% of our primary care docs have ambient listening, and the response is just amazing. I mean, people are crying tears of joy because they don't have to spend all this time documenting. The note is actually within 30 seconds, it's ready for the reviews.

DR. BERWICK:

I've heard that and seen it in enough places that I'm now confident in it. That's producing joy and work when you take away wasted time and allow people to get back to the patient, which is what they really want to do. So, unfortunately, it's pretty expensive right now, but I hope the technologies will become much, much less expensive.

DR. SCHAAL:

So, my line was it's priceless if we invest in the joy of physicians. But it's still too expensive. So, if anybody, you know, out of these companies listening to us now, lower your prices so everybody can have it. Every physician everywhere. And also nurses, you know this is coming to nursing as well. The documentation burden on the nurses is also huge. We are committed to providing the best care once you're already sick. You know, we're gonna give you the drug when you're sick. But how about we even prevent you getting the disease in the first place? So, I don't know if healthcare system, and quite frankly, I do not know if we ourselves are doing a good job in trying to prevent disease.

DR. BERWICK:

This is an unsolved issue. First of all, we do know a lot about prevention. I gave your colleagues a reading assignment, I'll do it to the listeners also. It's a book called"The Health Gap," The Health Gap. It was written in 2015 by Sir Michael Marmot, who's a revered epidemiologist. And what Michael did was analyze, really, the world's literature on health, and why, you know, say countries that have equal wealth can differ by five or six or eight years in lifespan. Why do we have gaps? Why across cities? I don't know the numbers in Houston, but I now in Boston between wealthy and poor areas of Boston, the life expectancy varies by 20 years. So, Marmot is saying what does this? And he came up with the five factors there, early childhood experiences, the quality of the education system for kids, especially girls, the properties of the workplace, the health of the workplace, the ways in which a society deals with elders in terms of preventing loneliness and providing social support. And then community resilience issues like housing security, and food security, and criminal justice reform, and environmental security, and recreational opportunities. So, those five points we know and he shows in that book just how powerful these are at determining health. Healthcare doesn't appear on that list. Healthcare isn't actually a very powerful determinant of health. We're a repair shop, hopefully we keep people going and we do prevent some things. But it's the world we live in. Now, the question, the hard question. Healthcare is taking 20% of the GDP now in this country. So, when you say,"Let's have more public housing, or more supported housing, or food security, or more recreational opportunities," where's the money gonna come from? And right now, healthcare is pretty well confiscating a lot of those opportunities. So, for a hospital system, say Methodist, it's a governance question. What is -- what's your job? What are you going to do? And, like, you know, I think there could be an argument made, well, it's that it's not just one lane, but you know, if healthcare takes a pass on these determinants of health, the resources are just not gonna be there to work on them. So, I think we need a new strategic plan, really. A new sense at the governance table about what it is we're here to do. And hospitals, I'm not sure they need to lead all of this, but there sure need to be players.

DR. SCHAAL:

What struck me when you mentioned that in the symposium is that how important our children are and also how important our elderly community is. Let me ask you a question that I ask all our guests, and this is the last question for this podcast, which is, what does quality mean to you?

DR. BERWICK:

Well, in the healthcare context, quality means care and attention in exactly the form that I would want my children to have. It's a very personal idea. It's focused entirely on what matters to the person, across all dimensions. Not just technical care, it's not just a professional deed. It has to do with the whole sense of the attitudes with -- I told a difficult story in my speech about my best friend who died a couple of weeks ago of pancreatic cancer. He had a biopsy done to determine basically his treatment and his diagnosis, a very consequential test. And it went well, "well," technically he didn't have a complication, didn't have a lot of pain. When I spoke to him afterwards, his question to me was,"I don't understand, when I asked them when the test would be ready, they answered,'Five business days.'" He said, "Isn't there something wrong with that answer?" You bet there's something wrong with that answer. That is not tuned in to his state, to his needs, to his -- who he was and where he was. And quality is the opposite of that. It's absolutely doing that transaction the way I'd want it for my kid.

DR. SCHAAL:

So, that story really hit a nerve, and many people came to me after your talk and said,"You know Dr. Schaal, we never answer like that at Houston Methodist. We would never say,"five business days." And also if somebody has cancer and we know that this is really, you know, they're waiting, they cannot sleep until they get their response of the biopsy, we are doing it as fast as possible. And we know it's important." Another thing that I, you know, kind of appreciate from this answer is that you said it's personal. And we tend, at least at the management level, to measure, you know, things that are numbers. And it makes sense, however we have to remember that quality is personal. So, thank you so much Dr. Berwick for your really wise, inspiring words. I so much appreciate the time with you.

DR. BERWICK:

Thanks, Dr. Schaal. It's a pleasure to spend time with you.

DR. SCHAAL:

And thank you for listening. Quality Time is part of Houston Methodist's Leading Medicine series of physician-led podcasts. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. If you enjoyed our conversation today, please consider rating this episode and sharing it with your colleagues. I appreciate your support, thank you, and until next time, I am always listening.♪ ♪