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"I am sure the average health care executive never thought that working on decarbonization or closing social gaps in health status would be their job when they were training. But it is."
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The Evolving Challenges Facing Health Care Leaders

By Donald Berwick | Thursday, December 1, 2022
The Evolving Challenges Facing Health Care Leaders Photo by Lavios Brown | Unsplash

During the pandemic, I have seen a pervasive level of resourcefulness and inventiveness that I have never seen before. Some of the adaptations that hospitals and clinicians have made — including communicating and collaborating in ways they haven't before — have been astounding. We developed effective vaccines faster than in any time in history.

But, as we all know, the pandemic has also taken its toll. The greatest price has been in the loss of lives and health for millions. In addition, almost all the health system leaders I speak to these days describe experiencing tremendous stress in their jobs. The work of running a hospital, health care system, or group has always been hard, but COVID-19 has made it all harder. Almost every pressure that health care was under before there was a pandemic has been ramped up.

The pandemic has made the problem of equity ever more vivid as it has disproportionately hurt people of color and people in marginalized communities. Clinicians are burning out faster than ever before. There is a vast shortage of nurses. Costs are rising. It has become increasingly clear that addressing social determinants of health has to be a priority. Climate change is the largest threat to human health on the planet, according to the World Health Organization, and health care has to do its part to reduce greenhouse gas emissions. Health care leaders also need to worry about the loss of traction on patient safety since 2019. Hospitals have sustained, in some cases, substantial financial losses this year. The list of worries is long, and it is relentless. I suspect the average health care executive and board may have never felt more stressed than they do right now.

Because of all these pressures, I fear that some health system leaders may treat challenges like improving equity, reestablishing the joy and well-being of the health care workforce, or addressing climate change as less important or (even worse) as distractions.

In my views, all of these issues — inequity, climate change, housing problems, burnout — are not extras. Facing all of them is central to the job of producing health and well-being, and if we claim to be systems in pursuit of health, we must have them on our agendas.

Yes, the job of a health care leader has changed. I am sure the average health care executive never thought that working on decarbonization or closing social gaps in health status would be their job when they were training. But it is.

To the health care leaders out there: You are my friends. I respect you. I know you are working hard already. But you do not get a free pass on these societal issues.

At the social level, it is not smart financially to have marginalized communities suffering from ill health, people developing serious illness that could be avoided, or individuals with unattended behavioral health problems that keep them from maximizing their abilities. It is not a smart investment for society to keep running health care as a repair shop without also moving upstream to the real generators of illness, injury, injustice, and disability.

But the most important rationale for health care to take on these issues is not about money. It is about the kind of world we want to live in, the people we want to be, and the communities we want to build. To those who say, “We can’t afford to do it,” I say, “We can’t afford not to.”

If you think the current payment system is not letting you do what you want to do, then fight like heck for a better payment system at a lower total cost, and one that allows you to move the money to where it is needed.

Being a health care leader is a hard job. I know that. But just as clinicians are finding a way through this mess to remain the doctors and nurses and pharmacists and therapists they want to be, our executives and boards need to find a way through these difficult times to lead the new kinds of organizations that are properly aiming for health and well-being.

You may think that you cannot ask your teams to do more than they are already doing. But if you earn their trust and co-design the future you envision with them, I think you will be surprised by the energy you can tap. People want to create a better planet and a more secure future for everyone. They want to create equity. Sometimes they just need to be called into the work. We need executives, boards, and governments to say, “Time out. The old system is not the one we need. Help us build a new one.”

We only have one life, and our kids have only one future. The quality improvement movement is about making life better for everyone. That is our aim. We have the methods, but without the aim, the methods simply lie fallow. We need to remember and remind others why we are here in the first place.

Donald M. Berwick, MD, MPP, FRCP, is Institute for Healthcare Improvement President Emeritus and Senior Fellow.

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