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The National Academy of Medicine's 2000 report "To Err Is Human" launched the health care quality movement in the US. Victor Dzau, MD, president of the National Academy of Medicine, and Don Berwick, MD, MPP, from the Institute for Healthcare Improvement, discuss progress to date in advancing quality and prospects for improving outcomes and reducing harms, errors, and cost in the next 20 years. Recorded December 22, 2020.
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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA. I am joined by two true American luminaries. So Victor Dzau, Don Berwick, I want to thank both of you for joining me today. It's a birthday, so it's really nice news. The IOM, formerly the IOM, now the National Academy of Medicine, which Victor has been the president of since 2014, is 50 years old. So happy birthday, Victor.
>> Victor Dzau: Thank you.
>> Howard Bauchner: We're going to discuss a remarkable series of events. Victor and Ken Shine, the former president of the IOM, have written an editorial that we just published about an hour ago, entitled "Two Decades Since To Err is Human, Progress, But Still a Chasm," and it's focused on three viewpoints. I'll read them quickly. Assessing Progress in Health Care Quality Through the Lens of COVID-19, by Corrigan and Clancy; Accelerating Global Improvements in Health Care Quality, Leatherman and Berwick; and then A Road Map to Advanced Patient Safety and Ambulatory Care, by Singh and Carayon. But I think I first have to start by taking people through the careers of these two remarkable individuals, and for very specific reasons. Victor's a cardiologist, trains at the Brigham, goes to Stanford from 1990 to 1996. Returns to the Brigham as chief of medicine in 1996 to 2004, then to Duke, then to the IOM. Don, like me, is a pediatrician. He's active in the Boston community, works at Harvard Community Health Plan, and in 1989 cofounds the Institute of Healthcare Improvement, which has gone on to become a preeminent QI institution in the world. Don becomes a member of the IOM in 1997. Victor follows the year later. Why the chronology? The two seminal reports, the two seminal reports of the National Academy of Medicine that have transformed certain aspects of medicine, are "To Err Is Human" and "Crossing the Quality Chasm". Don chairs, or cochairs, both committees, and I just want to read one piece, one short piece from "Crossing the Quality Chasm" because it's published 20 years ago and is still critically important to how we think of health care systems. Health care systems have to be safe, effective, patient centered, timely, efficient and equitable. Victor, when these two reports come out, they come out about six months or a year apart, Don is an author of both, did you know they were seminal reports when they come out 20 years ago?
>> Victor Dzau: Well, it certainly made an impact. As chief of medicine, a report came out, it caused a lot of buzz.
>> Howard Bauchner: Okay.
>> Victor Dzau: Because the report says there were 98,000 --
>> Howard Bauchner: Right.
>> Victor Dzau: -- people dying in hospitals from medical errors. And, of course, we were saying how can that possibly be, you know. I mean, certainly at that time doctors, hospitals were up here and, you know, yeah, no, we don't make errors, at least we didn't think so. So it really caught the attention. But I think what happened was a series of meetings and conversations that really took us to a point that we know we need to take it seriously. I was reminding Don that he came to summer retreats, then medical school, Partners Health Care had retreats, and Don was very passionate, and actually shared his own personal experience, and it really made an impression for me. And I also remember Chris Cassel [phonetic] came to give grand rounds on this, and the room was packed, and you could hear a pin drop because people were alarmed by these numbers, and I think in all good conscience, realized that if we don't do something about this and since we are the care providers and this is shining a big light on us, we better take this seriously. So that was the starting point. And, of course, there's lots of stories to tell that follow, but I think that report caught the entire medical community by surprise, but also caught their attention.
>> Howard Bauchner: Don, you worked on both reports, so just a couple quick questions. Were they meant to be simultaneous reports, or one that followed the other? That's the first. And the second is did you know what impact these two reports would have, not just in the United States but around the world; did you envision what they would mean? I think it's one of the great, great contributions of the National Academy of Medicine to global health. Don.
