Is Don Berwick The One?

The Blogosphere Rumor Factory is heating up with reports that Don Berwick, the world’s most prominent advocate for healthcare quality and safety, will be the next administrator of the Centers for Medicare & Medicaid Services (CMS). (Take this with a grain of salt, because the same Rumor Factory blew it last time on Glenn Steele.) Although I’ve sparred a bit with Don over the years on matters of philosophy, I think he would be a superb choice.

Don’s story is well known – a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality.

Then came the IOM reports on safety and quality (reports that Don had a major hand in crafting), followed by a national movement that promoted transparency, pay-for-performance, tougher regulatory and accreditation requirements, increased media and legislative interest, and voila: IHI became the essential organization – a source of networking, best practices, conferences, sustenance, courage, and more. To many in the quality and safety world, IHI became their church, and Don its Pope.

I admire Don enormously, and have no doubt that the world is a far better place thanks to his, and IHI’s, work. I’ve seen scores of examples of Don’s impact over the years, at hospitals, nursing homes, and clinics in the U.S. and around the world. Just recently, I spoke at a large Indiana patient safety meeting. Don had filmed a video greeting to the group, which was projected over lunch. These things are always awkward – people rarely cease their conversations to listen to a disembodied speaker. But when Don’s face came up on the screen, everybody stopped what they were doing, riveted by the force of his vision and his unique ability to touch and inspire people doing the hard work of change. His effect was astounding; it always is.

My mild beefs with Don and IHI have come from the fact that he has generally put his nickel down on the “Just Do It” side of questions regarding the importance of evidence in patient safety and quality. Although IHI’s 100,000 Lives Campaign promoted many key practices and energized thousands of providers and leaders, the choice to turn Rapid Response Teams into a national standard of care was, in my opinion, premature, backed by insufficient evidence that such teams really work. And IHI’s assertion that the campaign saved 122,300 lives crossed that crucial line that separates scientists from spin-meisters.

Moreover, when I hear Don speak, I often find myself awed by his poetic words and powerful ideas but shaking my head in mild disagreement. The latest example: I find Don’s version of patient-centeredness, described in his article aptly entitled “Confessions of an Extremist,” to be hard to swallow. In essence, he argues the consumerist view that patients should be able to get nearly anything they’d like, regardless of the evidence or cost. You might recall that he first articulated this idea at the ABIM Summer Forum a few years ago (I wrote about it here), to a mixed audience response (to be charitable). In a healthcare system rapidly going broke, such a philosophy just can’t work.

Don is a brilliant guy, and he understands this, of course. So why articulate this point of view? I believe that Don has seen his role to date as that of the Passionate Outsider, a provocateur trying to push us out of our collective comfort zone. Even when I find myself disagreeing with him, I admire him for that, since it would be far easier, and far less effective, to traffic around the margins of the status quo.

How will Don’s philosophy jibe with the realities of running an organization whose yearly budget is $704 billion, larger than the economies of Denmark and Argentina combined (if CMS were a country, its GDP would make it the world’s 18th largest), an agency slated to run out of money in about 7 years? It’s hard to know.

But if Don Berwick is at the helm of CMS, you can bet on an ambitious agenda (and the agency has plenty of tools to carry one out, as described in this recent NEJM article) in quality and safety, a larger focus on removing waste from the system, greater efforts to promote transparency but a measured approach to pay-for performance (Don favors the former and has been ambivalent about the latter, as shown here and here), increased attention to capacity building (which is, after all, what IHI has done best), promotion of more physician-hospital integration and care coordination (via new models like Medical Homes and Accountable Care Organizations), and a far more vigorous use of the bully pulpit. In short, while his “extremism” will be tempered, I can’t see Don Berwick being intimidated or beaten down, even by the Washington bureaucracy. In an agency and an industry sorely in need of fresh approaches, that’s got to be a good thing.

In any case, it’ll be one hell of a ride. Or, as Joe Biden might say, a Big F-ing Deal.

5 Responses to “Is Don Berwick The One?”

  1. Daniel J. Hanson MD March 27, 2010 at 12:09 am #

    I have attended many IHI conferences and am also very impressed with Don Berwick’s vision. There is a difference between him and many other leaders in healthcare that I suspect comes from the personal experience of having a loved one suffer in the hands of our current heathcare system. Given that, he has very deep empathy/passion for the patient’s perspective. It is a perspective that is sometimes too inpatient to wait for definitive proof for something that makes so much sense to patient advocates. For myself, I am fine with this as long as we are talking about a extra 0.3 FTE of an ICU RNs time to respond to rapid response calls and not lung advocating volume reduction surgery. Perhaps Don will be appointed and be the one who jump starts US Healthcare Center for Comparative Effectiveness. He has had a tremendous impact on US healthcare and will likely continue to do so regardless of whether he continues with IHI or takes a job with CMS.

  2. Bob Wachter March 27, 2010 at 9:36 pm #

    Looks like we got this one right, as reported a few minutes ago by the NY Times and the Associated Press.

    Congratulations to Don… and to President Obama, for such a bold choice.

  3. Bob Wachter April 20, 2010 at 7:34 am #

    And, finally, official confirmation (after a surprisingly long wait – perhaps the early leaks were a trial balloon?).

    The opposition doesn’t appear to be particularly vocal… yet. But don’t count them out.


  4. Tex Bryant May 14, 2010 at 2:50 pm #

    I belive that CMS will soon be requiring that primary care physician sites to adopt the Patient-Centered Medical Home model as advocated by Dr. Paul Grundy. Can Berwick lead this charge, as it seems most of his emphasis has been on hospital settings? With the new healthcare models being built as determined by the new Federal laws, is Berwick capable of leading this transition of emphasis?

  5. Paul Sabh MD,FACC June 21, 2010 at 8:50 pm #

    I have real concerns about Berwick’s nomination. I have dealt with this emerging class of non-physician physicians and worry that there has to be some middle ground between the private practice physician busting his butt to crank out patients to keep up their salary (and the worse excesses of the fee-for-service system)and the ivory towered MD,PhDs spouting off theories but who never had to run a practice and spend hours doing charts, calling patients back, worrying about RVU changes, employee costs, overhead etc. I have been to IHI twice and think it is as much cult as it is an organization. I voted for Obama and likely will vote for him again but all his choices and advice on health care seem to be from people who really dont actually provide any of the care.

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