Rehabilitating the E Word

The upside to Berwick being shown the door in Washington is the pleasure to be had in reading his first major talk¹ since leaving the office of CMS administrator on December 2, 2011. The occasion was the 23rd Annual National Forum on Quality Improvement in Health Care of the Institute for Healthcare Improvement, held in Orlando, Florida. Berwick was given the Picker Award for Excellence® by the Picker Institute, named for the son of the founder of a venerable imaging company that got its start producing portable radiography laboratories that were airdropped onto battlefields during World War II. In his December 7 acceptance speech, “The Moral Test,” Berwick had nothing to lose and no politics to play. Afterward, he would answer to no one but himself. Though he did take a few shots at those who had hurled the death-panel epithet, Berwick took the more important opportunity to rehabilitate the word efficiency in health care and to appeal directly to the only people capable of reforming it: the collective you. In what marketers call the money part of the speech (worth the price of admission), Berwick wove together the thesis of a 2004 article by Pacala and Sokolow² on carbon emissions with something that he heard when visiting Jönköping County, Sweden, while observing the headway made there in total–health-system improvement. Pacala and Sokolow came to the conclusion that no single thing would solve the carbon-emissions problem; Göran Henrik, the county’s chief executive of learning and innovation, explained to Berwick that Jönköping county had come to the same conclusion, saying, “Here’s the secret: We do everything.” Quality Dimension of Our Time Berwick reminded his audience of our stark choice: chop—and radiology has a visceral understanding of that approach—or improve. Whether we choose to spend the 17% of the gross domestic product that we are spending now or something closer to the 12% being spent in Europe, the rate of increase in health-care costs is unsustainable. Berwick acknowledges that efficiency is not his favorite dimension of quality improvement (with others being safety, effectiveness, patient-centered care, timeliness, and equity), but he refuses to apologize for using the word and emphasizes that value improvement is not enough. “It will take cost reduction to capture the flag,” Berwick says. “Efficiency is the quality dimension of our time.” Citing the quality gurus Noriaki Kano, James Womack, Taiichi Ohno (1912–1990), and W. Edwards Deming (1900–1993), Berwick adds, “The great leverage in cost reduction comes directly—powerfully—exactly from focusing on meeting the needs of the person you serve. Waste is actually just a word that means not helpful.” Berwick identifies six of what Pacala and Sokolow call wedges, or forms of waste, whose removal from the system would improve patient health and reduce costs: • overtreatment (rooted in outmoded habits, supply-driven behaviors, and ignoring science); • failures of coordination (when people fall between the slats); • failures of reliability (poor execution); • administrative complexity (meaningless charting rituals and nonsensical, complex billing procedures); • pricing failures (prices beyond cost and fair profit); and • fraud and abuse (when thieves steal, resulting in blunt inspection and regulation). Berwick estimates that $1 trillion in costs—possibly a third of the total cost of production—could be removed from the system if these wedges were worked. Urging all providers to take up this challenge, Berwick suggests these five guiding principles: Put the patient first; among patients, put the disadvantaged (the young, the poor, and the elderly) first; start at scale (meaning large scale, as there is no time to waste); return the money (hardest of all) by letting those who pay see their bills fall; and act locally (every state, community, organization, and profession must engage). Getting in the Game Health-care providers are being required to let go of their disdain for efficiency and embrace the need to manage resources, and this issue of Radiology Business Journal is replete with examples of providers taking up this challenge: Informatics is a key enabling tool. In cooperation with the Society for Imaging Informatics in Medicine (SIIM), RBJ has launched a competition to name the Top Five Medical Imaging Informatics Projects of 2012. The winners will receive an invitation to present their work at the SIIM meeting in Orlando, Florida, on June 7, and a scholarship to help underwrite the trip. We hope to see entries from every radiology department and private practice in the country. As Berwick says, it’s time to flood the triple-aim zone: improve quality, reduce cost, and widen access. I am sorry to see Berwick go, but he might now be in a place where he can be more effective. Washington can’t make this happen, but you can.