>> Don Berwick: I'll give you a quick history. The reports were the sequel to around table on quality that Ken Shine had organized on his own initiative at the National Institute of Medicine at that time. Several members there were very eloquent. David Lawrence, I think, deserves particular credit for having said it's time to put something on the table, it's real change. He said the chassis' broken, was his term. And I don't know the exact details, but Ken did something quite unusual. Victor may comment. Usually the National Academy responds to requests for reports. There will be a government agency or some other stakeholder will say could you organize a committee. Ken did it on his own initiative from the academy itself, set up the Committee on Quality Care in America, which I served on, and that committee was the committee that offered those two reports. I chaired one of the two subgroups named after David Lawrence's idea, the Chassis Subcommittee on Redesign. I had been working on quality for a decade and a half --
>> Don Berwick: -- and I knew it would be important, but I had no idea it would hit this way. So what happened was the committee was meeting and the Harvard Medical Practice Study had appeared. We had evidence on errors. And someone suggested that maybe, while we did the larger report, which became "Crossing the Quality Chasm", we ought to do a fast track report on patient safety because it was so urgent. I remember the meeting at which one of the distinguished members said no one will be interested [laughter], but we went ahead. We fast tracked the report on patient safety. The data were very good. We had a very good group in the committee. And so that report came out a year before the full report. They were conceived of as in sequence, but we had no idea that "To Err is Human" would hit the bell the way did it. It leaked. It leaked on a Sunday and the academy, therefore, accelerated the release and on that Monday we had a fire drill where everyone was doing interviews, and it just got a lot of press attention. The subsequent report, which I regard as more comprehensive, in some ways more important, didn't get quite as much attention, but by then we were confident we needed to produce a framework.
>> Howard Bauchner: Yeah, I finally read it like two or three times. It's like bookmarked, it's dirty, because to me it's the fabric of what a health care system should be. Victor, when you hear --
>> Victor Dzau: Howard, let me say something first.
>> Howard Bauchner: Yeah, go right ahead.
>> Victor Dzau: I want to give Ken Shine, I mean, amazing credit, my predecessor. And, in fact, I learned from him. As Don said, you know, we now [inaudible] we do a lot of things in a way that's timely --
>> Howard Bauchner: Yeah.
>> Victor Dzau: -- and not necessarily go through the bureaucracy --
>> Victor Dzau: -- sometimes within the academy can be pretty daunting. But Ken, even back in 1992, had this idea, and he actually took it through the council, instead of taking it through what would be the usual executive committee of the NLC [phonetic], we call it, right. And then he didn't have the money. We never actually got sponsor dollars. We took money from ourselves. And actually, Bruce Alvis [phonetic] was helpful, I believe, in funding part of this. So I think this is an example of leadership, of seeing the right issue, being willing to take the risk and willing to put your own resources to advance it. And as you said, I mean, this is probably our grand, our marquee --
>> Victor Dzau: -- in terms of IOM, NAM. Everybody knows when you say IOM, "To Err is Human".
>> Victor Dzau: And it's said in a way that probably for us to do what we are able to do today.
>> Howard Bauchner: Victor, when you think about these two reports, vis-a-vis your tenure since 2014, and you were just re-elected, so I don't know what the length of term is, but it's another four, five, six years, but when you think of this tenure, coming in 2014 and these two reports, where do you think the field -- what have been the successes and what are the remaining challenges?
>> Victor Dzau: Challenges plenty, and success plenty as well. As you know, when we conceived our [inaudible] this is 20th anniversary, let's celebrate --
>> Victor Dzau: -- this report, we came to you because we figured you're the right place to publish them. And so we have decide how many do we do. Now, I should point out that from 1999, year 2000, to now, we generated close to a dozen reports on the quality series.
>> Howard Bauchner: Oh, okay.
