Photo by Jess Bailey | Unsplash
As the Institute for Healthcare Improvement (IHI) marks our 30th anniversary, it is a good time to learn from our past. In the following interview, IHI President Emeritus and Senior Fellow Don Berwick shares stories and insights about IHI’s founding and history that not even those who have been engaged with IHI for decades may be familiar.
One person was at the center of IHI’s founding. And, according to Don Berwick, it wasn’t Don Berwick.
Berwick: IHI’s founders were a group of about seven or eight people that all gathered around Paul Batalden. At that time, he was at Hospital Corporation of America. All of us shared two things in common. One was frustration. We were all involved in health care. We were managers, policy analysts, and clinicians. We knew things could be better, and we’d been trying to improve the care we could give to people. We just kept running into stonewalls all the time. The other thing we had in common was Paul Batalden. He was the common point. We didn’t know each other, but all of us knew him. Paul Batalden started me on this journey. He was the one who very politely said, “There are different ways to think about this.” He changed my life.
You might say IHI started with a book club.
Paul Batalden suggested that this group start talking to each other, and he organized a bit of a book club. We read some books together. I think the first book might’ve been Peter Senge's book, The Fifth Discipline: The Art & Practice of The Learning Organization. It was almost a religious experience. I don’t want to overstate that but each of us said, “Whoa, wait a minute. There’s a different way to think about making complex things better, and we don’t have to be frustrated. We can study and learn and maybe bring some of these things back to our home organizations. Together, we can learn our way to better.”
IHI began as a demonstration project.
We originally started IHI as a research project funded by the John A. Hartford Foundation. A wonderful project officer by the name of Dick Sharpe gave us some funding to do a small demonstration project. I organized what became known as the National Demonstration Project on Quality Improvement in Healthcare (NDP) with Blan Godfrey, who was at Bell Laboratories in Atlanta at the time. That was in 1986. The NDP effort met this group that Batalden had organized and decided we should do something together to try to create momentum for science-based improvement and care. It was thrilling. And we were friends. We supported each other and that was the birth of IHI. And in 1991, 30 years ago, came the incorporation of a nonprofit entity, the Institute for Healthcare Improvement.
There was joy in work at IHI from the start.
There was an amazing sense of excitement and shared discovery. It was like everyone had this flashlight, and we started illuminating things together. It was so enthralling intellectually to learn together. We shared a common purpose. We were excited to help people more than we ever thought we could before. If you wanted to help, you were in. There was a kind of open door and shared intent out of our intrinsic motivation that was really strong. I don’t know a source of energy stronger than intrinsic joy.
From the very beginning, the founding group all had a sense about the importance of joy in work, pride. We learned that from Dr. Deming, who said, “All anyone asks for is a chance to work with pride.” I think [striving for joy in work] is often regarded as unrealistic. People’s jaws drop when you talk about it. We train joy out of too much of the workforce, but it is the secret. It’s not a secret, it’s the secret.
To improve health care, we learned from others who did “impossible” things.
My year of epiphany was [around 1985] when I had the very good fortune to visit with the National Aeronautics and Space Administration (NASA). They literally got to the moon, which was thought to be impossible. So, I got in touch with NASA, and they were only too ready to help me. Within a day of my cold call, a man named Guy Cohen [director of reliability, quality, and safety for NASA] was flying to Boston to teach me about how to get to the moon. I learned from hotel chains. I learned from manufacturing companies. I learned from Bell Laboratories. None of [the people outside health care I met with] had thought about health care at all, but once we crossed the bridge, we saw that we were dealing with a lot of the same things. Health care and other enterprises are surely not identical, but similar enough that I could learn from the comparisons.
Looking back, IHI has missed some important opportunities.
In the early days of IHI, we didn’t understand the crucial roles of executives and boards. It was in the literature, but the mavericks that were joining us, the pioneers who were taking our courses, and joining the breakthroughs weren’t generally in the executive suite or on the boards. Now we know more clearly that we’re not going to change health care without making quality strategic at the organizational level. That would involve a stronger connection to finance. At the heart of Deming’s theory is that quality and cost are not opposites. We didn’t get involved enough with cost. We still aren’t.
The Crossing the Quality Chasm report has equity listed as one of the six dimensions, but IHI didn’t focus on equity enough in years past. Now, we see equity as core to quality. I wasn’t smart enough at the beginning to realize how valuable it would be to have the patient in the room and listen to the patient and family voice. We learned it in Pursuing Perfection, thanks largely to Cincinnati Children’s. [Improvement] is a co-production partnership with the people and communities we’re helping.
There are also things IHI got right from the start.
What I think we got right early on, and still right, is heart and soul. Because there’s so much money involved in health care, it’s easy to think of care as transactional. We pay for performance and have value-based payments and accountability metrics. But you’ll never get excellence that way. The excellence comes from the heart. It comes from the meaning, the soul. I’m not naive. There are, of course, occasionally jerks in health care. There are people who are greedy and people who have lost their way, but I deeply believed when we started IHI, and I still believe, that it is in the nature of the human being to try and help others. That’s what we get to do when we’re in health care. We get to help.
The problem is that leaders, boards, and politicians too often engage in behaviors that treat people as objects instead of inviting them to help. I think when we wake up and finally work by invitation instead of command, work by relationship instead of transaction, work by meaning instead of incentive, work by support instead of control, we’ll get much better stuff done.
Editor’s note: This interview has been edited for length and clarity.
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