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Britain’s National Health Service

―I fell in love with the NHS…to an American observer, the NHS is such a seductress.‖1

―Like any lover it took me a while to see the blemishes of my beloved, though I soon had help from
people quite willing to point out the warts…Along came Tony Blair, who promised a makeover so we
could all fall in love again.‖2

―The NHS is one of the astounding human endeavors of modern times…It‘s easier in the United States
because we do not promise health care as a human right.‖3

―The NHS had its flaws, but its cost, clinical excellence, and universality proved that a nationally
organized, publicly funded, total system of guaranteed health care was one of the best public policy
options for a developed nation.‖4

―We are two Americans, privileged to have an inside view of the NHS and its proposed reforms, and we
share an optimism about the NHS that is hard to find in the UK nowadays.‖ 5

―The NHS was a wise choice when it began: it remains so, as a truly national system of care, second to
none in its ambition and capacity to serve the health of the public.‖6

―The NHS is not just a national treasure; it is a global treasure. As unabashed fans, we urge a dialogue
on possible forms of stabilization to better provide the NHS with the time, space, and constancy of
purpose to realize its enormous promise.‖7
―I‘ve spent many weeks in the UK working with the NHS and have fallen in love with that country and
that great, though troubled, health care system.‖8

―My confidence rests in the simple fact that history so often predicts the future. And, your history in
this search for a nation‘s health thrills me. I am still in love. You are the nation of Nye Bevan; the
nation that promises equity, access, universality, and justice in care…the nation that is good enough ask
who gets left out and that is good enough to stop it.‖9

―I personally believe that the NHS has had superb leadership, at least as long as I have had a window on
the people there…I also have to reserve a few words of praise for Tony Blair, whose focus and clarity
with respect to what the NHS must accomplish are superb, and of immense value. He has been as good
in this role—setting and pursuing clear, bold aims—as many of the best corporate executives I have
seen.‖10

1
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
2
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
3
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 26, 2008, p. 213
4
―The NHS: Feeling Well and Thriving at 75‖ by Donald Berwick, BMJ July 4, 1998, p. 57
5
―The NHS through American Eyes‖ by Donald Berwick and Sheila Leatherman, BMJ December 23-30, 2000, p. 1545
6
―The NHS through American Eyes‖ by Donald Berwick and Sheila Leatherman, BMJ December 23-30, 2000, p. 1546
7
―Steadying the NHS‖ by Donald Berwick and Sheila Leatherman, BMJ July 29, 2006, p. 255
8
―An Interview with Donald Berwick,‖ Joint Commission Journal on Patient Quality and Safety December 2006, p. 665
9
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
10
―Would the NHS Benefit from a Single, Identifiable Leader? An E-mail Conversation‖ by Donald Berwick, Chris Ham,
and Richard Smith, BMJ December 20-27, 2003, p. 1422
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About the NHS‘ progress: ―It takes my breath away. I can‘t believe you are going so fast. There are
still plenty of challenges, but the progress is incredible.‖11

―Those are my observations from far away—from an American fan, distant and starry-eyed about the
glimpses I have had of your remarkable social project. The only sentiment that exceeds my admiration
for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun.
I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at
scale of a health system that is universal, accessible, excellent, and free at the point of care—a health
system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and
just.‖12

―England in the postwar era needed a way to make sure that their population had health care. In 1948,
they created the National Health Service. It was a major change. It was almost as big a change there
then as it would be here now, but they knew they had to do it. They could not get care to the population,
and they made a radical change. They had the guts politically, and the imagination in leaders to say,
‗We are going to design a system here. We are going to redesign a system. It is going to be national.‘
They stated the rules: nationally funded, tax-based, and free at the point of care, universal.‖13

