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What the Berwick Choice Might Mean

April 2, 2010
by Mark Hagland
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If, as mainstream news media outlets had reported earlier this week, it turns out that President Obama does plan to nominate Donald M. Berwick, M.D., the president and CEO of the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI), as administrator of the federal Centers for Medicare and Medicaid Services (CMS); and if President Obama does in fact nominate him for that post, it would represent a watershed moment for healthcare system quality nationwide, for obvious reasons. By making such a move before the ink had even dried on the sweeping healthcare reform legislation passed by Congress at the end of last month, the administration would confirm what supporters of healthcare reform legislation had long claimed: that the concept of healthcare reform was not just about health insurance reform, as important as that element had been to the passage of the final bill through Congress; but that internal healthcare reform was also a key component in the administration's and Congress's intent in passing such legislation. After all, Dr. Berwick is justifiably famous as one of the industry's standard-bearers for the critical cause of improving patient safety and care quality, and has been for years.

And while the range of quality of CMS administrators has oscillated rather considerably over the years, on the whole, most CMS administrators have fallen somewhere along the able-but-routine-bureaucrat spectrum, with a few worthy exceptions. Don Berwick stands outside that mold, in manifold positive ways. And who better to help Health and Human Services Secretary Kathleen Sebelius develop a national quality improvement strategy, as directed by healthcare reform? Or to help shape how such highly commendable concepts as accountable care organizations, bundled payments, and medical home models, come fully into being? Dr. Berwick would be the executive overseeing the creation of the Center for Medicare and Medicaid Innovation that the legislation calls for, which presumably would be the main engine for developing such reimbursement innovations.

At the same time, Berwick would be entrusted with creating a Medicare-wide value-based purchasing program, which would establish system-wide the kinds of innovations that have borne such terrific fruit under the current CMS/Premier pay-for-performance program developed by CMS and the Charlotte, N.C.-based Premier Inc. And he would obviously be the federal executive who would have to interface with the independent Payment Advisory Board created under the legislation. Given his fierce advocacy of a healthcare system that provides higher levels of patient safety, care quality, reliability, and efficacy, I can think of no one better-qualified than Don Berwick to oversee CMS. I have interviewed him myself, and have found him to be as genuinely passionate about the great work he's done at IHI as he appears in articles he's written or that have been written about him.

There's no question that whoever takes the helm at CMS will be faced with a cornucopia of policy, payment, quality, and other issues, many of them deeply pressing. But if the Obama administration had wanted to signal a commitment to truly improving the quality and patient safety of the healthcare system, and not merely addressing the insurance and cost issues bedeviling U.S. healthcare, it couldn't have issued a more meaningful symbolic gesture than to apparently choose Don Berwick to lead CMS at this pivotal time in the history of U.S. healthcare.

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Comments

Joe Bormel,

Thank you for your excellent and exceptionally thoughtful comments!

First of all, as I noted, I was primarily concerned with the symbolic aspect of the apparent soon-to-be Berwick nomination, rather than looking at the potential fit between Dr. Berwick's skill sets and the actual CMS administrator post. As I had mentioned, I've interviewed Dr. Berwick in the past but unlike you, I don't know him personally, so can't comment on him at that level of depth.

In response to your question at the end of your comment, again, I have to emphasize that I don't know Dr. Berwick personally as you do but what I believe is that now could be an excellent time for CMS to get a leader who stands outside the mold of the typical "bureaucrat" type, if you know what I mean. Indeed, I would love for President Obama to re-envision the CMS administrator post to some extent with this apparent nomination-in-the-wings, because I believe that CMS needs a visionary leader, not just a bureaucrat, in order to succeed in the inevitably challenging times ahead. Keep in mind that the CMS administrator who is nominated at this time could potentially remain in that post for a number of years so the impact of the choice of individual in this case can't be overstated.

And in that context, I believe Don Berwick, from what I know of his record and accomplishments, appears to be uniquely qualified. Again, Joe, I don't know him personally, and so am not addressing your question on that level. But I do believe that it's time to shake things up on the U.S. healthcare system level when it comes to addressing patient safety, quality, quality-based purchasing, and a number of other issues facing us all in healthcare. Thank you again for your insights and perspectives!

Don is a strong leader, husband, father, academic, physician and visionary. In my studies in his course in the early 90s at HSPH, he introduced us to Brent James, Harry V Roberts (Quality is Personal), RJ Blendon (Juran Institute) and many others. He used a lot of experiential learning, including using a Personal Quality Checklist, playing the Bead game and Win-as-much-as-you-Can (classic adult learning exercises in Quality.)

