Berwick, Pronovost, and the Non-Scalability of Charisma

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.

Don, of course, has extraordinary strengths as a leader, particularly in visioning and communicating. His annual IHI speech is legendary, for good reason. Consider this, from a 2004 Boston Globe profile:

Just from appearance and demeanor, you’d expect the 5-foot-10 Berwick to deliver an earnest but dull PowerPoint speech. He doesn’t wave his arms and never raises his voice, which has a low, occasionally rasping quality to it…. But there is a quiet charisma about him. He knows how to simultaneously play on the emotional and logical sides of his listeners’ brains. He is also the king of metaphors. Over the years, his listeners have heard him explain health care in relation to his younger daughter’s soccer team; the sinking of a Swedish warship; the Boston Red Sox; Harry Potter; NASA; the contrasting behaviors of eagles and weasels; his wimpy Ford Windstar (a dated reference since he now drives a used BMW convertible); and his left knee.

I’ve heard Maureen speak on several occasions, and she is quite good. But she’s no Don Berwick.

So what will happen to IHI in a post-Berwick era? The Institute remains an essential resource for thousands of hospitals around the country, and will undoubtedly continue its vital role. But my guess is that IHI will ultimately need to find a charismatic physician-leader to fill Don’s humongous shoes (unless they can hold off until Don returns from CMS, which could be as soon as late-2011, if a pissed off Senate stonewalls him when his recess appointment expires). Part of IHI’s magic has been getting, and keeping, docs at the table, and I doubt Maureen will be able to do this over the long haul, notwithstanding her impressive skills. I hope I’m wrong, but I don’t think I am.

A few days after hearing of Maureen’s appointment, I read a JAMA piece by Peter Pronovost of Johns Hopkins. Peter, of course, is the Genius Award-winning architect of the Keystone Project, which nearly eliminated central-line associated bloodstream infections (CLABSI) in Michigan ICUs, saving hundreds of lives and millions of dollars. Based on this breathtaking success, Peter received megabucks from AHRQ and some philanthropists to roll out his checklist initiative to the other 49 states.

Peter tells me that there have been some real success stories in the first year – a couple of states have seen results comparable to Michigan’s. But the glass is more empty than full – the implementation rate in most states has been sluggish; in some, downright pitiful.

Why? In the JAMA paper, Peter writes, plaintively,

In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates…. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is?

Pronovost sees the root cause of this poor response as an accountability gap on the part of hospital executives and physicians. That’s clearly part of the problem, but a bigger one may be that there is only one Peter Pronovost, and he can’t be in 50 states. Peter, like Don, has one-of-a-kind charisma; recall Atul Gawande’s 2007 observations of him in the New Yorker:

Forty-two years old, with cropped light-brown hair, tenth-grader looks, and a fluttering, finchlike energy, he is an odd mixture of the nerdy and the messianic… People say he is the kind of guy who, even as a trainee, could make you feel you’d saved the world every time you washed your hands properly. “I’ve never seen anybody inspire as he does,” Marty Makary, a Johns Hopkins surgeon, told me. “Partly, he has this contagious, excitable nature. He has a smile that’s tough to match. But he also has a way of making people feel heard.”

The fact that it seems impossible to export Michigan’s success to the rest of the country is particularly disheartening, since there are few other safety and quality interventions with such strong evidence of benefit; whose successes were reported in the New England Journal of Medicine, the lay media, and now two books (by Gawande and Pronovost); and whose implementation is so straightforward – no technology or expensive equipment needed, just a 5-item checklist coupled with some leadership commitment, measurement, and a dab of culture change. If we can’t disseminate this intervention, what will happen when we try the hard stuff?

If you’ve ever spent any time with a professional investor, you’re familiar with the concept of scalability – a “desirable property of a system, a network, or a process, which indicates its ability to either handle growing amounts of work in a graceful manner or to be readily enlarged.” United Airlines isn’t very scalable – additional passengers require more planes, crews, peanuts, and fuel. Nor is General Motors. But Google and Facebook are endlessly scalable. Once they had their basic design and infrastructure down, the thousandth user added relatively little incremental cost over the 999th. Ditto the millionth. Venture Capitalist-types begin foaming at the mouth when they hear about a scalable idea, since profitability soars when you add new revenues without additional expenses.