―One day this June I was quietly minding my own business, when I got a phone call. A man said, ―This
is John Rankin, the British Consul General in Boston. May I ask you a question?‖ Here was his
question, ―If Queen Elizabeth were to offer you an honorary knighthood, would you accept it?‖ I said,
―Who is this? No, really… who is this? Is this Bob?‖ (He‘s my brother.) ―Is this Ken?‖ (He‘s my
weirdo best friend.) But it wasn‘t. It was Mr. John Rankin, the British Consul General.
That was a really tough question. It‘s not an everyday question. If the Queen of England offered
to make me a knight, would I accept? Hmmmm…. So, I thought about it, and then I said, ―Sure.‖ I
mean, why not? So, on December 5th—last week—at the British Embassy in Washington, the British
Ambassador Sir David Manning held an investiture ceremony certifying me as an Honorary Knight
Commander of the British Empire….
Actually, the knighthood means a lot to me personally. So many people—colleagues of the
IHI—have been working in the UK for now nearly a decade to modernize the NHS. The NHS is an
equitable and universal health care system, free at the point of care, and deeply committed to primary
care. I think the NHS is one of the great human health care endeavors on earth. It can be an example for
the whole world, an example, I must say, that the United States needs now more than most other
countries do. Helping the NHS realize its full potential is a massive task, lots of ups and downs, but it‘s
been a thrill to have the chance to work with so many committed, gifted, and open-minded NHS
leaders…The actual truth is that, when Mr. Rankin called me, I was so moved that I cried.‖14

The British and American Health Systems Compared


―At last a nation where health care is a right and carrying a semi-automatic machine gun is a privilege,
instead of the other way round.‖ 15

11
―A Case of US and Them—The HSJ Interview: Don Berwick‖ by Paul Dempsey, Health Service Journal April 10, 2003
12
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
13
―Wanted: A Health Care System that Has Your Back,‖ interview with Chris Salazar, DocTalk June/July 2008, p. 42
14
―Power‖ by Donald Berwick, speech to 17th annual National Forum on Quality Improvement in Health Care, December
2005
15
―The NHS: Feeling Well and Thriving at 75‖ by Donald Berwick, BMJ July 4, 1998, p. 57
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―It is a continuous source of frustration and some embarrassment to me that when I come to the UK, I
come to a country that says: ‗You will have health care.‘ And when I am in the US, I am in a country
that has not said that.‖16

―Cynics beware: I am romantic about the National Health Service; I love it. All I need to do to
rediscover the romance is to look at health care in my own country.‖17

―The NHS can do for people in the UK what the health care system in the US cannot.‖18

―You continue to know that you started off right in 1948, and with some important midcourse
corrections, you remain well on track. Maybe some day healthcare leaders in the United States will
catch up. I am sure you will help them if they ask.‖19

―In the US, we need to think about populations, about teamwork. It is an uphill battle because we are so
individualistic and have built such fragmented systems. When I go to the NHS, I see a kind of dream.‖20

―Both the UK and the US are struggling to improve their troubled healthcare systems. Which is more
likely to succeed? The two countries are strikingly similar in the problems they face, and equally
dissimilar in their plans of action. I am a fan of both but, when bets are place, my money will be on the
UK.‖21
―The cost of health care…has been maintained in the United Kingdom at a remarkably low
level…Though it has taken its share of criticism for its queues and rationing choices and for the
development of a privileged private care market, the NHS remains overall a system that compares
favorably to the American system in its commitments to equity of access and cost control.‖22

―As for my optimism about the NHS—sorry, Richard, I simply can‘t help it. I do meet many leaders, in
whom I have great faith, but I also meet many of the dedicated staff and patients, almost all of whom
continue to be incredibly loyal to a pathfinding system of care that the United Kingdom started a half
century ago. They are smart enough to know a good thing when they have it, even while they demand
that it get better. I would trade the UK‘s NHS, warts and all…for my nation‘s health care chaos any
day.‖23

―I lose friends on this, but I think a lot of the other systems around the world, in the UK, Canada,
Scandinavia, they‘re far better models than we have. They consolidate payment, they make public plans
for progress, they‘re able to make changes and they‘re able to move resources around more easily than
we can.‖24

