It’s often difficult to accept reality, even when it’s presented in good, solid data. The stories they contain sometimes do not correspond to our own perceptions of our performance. In fact, we’ve found that people who are confronted with data that presents a less-than-favorable picture of their organization’s performance generally go through four stages of coping. These stages are inevitable, and we encourage you to journey through them all, one at a time…but please do it fast.
At the end of the journey is a state of mind the Japanese call “jiseki.” Read on…
Stage One: “The data are wrong.”
With any data set, there are always questions about adjustments, hidden variables, sampling, poor input information, and so on. It’s very easy to hide behind the belief that the data do not reflect reality. To be sure, no data set is ever perfect, but in general, most are plenty good enough to act upon.
Stage Two: “The data are right, but it’s not a problem.”
People in this stage believe in the integrity of the data, but point to natural variation as the cause and the justification for inaction. Phrases heard from Phase Two thinkers include: “This is just the hard reality,” or “Mistakes happen,” or “The care we provide may not be perfect, but it’s pretty darn good.” The status quo remains acceptable.
Stage Three: “The data are right, it’s a problem, but it’s not my problem.”
This stage can best be characterized by the Japanese word “taseki,” which Don Berwick included in his list of “dirty words in health care” in his 2000 National Forum plenary speech:
I don't know a single word synonym in English, but “taseki,” if I get it right, means, "The dog ate my homework.” “I didn’t do it.” “Not my problem.” Or maybe, “Somebody ought to do something about this.” “Your burden,” it means, “not mine.”
It is the standard defensive position for inaction on the quality frontier. “Taseki” is the long list of reasons why we cannot openly address patient safety — the malpractice lawyers, the inevitability of hazards, the problems of measurement, or the resistance of "those doctors." It is behind the claim that our outrageous health care costs come from insatiable appetites for care, that doctors won't "buy in" to change, that we could make changes if only there were no unions, or improve profits if only the payers would pay us more. It blames our inaction on the Joint Commission yesterday, the Balanced Budget Act today, and unwise consumers tomorrow. It resists authentic inquiry about how they do so well with so much less expense in the health care systems of Canada, Holland, Norway, Sweden, and a dozen other Western nations by saying, "We are different, case closed."
Stage Four: “The data are right, it’s a problem, it’s my problem.”
People in Stage Four believe that the data are good enough, it is a problem, it is our problem, and we intend to do something about it. The Japanese term for Stage Four is “jiseki.” Dr. Berwick continues:
“The opposite of "taseki" in Japanese is "jiseki." "My burden." "I'll handle it." "I can; I will." It’s “The Little Engine That Could,” for children; Dunkirk or Normandy or Americans on the moon for adults.
The shouldering of responsibility — "jiseki" — is part of the training and romance of the health care professions at their best. Alan Gregg, for decades the head of health care programs at the Rockefeller Foundation, wrote: "…Sometimes it helps if you remind the desperately ill patient that it is the doctor's job to do the worrying, because the patient is too busy being sick to take on anything additional."
When was the last time America's health care leaders have reminded the public we serve that it need not worry about our caring? That we will do the worrying? That we know that they are too busy suffering — being sick, at risk, or frightened — to take on anything additional? Joanne Lynn of Americans for Better Care of the Dying calls this "making promises," and it is "jiseki," taking the burden, not "taseki," passing the buck. What promises have we made?
"Jiseki" makes mincemeat of some other words that "taseki” likes. If we bear the burden, then we cannot think much of claims that patients expect too much, or that our system would perform better if consumers took more risk. If we want to talk about "partnering" with patients, we would have to mean it, not use it as code for blaming them for their choices. We would bear the burden of explaining our work, of resolving confusion, and of revealing our errors. We would seek excellence, no excuses. We would figure out how better to use the abundant resources we have, instead of complaining about the resources we lack. We would be optimists, not victims. We would talk far less about payment for old things, and far more about revenues for new ones; far less about costs, and far more about waste. We would tell our publics not how bad things are, but how good we will make them. We would make far fewer explanations, and far more promises.
Quality is "jiseki," our burden. Our care will improve when and if we decide it will improve, not before, and not without. We got to the moon because we decided to; we did not decide to because we knew how. We will improve health care only as much as we decide to improve — not a particle more.
I think soon, if not now, our nation may have had its fill of excuses about health care. We hold in trust nearly $1.5 trillion a year, put in our hands for the sole and worthy purpose of relieving the suffering of our fellow human beings. In giving us that resource, and in trusting us enough to hope that we will use it wisely, the public we serve has done its job, completely. They are too busy needing us to take on anything additional. The job of meeting that need is now our burden, "jiseki," up to us, or we ought to give them back the money with our apology that we, not they, have failed.
So, take the journey to “jiseki.” It’s not an easy passage for some, but it’s a critical foundation for anyone who intends to play an active and engaged role in improving health care.