Trying to Heal a System’s Flaws

October 6, 2011

Reporting from Atlanta— The cardiac intensive care unit at Egleston children’s hospital in Atlanta gleams and hums with a dazzling array of scientific wonders that breathe for tiny lungs and monitor every beat of an infant heart.  But on a recent visit, Dr. Donald Berwick was especially pleased by something decidedly low-tech: a quiet zone where nurses can place medication orders without being interrupted, even during emergencies.

by Noam N. Levey
Los Angeles Times

Hospital leaders created the zone — little more than a computer terminal in a corner of the room behind an orange sign on the floor that reads “Shh … We’re in the MedZone” — two years ago after noticing that distracted staff members were making dangerous mistakes when ordering medicine.

The deceptively simple system, built on a principle used in aviation, cut medication errors by two-thirds, saving money and lives.

It’s the kind of innovation Berwick is pressing for nationwide as steward of the Medicare and Medicaid programs, where errors, unnecessary care and other waste may account for about a third of the nearly $1 trillion a year that taxpayers spend on the programs.

“Too many Americans are being harmed by the care that is supposed to help them,” says Berwick, a pediatrician who has spent much of his professional life working to make American medicine safer by learning from other industries.

In commercial aviation, safety is so deeply engineered into every aspect of flying that the average air traveler now has a 1 in 20 million chance of dying in an accident. By contrast, 1 in 7 Medicare patients is hurt during a hospital stay, a 2010 government study found.

The partisan rancor over the healthcare law notwithstanding, there is consensus that increased efficiency could offer the best hope for saving the nation’s healthcare system.

But time is short. As one of the Obama administration’s senior healthcare officials, Berwick has become a lightning rod for criticism and may soon have to step down.

More broadly, healthcare is at a crossroads, as Berwick sees it. If costs are not controlled by making care better and less wasteful, budget cuts may force Americans to simply make do with less.

“Improvement is the better option,” Berwick said.

A soft-spoken, self-effacing man, Berwick, 65, looks like he’s just stepped out of an exam room after peering down a toddler’s sore throat.

He knew he wanted to be a doctor as a boy, watching his father tend to patients in their small Connecticut town. And he trained at Harvard Medical School and Boston’s renowned Children’s Hospital, where he saw the best of American medicine.

But Berwick also saw something else: conscientious doctors and nurses making dangerous and expensive mistakes in systems that set them up to fail.

He still recalls that as a young, sleep-deprived resident he gave the wrong transfusion to a baby, with nearly lethal consequences. “I still feel guilty about it,” he said recently.

“We’re frail,” Berwick said. “I have four children. I mix up their names all the time. I dropped my cup of coffee and spilled it on myself. … But mistakes can be prevented by redesigning systems to protect human beings from their own frailty.”

The aviation industry did that 30 years ago after a series of fatal crashes was linked to errors by distracted flight crews.

Recognizing that humans are prone to distraction, the Federal Aviation Administration issued the “sterile cockpit rule,” prohibiting nonessential conversation during crucial periods such as before take-off and landing. The rule is credited with helping dramatically cut accidents.

This is the domain of systems engineering, a blend of science and psychology that has been used to powerful effect in the space program, the auto industry and elsewhere. For decades, however, it was scarcely practiced in hospitals and other medical facilities.

In 1986, as a frustrated quality officer at a Boston health plan, Berwick set out to change that by looking at trailblazing companies such as Swiss Air and AT&T.

On a trip to New Jersey’s Bell Labs, then owned by AT&T, he learned how the company pioneered systems engineering as a tool in building global telecommunications.

“When you worked at AT&T, you thought in a system,” said Blanton Godfrey, a former senior quality official at the company, who went on to collaborate with Berwick. “Your line has to work to your switch. That switch has to work to the next switch. Every piece has to work or the system fails.”

Medicine was no different, Berwick saw. But few people in American healthcare viewed caring for patients as an interconnected process. Doctors didn’t talk to each other. Few hospitals and fewer doctors kept track of the effectiveness of treatments or the frequency of errors.

They rarely asked about patients’ experiences, feedback that high-performing organizations considered crucial. And while medicine focused on individual “bad apples,” the best companies asked why errors occurred and how to prevent them.

In a classic example of a system breakdown, Berwick describes a hospital where babies were dying at an alarming rate because nurses administered epinephrine, which helps newborns with trouble breathing, instead of Vitamin E, a dietary supplement. The two medications came in virtually identical brown bottles with blue-and-beige-striped labels.

That system was “perfectly designed to kill babies by ensuring a specific, low but inevitable rate of mix-up,” Berwick said.

While at Harvard, Berwick began criss-crossing the country pushing hospitals and doctors to protect patients by developing quality systems modeled on industry leaders like Toyota, Xerox and Dell.

“Bringing those ideas into healthcare was something totally new at the time,” said Dr. Gary Kaplan, head of the Virginia Mason Health System in Seattle, an early pioneer on quality who has worked extensively with Berwick.

Other health systems have followed, joining with Berwick and his team to redesign their systems to improve quality and efficiency.

Ascension Health, the nation’s largest nonprofit health system, virtually eliminated injuries to babies during delivery at its hospitals in Austin, Texas, in part by developing protocols to ensure that mothers were given labor-inducing oxytocin only under the right circumstances.

In Pittsburgh, the UPMC health system slashed infection rates to near zero for knee and hip replacements after standardizing operating-room procedures and involving patients more in planning.

“It can be done. It is being done,” Berwick said.

Since he took the helm of the federal Centers for Medicare and Medicaid Services last year, Berwick has plunged into what he calls “bringing excellence to scale.”

He has already mobilized thousands of hospitals, doctors and others behind a new campaign to cut hospital-acquired infections and other problems by 40% by 2013 and hospital readmissions by 20%.

Meanwhile, at CMS’ new Innovation Center, some 180 health policy experts are fielding and analyzing hundreds of suggestions about ways the federal government can help improve quality.

For example, Berwick’s team is looking at whether paying nurses to make house calls to very ill seniors could keep the patients out of the hospital and save money.

They also are investigating ways to reward caregivers who implement systems to eliminate bedsores, a painful and preventable condition that costs millions of dollars annually.

But institutional and political obstacles remain.

Since the bitter healthcare debate, GOP lawmakers have criticized Berwick, accusing him of advocating the rationing of care because he has praised the British health system and advocated more humane, if less invasive, care at the end of life.

“Americans will not know how much saving a life is worth until Dr. Berwick is calling the shots,” Sen. Pat Roberts (R-Kan.) said last year.

It’s a charge that patient advocates, doctors and healthcare leaders from both parties say is ludicrous, noting Berwick’s decades-long advocacy for patients. But after President Obama circumvented the Senate confirmation process — and Republican opposition — Berwick’s foes pledged to block his permanent appointment.

He will have to leave his post at the end of the year.

For patients, the stakes are higher. Washington’s current focus on cutting federal spending threatens to tip the balance away from the relatively slow process of curbing costs by improving quality.

“The country is in a kind of race,” Berwick said. “And the other horse in the race is just cut stuff, just stop doing things.”

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