―So, you could have had a simpler, less ambitious plan than the NHS. You could have had the
American plan. You could have been spending 17% of your GDP and made health care unaffordable as

16
―A Case of US and Them—The HSJ Interview: Don Berwick‖ by Paul Dempsey, Health Service Journal April 10, 2003
17
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 26, 2008, p. 213
18
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
19
―The NHS: Feeling Well and Thriving at 75‖ by Donald Berwick, BMJ July 4, 1998, p. 61
20
―A Case of US and Them—The HSJ Interview: Don Berwick‖ by Paul Dempsey, Health Service Journal April 10, 2003
21
―The Improvement Horse Race: Bet on the UK‖ by Donald Berwick, Quality and Safety in Health Care 2004; 13, p. 407.
22
―Quality Management in the NHS: The Doctor‘s Role—I‖ by Donald Berwick et al., BMJ January 25, 1992, p. 235
23
―Would the NHS Benefit from a Single, Identifiable Leader? An E-mail Conversation‖ by Donald Berwick, Chris Ham,
and Richard Smith, BMJ December 20-27, 2003, p. 1424
24
―Re-Engineering Health Care‖ by Pat Kiernan, CNNfn, June 6, 2002
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a human right instead of spending 9% and guaranteeing it as a human right. You could have kept your
system in fragments and encouraged supply-driven demand, instead of making tough choices and
planning your supply…You could have obscured—obliterated—accountability, or left it to the invisible
hand of the market, instead of holding your politicians ultimately accountable for getting the NHS
sorted. You could have let an unaccountable system play out in the darkness of private enterprise
instead of accepting that a politically accountable system must act in the harsh and, admittedly,
sometimes unfair, daylight of the press, public debate, and political campaigning. You could have a
monstrous insurance industry of claims, rules, and paper-pushing, instead of using your tax base to
provide a single route of finance.‖25

The NHS and Health Care Rationing


―You cap your health care budget, and you make the political and economic choices you need to make
to keep affordability within reach.‖26

―[NICE has] developed very good and very disciplined, scientifically grounded, policy-connected
models for the evaluation of medical treatments from which we ought to learn.‖27

―[NICE and similar] organizations are functioning very well and are well respected by clinicians, and
they are making their populations healthier and better off. Nor are their policies resulting in injury to
patients in any way…These organizations have created benchmarks of best practices that we could learn
from and adapt in this country.‖28

―NICE is extremely effective and a conscientious, valuable, and—importantly—knowledge-building


system.‖29

―The decision is not whether or not we will ration care—the decision is whether we will ration with our
eyes open.‖30

―Here, you choose the harder path. You plan the supply; you aim a bit low; you prefer slightly too little
of a technology or a service to too much; then you search for care bottlenecks and try to relieve them.‖31

―Denying Patients a New Treatment: A doctor working in an NHS trust thinks it is wrong that his
patients will be denied a new treatment for cancer. Should he contact the local media? Should the trust
punish him if he does? The ―balance‖ principle recognizes that a tension exists between what is good
for individuals and for populations. It was probably on these grounds that the committee decided that
the new drug would not be made available. The ―cooperation‖ principle suggests that the doctor should
cooperate with his colleagues and implies that contacting the media would not be helpful. But the
―openness‖ principle means that the committee should be open with patient, doctors, and the community
on why it is denying patients a drug. The doctor might decide that the hospital is not living by the