>> Victor Dzau: And really looked at all different aspects, from nursing, leadership, education, information technology and, of course, more recently, the global -- the ambulatory and, of course, the global aspect that Don led in 2018, and so on, so forth. So we had to step back and say, talking to you, what do we do to celebrate this, and you kind of asked us what are the big issues --
>> Victor Dzau: -- going forward. Successes are plenty, and maybe Don can say more because after all, who doesn't know about patient quality, right? I mean, it is the way in which we now care and deliver health care. Not perfect. Our numbers are still not great. But when you go into a hospital, and you know that that's what people focus on. We got to deliver quality, those six elements. And, of course, safety is a key part of this element. I want to come back to one of them, as I see forward. So I think it changed the way, as you said, it changed the way the rest of the world because NHS came up with a similar kind of declaration a year or two later, and then the WHO in 2004 say this is it. Don and I had been involved with many international forum, right. The last one, Don, I think you and I [inaudible], right, and there's a movement around the world that no health system can come into existence, if you will, and try to meet universal health coverage without quality, and Don can say more about this. I think the reason that going forward we picked on three, four areas, and I would like -- you already read them. One, of course, is that the ambulatory care so much work is Don on hospital --
>> Howard Bauchner: Yeah, right.
>> Victor Dzau: -- events, ambulatory care, and associated with that is the digital technology. There's so much now coming out. Second is the [inaudible] of COVID. COVID has really pressured test our system and showed that we have lots of weaknesses still. And third, of course, as Don has led, the global aspect; what about rest of the world. So we chose these three, plus a [inaudible] by Ken and myself. But going forward, I think I talked to you about this, we really think that equity is the long -- the unifier of all these things, so we want to work on that as well, which is one of the six elements. Thank you.
>> Howard Bauchner: Yeah, I know. It's interesting, Victor, that 20 years ago, equity is so prominent in "Crossing the Quality Chasm". So there are very smart people who recognized 20 years ago, 30 years ago, it was an issue. Don, the successes and the challenges?
>> Don Berwick: The successes Victor has talked about, the catching on of the issue, I'm somewhat narcissistic when I say I wrote those six aims. I remember being in Woods Hall upstairs in one of those rooms and we wrote them on a flip chart and debated them, but the ability to get that whole committee together and say we're going to declare aims and those were the six, and they took off. You now find them in mission statements all over the world, and it was time for this group to declare improvement's needed. And by the way, the scientific category was incontrovertible. We reviewed hundreds and hundreds of papers. We said nothing that we didn't have very strong evidence for, as is the way with the academy. So awareness has grown, concern has grown. Patient safety took the lead. It's the most charismatic -- and the most easily understood, and that's been very good news because even the World Health Organization now has centered that in its strategy. Second has been, I would say, local breakthroughs. If any dimension of quality now, any of those six dimensions, we know places around the world that have made very remarkable improvements on patient safety for sure, on effectiveness absolutely, patient-centeredness, we have a whole new way to think about it. Timeliness, yes, we have reduced delays to zero in some places. And waste reduction has been a problem. I think the weaknesses have been -- I'd say there are three weaknesses. The first is I think we probably should have put equity first. I mean, I --
>> Don Berwick: -- it was the sixth of the six. I don't know if we nailed it the way today now modern sensibilities are seeing it. I just am -- I'm saddened and shocked every time I look at the data on how uneven this world is with respect to the well-being of people, and that's got to be quality problem one, I think. Number two is we didn't have the funding to put public health into the picture. So this is a report about health care less than about population. What today we call population health. Luckily, the academy and others have led on that, and as you know, in 2006, my colleagues Tom Nolan and John Whittington published the paper on the "Triple Aim", which broadens the view, the six aims are in care delivery, but then what about population health, what about lowering per capita costs. I think the third is a strategic gap still. If you go into the C-suites of hospitals or clinics all over the world, I think people would be aware of this, but it is really not the most common phenomenon that the senior executive leadership put the improvement of quality at the top of the strategic agenda. There are so many other things on their minds. And unless and until that happens, we won't make the global progress we really need. It's a tough job to lead, but this has got to be central.
>> Howard Bauchner: Victor --
>> Victor Dzau: You know, Don, when I was CEO at Duke, I can tell you that the board, the board of directors, put [inaudible] of mine. The board has a committee --
>> Don Berwick: Yes.
