Request for Proposals: Replacing Don's Right Knee

Donald M. Berwick, MD, MPP
Institute for Healthcare Improvement
Boston, Massachusetts, USA
 
In his plenary speech opening the 15th Annual National Forum on Quality Improvement in Health Care on December 4, 2003, in New Orleans, Louisiana, Dr. Donald Berwick issues a Request for Proposals to hospitals interested in performing his knee replacement surgery.
 
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"No Needless Death" – Don’t kill Don.
  • Show evidence that you know the risks of fatal injury from your care.
  • Discuss how you mitigate those risks, including, but not limited to…
      1. Eliminating surgical site infections
      2. Eliminating respirator-acquired pneumonia
      3. Eliminating deep vein thrombosis and embolism
      4. Eliminating medication errors
      5. Eliminating blood product transfusions mishaps
      6. Detecting esophageal intubation promptly
 
"No Needless Pain" – Don’t hurt Don.
  • Don’t do things that cannot help me: Show evidence that you avoid doing stuff to Don that cannot help him.
      1. Demonstrate your awareness and use of "The Dartmouth Atlas" to study and eliminate excessive care in your place.
      2. Explain how you guarantee that your care is based on the best available evidence.
      3. Report three procedures (tests, surgical procedures, medications, types of visit, etc.) that you eliminated from your care last year in response to new scientific information.
  • Reliably do things that can help me: Show evidence that you reliably carry out helpful care, including, but not limited to…
      1. Consistent preoperative, intra-operative, and postoperative processes across surgeons ("substitutability").
      2. Doing the right operation.
      3. Establishing and maintaining an open culture of team communication, to assure high cooperation, and to capture and use the contributions of any team member whose knowledge could help Don. Do you use multidisciplinary rounds?
      4. Proper use of well-supported nurses in advanced practice and coordinative roles.
      5. Patient registries, with long-term follow-up to coordinate care and increase your learning. How do you "remember" Don, while he is with you, and long after he leaves?
      6. Communication and information exchange with other sources of care.
      7. Show your measurement of functional outcomes and complications of your total knee replacements, short- term and long-term, with examples of how you use those measurements to improve.
      8. Show how you discover Don’s goals for his care (hint: He wants to cross country ski), and assure the best odds of achieving them.

 

"Relieve my pain"Reduce Don’s pain.

      1. Physical pain 
          • Show your use of state-of-the-art pain management.
          • Show your pain measurements and results.
      2. Emotional pain
          • Promise never separate Don from his loved ones, unless he asks.
          • Answer Don’s questions quickly and until he is satisfied with the answer…
          • Day or night
          • Before, during, or after his admission
          • In person, by email, or by telephone, as he wishes
          • Truthfully

 

"No Helplessness" – Don’t make me feel helpless.
Make Don the boss, to the extent he wants. He is a control freak, and that is your problem, not Don’s.
  • Promise that no staff will humiliate Don by deed or word, as Don judges it.
  • Give Don whatever control over his care he requests, with no hesitation, criticism, or barrier, including, but not limited to….
      1. Taking his own medications
      2. Keeping and reading his own medical record and lab results
      3. Wearing whatever he wants
      4. Eating whatever he wants
  • Demonstrate how you use formal methods of shared decision making to involve Don in decisions about risks and outcomes.
  • Demonstrate how you assure that all of your staff know how to give control to Don, and want to.
  • Show how you reliably ask Don how you are doing, and how you use that information to improve.
  • Show systematic, measured reports from patients about their experiences in your care, compared to the best known in the developed nations.
  • Explain how you manage noise, clutter, dirt and disorder in your facility, and how we you are doing at it.
 
"No Needless Waiting" – Don’t make me wait.
Don’t make Don, or those who take care of him, wait for anything they need or want.
  • Manage access: In outpatient care, illustrate your consistent use of Advanced Access.
  • Manage flow: In inpatient care, illustrate your consistent use of modern principles for smoothing flow.
  • Keep track of things: Everywhere, explain your approach to avoiding loss of things or information.
  • Report your delays and cycle times for key processes, comparing them to the lowest known in the developed nations.
 
 
"No Waste" – Don’t waste money.
Reduce total costs to Don and society to a minimum consistent with the above.
  • Everywhere, explain your approach to avoiding loss of things or information (see “No Needless Waiting”: Keep track of things).
  • Show your procedures for studying systems that perform at lower cost than yours for the same or higher quality, and how you incorporate the lessons learned into your processes. (Extra credit for studies outside the USA.)
  • Report your costs – per unit, per case, and per person – comparing them to the lowest known in the developed nations.
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