Our problem is that Pronovost doesn’t scale, and neither does Berwick. Trying to roll out the checklist initiative without Pronovost’s cheerleading and handholding doesn’t work very well. Nor can IHI replicate the mass enthusiasm that accompanied its 100,000 Lives Campaign without Berwick at the head of the parade.

What does this mean? I fear that it means that the business case to improve quality and safety has not yet reached the point where full engagement by healthcare organizations and caregivers isn’t dependent on the personal engagement of individuals with unique leadership and communication skills. We’ll know it has when states and CEOs are asking – even begging – Peter to help them prevent ICU infections, and when IHI and similar organizations are being tapped constantly for help, even if the answer to the predictable question, “Can Don come to our hospital to kick off our initiative?,” is always “no.”

We’re blessed to have the likes of Pronovost and Berwick in the quality and safety arena – we’d never have gotten to where we are today without them. But we’ll know that we have truly arrived when we no longer depend on them to get the work done.

21 Responses to “Berwick, Pronovost, and the Non-Scalability of Charisma”

  1. menoalittle July 24, 2010 at 3:25 am #

    Bob,

    Your are spot on. Patient safety is not scalable. It requires hard work, attention to patient care detail (on a checklist, cookbook, note cards, or what have you), appropriateness review committees, lessons learned reviews, and other time consuming endeavors which sap everyone’s time and financial budgets to enact.

    Beginning now with the need to meet meaningful use requirements using poorly usable HIT and CPOE systems, attention will be further diverted from patients and their safety to curing and mitigating the viral diseases of the EMRs.

    Best regards,

    Menoalittle

  2. Adam July 24, 2010 at 4:15 am #

    Scalability requires that growth drives down marginal cost. Most health care delivery organizations – like hospitals – become increasingly complex with size and therefore virtually no solution can be implemented in a scalable way. Successful organizations like Partners, Geisinger, Kaiser, or Cleveland are not exempt – their success comes more from an ability to spend more after they capture excess revenue through pricing power (in the cases of Partners and Cleveland) or owning the underwriting cycle (in the cases of Geisinger and Kaiser) than operational excellence through scale.

    The lone examples where scalability can spread in healthcare delivery are home health agencies like Amedisys and retail clinics like MinuteClinic. Both have national footprints and standardized clinical processes because the operating units are small, distributed and plug into a centralized infrastructure. Granted, these examples have les clincal complexity, but until the acute care setting begins to dis-integrate into smaller operating subunits liked together by a management platform, performance improvements will be incremental at best.

  3. Bob Wachter July 25, 2010 at 4:44 am #

    This comment from Paul Levy, the blogging CEO of Beth Israel Deaconess Medical Center (posted with Paul’s permission):

    Well stated, Bob. Don and Peter and others like Paul Batalden have been toiling in the vineyards for years, and it is striking that the academic medical centers, in particular, have generally failed to take on quality and safety as strategic priorities and as areas of academic interest. Having previously been involved with other industries (e.g., energy and telecommunications) that have gone through structural changes, I am struck by the relative slowness and recalcitrance of many of the institutions and people who you would have hoped would be thought and action leaders in these realms. (More here: http://runningahospital.blogspot.com/2009/01/what-does-it-take.html)

  4. AD July 26, 2010 at 1:51 am #

    Donald Berwick is a ray of light for CMS. Unfortunately a good man is vilified for the right ideas, Shirley Sherrod eh?

  5. Anonymous July 26, 2010 at 3:27 pm #

    Question for all of the CEOs out there: Are you in the business of saving lives or the business of filling beds? If you answered the second choice, I would guess that your hospital has not pursued the reduction of central-line associated bloodstream infections.