>> Victor Dzau: -- and we're to report back on quality and safety. I think when institutions are taking that seriously, that's when you're going to see the change, the C change.
>> Howard Bauchner: Victor, you've been at some remarkable institutions in Massachusetts, California, North Carolina, now you're back in Washington. Let me just read how you defined equitable 20 years ago. Providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location and socioeconomic status. Victor, through your lens of your career, and now as president of National Academy of Medicine, why has this been such a struggle in the United States?
>> Victor Dzau: Well, first of all, we have to recognize how important this issue is. I think COVID, in many ways, unmasked further the problem because we'll always find out that the vulnerable population --
>> Victor Dzau: -- those with socioeconomic challenges, are the ones that suffers most in terms of quality and safety of their care, also of the population health itself. I think it's been shown again and again with climate change, you name it. So as Don said, this is something we've now got to work on, shining a lens on the quality and safety issue. That really comes down to understanding social determinants of health, the socioeconomic circumstance which they live, the work, and -- -- educate the issue of trust, the really important issue of getting trust and working with the community to achieve those kind of quality standards and points of data. You know, during COVID, there's actually no system that we're collecting data, and it's really quite amazing. If you really want to make a change, as my friend Don always says, you can't improve what you don't measure. You really got to collect the data. And, of course, culture and leadership. So it is so important for us to work on this issue, and we believe that in this country, I think it comes down to socioeconomic and other issues. And, of course, communities of color who are greatly affected, we know there's a deep issue on our structural racism that we need to address as [inaudible].
>> Howard Bauchner: Are you optimistic, Victor?
>> Victor Dzau: Oh, my. I'll tell you, I wake up, no exaggeration, every day thinking of how we can overcome this issue. And if you look at today's the political scene, and how some of the -- shall we say our nation's behaving some, this way or that, it worries me a lot, but we are up to a challenge. We have to work on this, we have to change it because if we don't, you can imagine how worse things could be. So I am -- I would say I'm encouraged by the recent events and the willingness of many people facing up to issue of structural racism. There are many conversations now, you know. I would say not too long ago medical schools don't tell you about social determinants of health, and now everybody's teaching it. I do think that people recognizing this, so in that regard I'm optimistic, but I do think the bigger issue for our country is really getting the entire nation to understand how important this is and to work at this.
>> Howard Bauchner: Don, you were in Washington. You know the rancor that can pervade the District of Columbia, Washington. You ran for governor of Massachusetts, a liberal state. Are you optimistic?
>> Don Berwick: I am when I meet youth. I think -- I'm not being -- I'm being honest about that. What gives me optimism, every time I meet students and young people in our profession and in the communities, they know what has to happen. And so, yeah, I think the future is going to depend on their energies, and anything I can do to tell youth this is their time to take over and make this right. The incumbent stakeholders are very reluctant to make the changes we need. We've got to get resources into social determinants, as Victor has said, and that's not a vague idea. The social determinants are well understood. The science is superb. We just don't have the political will to move it yet, and that's going to take some real mobilization. I wrote a viewpoint in JAMA, as you know, Howard, on the moral determinants of health --
>> Howard Bauchner: I was going to ask you because you tried to reframe the discussion slightly. Could you talk about moral determinants of health?
>> Don Berwick: Yeah. I mean, it's a question really. I mean, we have the data. We know how to make societies healthy, we really do. The evidence is overwhelming and well-established, and yet we don't see investments in most countries, certainly not in the U.S., in proportion to where the health can be found. And I say, well, why not. Well, is it economics, the economics don't favor it. As I say, the incumbents have a lot of money and they don't really want to see a lot of change right now. They're making a lot of money. And they're good people. They're not evil people. And it could be the political fractionization of the country. So I say where are with the energy, the morality. I know that's so high-minded and risky, but we've got to look at what is right, and it is not right to live with the suffering that we live with, especially when we know what to do about it. So the moral determinants is a list of agendas that I think the health care industry should adopt. I think it is -- we need to own it. Eighteen percent of the economy, a lot of gravitas. Victor's been brilliant taking one of these on in climate change now. He's announced it in the National Academy's -- at the 50th anniversary. We need to get engaged, and if we can, yes, I'm optimistic, but right now we're too many bystanders.
