Summary
- “Every experience I've had as a leader shows me that correctly invited, the workforce is ready, willing, and able to step up and do what is important.”
In the following interview, IHI President Emeritus and Senior Fellow Don Berwick offers a preview of his 2025 IHI Forum keynote.
What’s on your mind right now when it comes to quality in health care?
Right now, I’m seeing the development of work on quality in four phases, which today coexist. The first phase is the most familiar: project-by-project improvement. We pick a focused area, such as central venous line infections, or pressure ulcers, or waiting times. We put together a team to understand the causes and improve the process using quality improvement science.
The second phase is a view of quality at an organizational level. It expands our aims to matters related to social determinants of health. There’s a greater focus on what matters to patients and families, and the control of our agenda shifts more and more to them.
The third phase is working outside of health care on collective action problems that strongly affect health. That includes, for example, climate change, equity, criminal justice reform, and pollution. Health care organizations get involved in improving the circumstances of communities and society that lead to ill health or that can improve health.
The fourth phase is political action. A lot of opportunities to improve health have been politicized. We need to speak up as champions for policies that allow us to work on the causal systems for health, and especially to defend health care for the poor. We might not normally think of that as quality. We can use the same techniques that we use to prevent infections to improve processes that impact a particular social determinant of health.
There’s a lot that appears urgent in health care practice and in public health right now. When there are many competing needs, how do you prioritize or find ways to move forward?
Part of me says, we have to do it all. I couldn’t say that a hospital just doesn’t have the resources to treat appendicitis. The duty to treat comes with our core mission. When you look at what we now understand determines health, I’m not sure we can walk away from any of these important causal factors.
Two resources can be called into play. First, there’s a lot of energy in the workforce for issues such as climate change and equity. I think leaders who want to move in that direction will find a workforce that can contribute, and wants to.
Also, we now are hopefully readjusting power relationships with communities and patients. When we ask the patient, “What matters to you?” or work with the community in a co-production mode, things become possible that wouldn’t happen if we tried to do everything ourselves. There are partners out there who we need to engage. Smart clinics and systems are drawing on wholly new ways to build upon that energy.
What examples have you seen recently of the workforce or the community taking action?
I’ve been looking for health care organizations that have really stepped up. I just came back from a visit with UT Southwestern Parkland Memorial Hospital in Dallas, Texas. They’re doing extraordinary work to address social determinants of health. For example, they’re conducting outreach and improving ease of access for maternity care, especially people in populations that have fewer resources. It’s a matter of dialogue with and deference to the community.
We recently had a meeting of the IHI Leadership Alliance, and Denver Health reported on a large number of community efforts. For example, we had a panel with a Medicaid leader from the Denver governor’s office and the CEO of the hospital of Denver Health, which demonstrated their unique partnership. That’s a different kind of outreach, a synergistic relationship between the government agency and the health care delivery system, which can do more combined than each trying to act separately.
What suggestions do have for how to “do it all,” especially for those who are newer to this work? What helps you feel like you’re moving forward?
Do it together. That’s my biggest piece of advice. The more we form and join coalitions to solve common problems, the more fun it is, and also the more effective we can be.
In that meeting of the IHI Leadership Alliance, it was evident that organizations are struggling with problems such as the changing payment system, impending Medicaid cuts, and the complexities of artificial intelligence. But you could also feel in that room that when people shared their worries, asked questions, and described how they do their work, the energy grew. What started off as a hand-wringing problem suddenly became a project that people could work on together.
My advice is to find others working on the same problems, and join up. They say joy shared is doubled, and pain shared is halved. No single organization is going to solve greenhouse gas emissions or safe neighborhoods. But together we can do it, and especially if we join together with patients.
What lessons do you draw from your service as CMS Administrator and from other health care leaders about what it looks like to serve the public right now?
First, listen to the public. It’s not one-way communication, it’s two-way. It seems simple, but it’s not, when you’re being driven to do 30 hours of work in a 24-hour day. But it’s crucial. Slow down and listen.
People need to feel proud of their work. They need to feel efficacious, a sense of agency. It’s a leadership task to bring the message to everyone of welcoming ideas and efforts that come from each person. Under pressure, the tendency may be to move into a command-and-control mode — but that is exactly the wrong thing to do. That’s the time to open the doors and move into a mode where people can bring their gifts.
The budget and the bottom line are important, but they’re not the reason we go to work. Open opportunities for people to rediscover meaning in their work in health care. What we do really matters to people.
Leadership needs to be long-sighted. As far as I know, there’s no way to listen fast. You have to build that environment and tune in. It’s hard, hard work. I’m not pointing fingers or blaming.
Every experience I’ve had as a leader shows me that correctly invited, the workforce is ready, willing, and able to step up and do what is important. The leader’s job is to make it possible for them to contribute.
Is there anything else you’d like to share?
The IHI Forum has never been more needed. People are divided, feeling isolated, and lacking in agency. Coming together in Anaheim is going to be so important, especially at this time.
Editor’s note: This interview was edited for length and clarity.
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