Preventable Adverse Events (PAE’s) is the #3 cause of death in the US leading between 210,000 and 440,000 American deaths annually. This must stop. But how? The answer involves one of the best stories in US healthcare history.
It started when Dr. Donald Berwick, the co-founder, president and CEO of the Cambridge-based Institute for Healthcare Improvement (IHI), was driving with his son, Dan to the airport. Dan, a political campaign strategist, explained that he was bringing 350 volunteers to Florida for a weekend to knock on 50,000 doors for his candidate.
Awed by the numbers, Berwick, 57 at the time and a clinical Professor of Pediatrics and Health Care Policy at Harvard, shared IHI’s frustration about the slow pace of change in medicine when it came to adopting practices known to improve care and reduce errors. As the former head of quality-of-care measurement for a large HMO, Berwick knew the numbers: As many as 98,000 American hospital patients die annually from poor care or medical errors. IHI researchers estimate that approximately 15 million incidents of medical harm occur in U.S. hospitals annually, roughly 40,000 every single day.
So, Berwick asked his son the critical question: “What makes your work so effective?” Dan explained what it takes to run a successful political campaign – coming up with concrete numbers (i.e. how many people you want to reach), establishing field offices to reach more people locally, inviting the widest possible participation, giving specific instructions to workers, and setting a deadline.
The IHI only had 75 people on staff at the time and no way to mount the national campaign needed to create any significant change, or did they? On December 14th 2004, Dr. Berwick gave a speech to a room full of hospital administrators. He said, “Here is what I think we should do. I think we should save 100,000 lives. And I think we should do that by June 14, 2006 – 18 months from today. Some is not a number; soon is not a time. Here’s the number: 100,000. Here’s the time: June 14, 2006.”
To accomplish this the IHI proposed six specific interventions for hospitals to adopt that had been proven to reduce unnecessary deaths. If you have been reading the blogs on the book Switch by Dan and Chip Heath you will appreciate that the “rider” now had a clearly defined goal to achieve.
But this was a challenge for hospitals to embrace and get behind. If they did it, it implied that unnecessary deaths were occurring in their hospitals. So, Dr. Berwick made it personal. At his speech he asked the mother of a girl who had been killed by a medical error to join him. She said, “I’m a little speechless, and I’m a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine…. But, I’m happy, and thrilled to be a part of this, because I know you can do it, because you have to do it.” Another guest on the stage, the North Carolina State Hospital Association Chair then spoke up: “An awful lot of people for a long time have had their heads in the sand on this issue, and it’s time to do the right thing. It’s as simple as that.” (Switch: the elephant was motivated).
The IHI made joining the campaign easy; hospital CEO’s only had to sign a 1 page form. Once a hospital enrolled, the IHI team helped them embrace the new interventions. Research, step by step instructions guide and training were provided, and regular teleconferences with the hospital leaders to share their victories and struggles were arranged. Hospitals with early successes were encouraged to become mentors of hospitals who joined the campaign later. (Switch: the path had been made easy).
But would they achieve the goal? Eliminating errors and documenting the results had not been done this way ever in the US Healthcare system. As a patient, the challenge of finding an excellent facility and doctor to use can be daunting.