  6. Andrea Ellis July 26, 2010 at 6:31 pm #

    I’m wondering if you are questioning Maureen Bisognano’s ability to lead IHI because of her lack of charisma or her lack of MD credentials? There are many charismatic, effective nurse leaders and Ms. Bisognano should be given a fair chance and evaluated for her ability to lead and manage, not dismissed at the outset because she isn’t in the MD club.

  7. Bob Wachter July 26, 2010 at 9:33 pm #

    Hi, Andrea — thanks for your question. In fact, I struggled with the issues you raise as I was writing the blog.

    Before I address these issues, let me clarify a few things. First, I don’t question Maureen’s ability to lead IHI at all — I think she’s extraordinarily talented and will do it very well. Secondly, I don’t think she “lacks charisma” — she has plenty, just not at Berwickian levels. Few do.

    Although I’ve picked a bone or two with IHI over the years, I have no doubt that the Institute has helped push the safety and quality ball up the hill, and so I’m rooting for the organization to thrive under Maureen’s leadership. That said, here is the math as I see it:

    1) QI/safety projects that lack physician buy-in and engagement tend to stall out; and

    2) Doctors are more apt to be engaged by other doctors (I don’t say that with pride; it’s just an observation).

    So the bottom line is that I do worry about the organization’s future… though I suspect that Don will return, bearing some battle scars but also some hard won insights, at the end of his CMS tenure.

  8. Andrea Ellis July 27, 2010 at 5:56 am #

    Thank you Dr. Wachter for responding. Unfortunately, I have to agree that generally physicians buy in to physician lead projects. It disappoints me that nurses and physicians still are working in separate worlds even when working on the same patient. I may be too idealistic. I am looking for the nurse that can bridge that gap. I think patient’s are safer when physician’s and nurse’s can collaborate respectfully. But my point of view is from the bedside and perhaps not appropriate at the level of IHI management. At any rate, It seems to me that IHI was sputtering out over the past few years. In our hospital IHI initiatives have been replaced by JCAHO, administrative mandates, cost saving changes etc. When and if Dr. Berwick returns, I hope it will be with gusto and new insights. In the meantime, I hope that Ms. Bisognano can bridge the nurse/physican worlds so that we can all look at the patient together.

  9. Jack Percelay July 27, 2010 at 1:34 pm #

    Another question your column raises is whether charisma can be taught, or at least nurtured, honed, and developed. No doubt that some people are born with a gift, the Berwicks and the Provenosts in your example, other examples among SHM current and former Presidents. But there are many local leaders who could benefit from some executive coaching/formal training in inspiring change.

    Note this recent article in the NY Times describing acting lessons for Davos fellows:

    http://www.nytimes.com/2010/07/10/theater/10acting.html?scp=5&sq=teaching%20public%20speaking&st=cse

    As I have watched physician colleagues grow in their leadership roles over time, Thespianesque skills can and do play a role in creating some of this charisma. Maybe not at the uppermost echelons, but for a clinician educator, department chair, hospital medicine group leader, and/or hospital CEO, I do think that these skills can be developed to the point that programs can successfully achieve copycat success without a Provenost, a Berwick, or a Wachter leading efforts at your local institution.

    And that’s the point, isn’t it. Tenure review committees may be concerned about who had the original idea, but patients don’t care about plagiarism, as long as the idea is good and is effectively and reliably executed.

  10. Marly Holbrook July 27, 2010 at 4:16 pm #

    AD said:

    Donald Berwick is a ray of light for CMS. Unfortunately a good man is vilified for the right ideas, Shirley Sherrod eh?

    so true

  11. Bob Wachter July 28, 2010 at 3:00 am #

    Sorry, we’re having a little technical problem with the comments — a few folks have tried to post comments but have been bounced. This is from Dr. Chris Johnson:

    In my experience, safety initiatives often sputter (or are spiked outright) by a combination of intramural politics — often doc vs hospital — and overall physician cynicism about these sorts of things being just kabuki theater for JCAHO and such. Is there any evidence that these things go better at integrated practices, those in which the physicians and the hospital are part of the same organization and work for the same master? I’m thinking of places like Kaiser or Mayo.

