What Dr. Berwick Does Not Understand About Quality Management in Healthcare


Donald Berwick, MD, former head of CMS, has written an article for the Journal of The American Medical Association, April 5, 2016, Entitled “Era 3 For Medicine and Healthcare.”  In it, he describes Era 1 of healthcare as the time when doctors and other health professionals were simply trusted to practice, and spend healthcare dollars, without much oversight out of respect for their education and status.  This era ended because clinicians, left to their own devices, proved unable to restrain healthcare spending or follow scientifically-proven best practices.  Era 2, of which Dr. Berwick was an important proponent, was the era of overweening healthcare management, with clinicians forced to use electronic health records that worked very poorly in pursuit of dozens of goals, many of which were of no proven value.  This era is itself in the process of ending badly, with CMS publicly backing off its support of Meaningful Use, the widely reviled initiative to dictate to physicians how to use the EHR’s they weren’t sure they wanted in the first place.  Era 1 was unsustainable, but era 2 has had the effect of demoralizing physicians to the extent that physician burnout is being described as an epidemic.

In his proposal for era 3, it is clear that Dr. Berwick has not repented of his role in inflicting era 2 on American healthcare.  Some of his proposals have merit: the number of outcomes that are measured should be drastically reduced so that attention can be paid to a few, important outcomes.  Professional prerogatives can be a barrier to doing things better- physicians should not be able to pull rank when making decisions about outcomes that require the actions of teams.  Some of Dr. Berwick’s recommendations are simply wistful: we should all behave civilly to each other.  We should reject greed, and focus upon the common good.  But the heart of Dr. Berwick’s essay is his belief that the problem with era 2 was that sound ideas were badly applied.  He does not seem to see that quality management, as he conceives of it, cannot be applied to much of healthcare.

There are certain healthcare processes with clear, measurable good and bad outcomes that lend themselves to quality management as if they were industrial processes.  It is clearly bad to have a wound infection after major surgery, and the processes of major surgeries should be managed to decrease the number of wound infections.  The way that myocardial infarctions are properly treated in 2016 is better than how they were treated in 1986, and steps should be taken to ensure that MI’s are treated as they should be in the modern era.  The situations in healthcare that are well-suited for scientific management are highly important, but they are few in number.  For the great majority of healthcare encounters, quality is hard to define, let alone manage.

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