>> Howard Bauchner: Victor, what's the role of the National Academy?
>> Victor Dzau: Well, let me just say what Don says, and so eloquently, and expand that a little bit. I think it's not only a health issue. At the end of the day you're not going to get there in health without getting there everywhere in our social construct and the challenge we face, right. So social determinants, to me, as we look at it as determining health but, in fact, they determine the entire welfare of a society. And we really need to work at all of them, and by working all of them, that's when health would improve. If you only have the health lens on this, it's not going to get there, right. You can go and provide much better social services for the community, but they're still poor, they still have challenges. You can provide better educational opportunity, but still, there's a big divide. I think that until we readdress the entire issue of our society, we're not going to get there. That's what I meant when you say are you optimistic. That being said, I'm optimistic with the new administration. There are lots of good people there and they are having the right conversation. And I do know that the new administration have all the right intentions, so let's do everything we can to help them. And that's when I come back to your question about what do we do --
>> Victor Dzau: -- at NAM.
>> Howard Bauchner: Right, right.
>> Victor Dzau: That's what we need to do. I need to be able to look at an issue and not be shy and timid about it, but being able to look at it, call it out and work on it. I need to work with people beyond health to really try to change the construct in our society. I need to work with the administration to see if we can help in any way getting people like Don, like you and others, to get the best minds together to give them advice, and that's what we can be doing.
>> Howard Bauchner: It's interesting, your comment, Victor. Sandro Galea wrote a really wonderful piece for us about who owns social determinants of health, and he doesn't want to indicate that medicine should turn its back on social determinants of health, but he has argued that we can't do enough, and it may not be appropriate for health care to do everything; that it's a societal issue and somehow, unless we make it a greater societal issue, the likelihood of success is going to be diminished. It was a very interesting piece because of this controversy about how much does medicine own, but how much does society own. Don --
>> Don Berwick: Totally agree.
>> Howard Bauchner: Don, so in between Ken Shine and Victor was Harvey Fineberg, who's a friend for the three of us. Harvey's now at the Moore Foundation. And just taking it back to safety and quality for a second. Harvey has invested quite a bit of Moore Foundation money in ambulatory safety and diagnostic accuracy. It's very interesting. You know, if you talk to Harvey and the other people who have worked on it, they're worrying, they've worried that we've missed a step, and that's around diagnostic accuracy; that if you end up on the wrong train or in the wrong algorithm, you're destined not to improve quality and safety. Could you talk about that a little bit, Don, from your perspective?
>> Don Berwick: I think it's an important supplement to -- with the work that's gone on. I credit the institute, the National Academy. I believe Chris Cassel was chair of the Committee on Diagnostic Error, and they did a good job. You know, I must say my overall view is that -- it comes from Paul O'Neill, actually, who was the head of Alcoa, taught me a ton, and was Treasury Secretary. Paul was just a tremendous leader in the area of quality, and he said you can't be excellent at some things, that excellence is a -- it's a characteristic of everything you do. And so picking up on this issue of accuracy of diagnosis absolutely belongs on the table. What I want to caution against, and Harvey is a fantastic leader and the Moore Foundation is doing exactly the right thing in this world, but as we consume this, it's important not to have an either/or view of the whole dimension of quality, back to O'Neill's idea. It's not like we drop something to work on something else. We've got to have a sense of performance across the entire array of what people need and, yes, diagnostic excellence belongs there. I do have a little bit of a -- maybe a scientific question here, is I think when you think about health care delivery, I'm talking about the acute care now, I think we often do things for people that help them very effectively without a diagnosis. And so it's an interesting debating point as to whether you always need diagnosis on the route to excellence.
[ Laughter ]
>> Don Berwick: I'm not sure --
>> Victor Dzau: But, Don, you would agree the error in diagnosis is a problem, right?
>> Don Berwick: Absolutely. Getting it wrong is a problem.