    Chris

  12. Bob Wachter July 28, 2010 at 3:10 am #

    Good question, Chris — here’s a 2009 review, written by Stanford health economist Alain Enthoven, of the evidence that integrated delivery systems deliver on their promise. The evidence doesn’t knock your socks off, but it seems real.

    And here’s a 2003 article by Harvard’s Ashish Jha documenting the great improvements made by the VA system after a major reengineering effort to focus on quality and safety. Note that VA patients improved significantly more than Medicare fee for service (non-VA) patients over the same time period.

    Having worked at both the VA and Kaiser Permanente earlier in my career, my impression is in sync with this evidence. To me, integration makes all kinds of sense.

  13. John Murphy July 29, 2010 at 6:23 pm #

    The VA appears to be an organization that leveraged the influence of a charasmatic leader to sustain quality initiatives after the departure of said leader. In the case of the VA, that leader was Ken Kizer, one of the authors of the NEJM piece you reference. Of course, in the VA system, incentives generally align for quality in a way that is not generally the case in much of the private sector. One hopes that pilot programs for quality buried in the health reform act help with the incentive alignment piece so quality is more easily spread once it has been catalyzed with charisma.

  14. Andesson123 July 31, 2010 at 8:29 am #

    Read more: Ferienhaus, Darss,Zingst, … Wollen Sie einen Traumhaften Urlaub erleben? Schauen Sie doch mal hier!

  15. adelaideadrienne July 31, 2010 at 9:14 am #

    good topic

  16. adelaideadrienne July 31, 2010 at 9:15 am #

    The VA appears to be an organization that leveraged the influence of a charasmatic leader to sustain quality initiatives after the departure of said leader. In the case of the VA, that leader was Ken Kizer, one of the authors of the NEJM piece you reference. Of course, in the VA system, incentives generally align for quality in a way that is not generally the case in much of the private sector. One hopes that pilot programs for quality buried in the health reform act help with the incentive alignment piece so quality is more easily spread once it has been catalyzed with charisma

  17. Davis Liu, MD August 2, 2010 at 5:47 am #

    While a Berwick, Pronovost, and Wachter aren’t scalable, the issue at hand is whether the process exists that systematically produces physician leaders in adequate numbers to implement changes needed to improve the healthcare system. In the April 2010 Harvard Business Review, Dr. Thomas Lee penned the article, “Turning Doctors into Leaders” which reflected the tremendous challenges because the healthcare of today is far different than the one decades ago. As a consequence, the leaders today must be different as well.

    Are medical students and residents trained today to become future physician leaders or is their education unchanged from years ago? Leadership can be taught much like any other skill and it should be an integral part of medical education.

    As for integration though it makes sense, the reason for performance improvement isn’t because of pricing advantages or owning the underwriting cycle (as people may recall Kaiser had significant financial difficulties in the late 1990s), but physician leadership at every level of the organization whether at Mayo, Cleveland Clinic, and Kaiser.


    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    (available in hardcover, Kindle, and iPad / iBooks)
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  18. Jan Krouwer August 2, 2010 at 10:45 am #

    Management skill not charisma

    Interesting post – I was unaware that the checklist procedure begun by Pronovost has not been adopted by all. But I would argue that management skill, not charisma is what is needed. There have been studies on charismatic CEOs – charisma does not always mean that the right decisions or strategies are made. Some of the hospitals that have chosen to ignore the checklist procedure may have charismatic leadership. I would argue that management skill (and some technical knowledge) are required, not charisma.

  19. riechmar August 6, 2010 at 4:55 pm #

    Can’t berwick export the provonost success with a single swipe of his pen across a no pay error diagnosis for Central line sepsis? Every hospital in the country would have a checklist and an administrator in the ICU overnight…

  20. Barnice September 14, 2010 at 12:07 pm #

    good topic

  21. Nicolasa77 April 9, 2011 at 3:12 am #

    I think very good….

Leave a Reply