Prior to this, in his 1980s writings, he introduced healthcare to the 50+ year old domain of scientific quality practices (including the type 1 and 2 foreman, focused on driving in fear and inspection, and it's opposite, the process view.)

More recently, he used the analogy of the car whose top speed cannot be improved with incentives (carrot and sticks.) He brought us the prospectives of Escape Fire, My Right Knee, High Reliability Organizational thinking (Karl Weick, Kathleen Sutcliffe), and the value of a good marketing campaign (100k lives). Remaking American Medicine comes to mind as another impactful vehicle, and I could probably go on and on, as far as examples of the useful, inspirational and effective programs that Don was instrumentally involved with bringing us. As you pointed out, he has the highest humility (level five    plus, see Exhibit 2 to the right for this Collins/Jaques hybrid notion) and a demonstrated ability to get outstanding results through other people. These are critically important and rare qualities.

I struggle, however, with the notion of the role of administrator of CMS for Don. Don't get me wrong. I know many talented, effective people who create value working as executives for government agencies in Washington. I have friends and colleagues who currently or have worked at CMS, AHRQ, and the FDA. They've achieved critically important and valuable things. The PSO structure comes to mind as a recent example, but there are many, many other accomplishments. I've blogged about resources on the AHRQ site as another recent example.

The CMS government role for Don? Let's look at a related example. Most intelligent insiders I know felt that Dr David Brailler, as newly created ONC czar, did not receive the necessary support he had earned. His strategic blueprint underlies the key, positive components of ARRA. His personal energy and political savvy were exemplary. It's dangerous, of course, to cite an example without someone saying "well, he was different." He simply did not get the support he had earned.

Similarly, one could rightly say that Brailler did have the hugest impact possible, but one has to look at five and ten year outcomes, not seasonal political wins with congress. Possibly true.

My point is simply that the symbolic value of a Berwick appointment, while positive (as you effectively pointed out), may not be satisfying or productive for Don. I'd like to believe that there are conditions that would be effective for the Country and for Don.

I think those conditions, i.e. establishing the context where Don Berwick can be successful is considerably more important than simply getting the right people on the bus.

Mark, aside from your articles and blogs, you've written several books on Quality Improvement and HCIT issues. Do you think this is the right time and place for Don Berwick, and, of course, why?

Joe Bormel,

You make great second-round points, too! :-) First of all, you're very right in distinguishing between the virtually pejorative "bureaucrat" and the much more positive-sounding "executive." I hope, if nominated and confirmed, that Dr. Berwick will bring the best qualities and assets of the "executive" to the position, of course, as opposed to some of the negative elements of the "bureaucrat."

Meanwhile, physicians and other clinicians are right to note that past CMS directors have not taken care of patientsand that, indeed, might be yet one additional qualification that Dr. Berwick might bring to the postnot that having taken care of patients automatically brings vast insight to an individual but most often, it does.

Great points all around, thank you, Joe Bormel!

Mark,
You make a great point. Bureaucratic savvy is essential in this role. When complemented by visionary clinical experience with deep roots in effective implementation, there is a greater potential.

I am in meetings every week with clinicians who have busy practices, work twelve to sixteen hour days out of a commitment to make themselves available, and rarely complain that they are underpaid (between levels 4 and 5 on the above graphic). Often, their first and only carefully chosen comment is that the head of CMS has never taken care of patients.

I've worked for several great executives who are very smart, very empathetic, non clinicians, and people who I would trust to arrive at the right clinical decision for me if needed. They wouldn't shoot from the hip or go from their gut. They wouldn't simply take a vote from subordinates or experts, although they would would ask and actually listen. They would consider fairness, values and the long view.

When you use the word Bureaucrat, I think most of us don't think of those great executives. We think of people who know how to get things done in the system. But not necessarily the right things.

As you point out, Berwick has the proven skills and experience to direct the decisions around billions of clinical dollars impacting millions of citizens. Few other nominees would have prior CEO experience (see my current blog post), patient care, scientific research and teaching experience critical to leading our healthcare reform.

Thanks for sharing your opinions, Mark.

Mark Hagland

Editor-In-Chief

Mark Hagland

@hci_markhagland

www.healthcare-informatics.com/blog/mark-hagland

Mark Hagland became Editor-in-Chief of Healthcare Informatics in January 2010. Prior to that, he...