>> Victor Dzau: Getting it wrong is a problem. I mean, think about this. It's the foundation of patient management. At least you got to figure out whether you do a test or not, you have to have a diagnosis at least.
>> Don Berwick: Yeah.
>> Victor Dzau: And so imagine when you get it wrong, everything goes wrong afterwards.
>> Don Berwick: Yeah, I agree with that. The other evolution though around patient centeredness is to move medicine toward what matters to you. You've heard that language now worldwide. Instead of saying what's the matter with you, the diagnosis, you say what matters to you, and you organize efforts around the -- it's a shift of power, in which the patient and family community get to say, well, this is the kind of help I would like, which isn't necessarily about diagnosis only. So I'd say it's an and, not an or.
>> Howard Bauchner: Final words from you, Victor. What's it meant to be president of the National Academy of Medicine?
>> Victor Dzau: Well, I always say I serve the members, I serve the nation, I serve globally, and that's what it's like. And you know that, Howard. You and I had several conversations about this. You know, it's not as if I'm here, the emperor, or even, you know, a king. In fact, everything is I see myself as a servant, as someone who serves everybody. And I do think it's important for me, for NAM to get the right people, the right thinking, to think together collectively to go forward. So my job will be to do something like this, to see what's going on, what's important, and the willingness, as Ken Shine did, to take a leadership role, be bold enough to move things forward, but always with the idea of serving the nation.
>> Howard Bauchner: Don, a final word from you, but before I move on, I just want to mention, Don's a member of the JAMA Editorial Board, which I should have mentioned earlier on. We either ask Don to write for us or he spontaneously writes for us a few times a year, and it is my extraordinary privilege, along with Phil Fontanarosa, because we edit all the viewpoints and editorials together, to read virtually anything that Don Berwick writes. There are few people in medicine who can assemble the human language without a thesaurus, words I can understand, but can assemble them in a way where he tells a remarkably evocative story. And so I would say to all of our listeners read everything that Don Berwick writes because his choice of words and language are remarkable. But, Don, last comment from you. Has it achieved what you wanted; did the two reports achieve what you wanted?
>> Don Berwick: Well, first, thanks for that extraordinarily generous comment, and I don't want to close without a word of gratitude and admiration for Victor. I'm watching the academy thrive under his leadership and grow and expand its visual fields. He stands on the shoulders of giants, but he himself is one, and it's just such a pleasure to work with you. You know, I guess the reports, Howard, began what I dream of, but they haven't accomplished it yet. They do do very important things. They say that we have a problem and they give the pedigree, the scientific pedigree for that, they establish the science. If they're read well, they convert our thinking from a culture of bland and individual accountability and trying harder, which will never work, to a culture of systems thinking and understanding we are interdependent. It's one world, one effort. Even a single patient requires us to work together. So it introduces systems thinking and it lays out some pretty clear guidelines for what leadership needs to do. So the charter is there. Those reports, plus the "Triple Aim", which I credit Tom Nolan and John Whittington with, the architecture, they're the blueprints. Now it's up to the leadership. We have to somehow convince or win over leaders all the way from ministries of health to individual chairs of departments, to individual clinicians, to understand that the quality as the strategy is the best thing we can do for the world. It's the best way for we to help the people that are suffering, and it has to be strategic, the way Victor described at Duke. So it will get there. It's going to require one more turn of the wheel as leaders begin to see that meeting peoples' needs directly through a focus on quality is the best route to the systems we want.
>> Howard Bauchner: This is Howard Bauchner, Editor in Chief of JAMA. I've been joined by two remarkable individuals, two luminaries in medicine, both in the United States and around the world; Victor Dzau, who is current president of the National Academy of Medicine, and Don Berwick, who's president emeritus of the Institute for Healthcare Improvement. To all our listeners, this is the last conversation of the year. I wish you all seasons greetings. If you celebrate the holidays, enjoy them. Good health and stay safe. And to Don and Victor, both of you, please stay healthy and thank you for your time today.
>> Don Berwick: Thank you.
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