25
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
26
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 26, 2008, p. 213
27
―Rethinking Comparative Effectiveness Research,‖ An Interview with Dr. Donald Berwick, Biotechnology Healthcare
June 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/pdf/bth06_2p035.pdf
28
―Rethinking Comparative Effectiveness Research,‖ An Interview with Dr. Donald Berwick, Biotechnology Healthcare
June 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/pdf/bth06_2p035.pdf
29
―Rethinking Comparative Effectiveness Research,‖ An Interview with Dr. Donald Berwick, Biotechnology Healthcare
June 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/pdf/bth06_2p035.pdf
30
―Rethinking Comparative Effectiveness Research,‖ An Interview with Dr. Donald Berwick, Biotechnology Healthcare
June 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/pdf/bth06_2p035.pdf
31
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 26, 2008, p. 213
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openness principle and contact the media himself. If he does that, he should abide by the openness
principle and give the whole story, not just his version. If the trust has lived by the principles and the
doctor has not, then it might be legitimate to punish him. It clearly would not be legitimate if the doctor
lived by the principles but the trust did not.‖32

Forces of Health Care Change—Governments vs. Markets


―I do not think the sociology and structure of your systems are going to lead you to this kind of ‗do
better or I‘ll move‘ approach. You do not have the social dynamics or the supply structures to make that
work. Competition in short will hurt you, not help you. Planning will help you and I would stick with
the plan theory.‖33

―When you rely on incentives, market forces, competition, and upward reporting for excellence, you are
playing with fire. I believe it is better to rely instead, whenever possible, on spirit, purpose, learning,
cooperation, and joy in work.‖34

―Universal coverage does not automatically imply nationalized health care; indeed, most western nations
committed to universality have not created a behemoth like the NHS. Are there sufficient benefits in the
monolithic NHS to balance some of the costs? We think nationalized health care was a wise choice in
1948 and that it remains so now.‖35

―In the US, we can hold no one accountable for our problems. Here, in England, accountability for the
NHS is ultimately clear: the buck stops in the voting booth.‖36

―One of the reasons I love the NHS is because it is political, because the political voice properly owned
is the voice of the people. It is the consumer telling the system what it really needs to do.‖37

―Policy has focused on market forces and choice. Private companies with values far different from
those of the NHS are being invited into delivery and commissioning. As Americans, we know
dependence on market forces for constructive change is playing with fire.‖38

―Please don’t put your faith in market forces—It‘s a popular idea: that Adam Smith‘s invisible hand
would do a better job of designing care than leaders with plans can. I find little evidence that market
forces relying on consumers choosing among an array of products, with competitors fighting it out, leads
to the health care system you want and need. In the US, competition is a major reason for our
disruptive, supply driven, fragmented care system.‖39 [Emphasis original.]

―I cannot believe that the individual health care consumer can enforce through choice the proper
configurations of a system as massive and complex as health care. That is for leaders to do.‖40

32
―Refining and Implementing the Tavistock Principles for Everybody in Health Care‖ by Donald Berwick et al., BMJ
September 15, 2001, p. 618
33
―A Case of US and Them—The HSJ Interview: Don Berwick‖ by Paul Dempsey, Health Service Journal April 10, 2003
34
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
35
―The NHS through American Eyes‖ by Donald Berwick and Sheila Leatherman, BMJ December 23-30, 2000
36
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 26, 2008, p. 213
37
―A Case of US and Them—The HSJ Interview: Don Berwick‖ by Paul Dempsey, Health Service Journal April 10, 2003
38
―Steadying the NHS‖ by Donald Berwick and Sheila Leatherman, BMJ July 29, 2006, p. 254
39
―A Transatlantic Review of the NHS at 60‖ by Donald Berwick, BMJ July 2008
40
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
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―And so we happen upon the agenda of ‗reports to consumers‘ as a bright new hope for improving the
health care system. ‗Gather enough information on performance, use good enough tools, and report the
findings to the payers and the public,‘ goes the theory, and the market will do its work. Health care will
improve through the invisible hand of competition. I have some doubts.‖41

―Who will be the stewards of knowledge that can benefit the public‘s health and conserve strained
medical resources? Is the market steward enough? We think not.‖42

―The government must step forward to alleviate the scarcity [of a public good], usually through
regulation. The relative lack of primary care doctors in the United States is a good example of scarcity
due to breakdown of market forces. It has had to be addressed through regulation of physician training
and distribution.‖43

―We doubt this will be a period of deregulation. The ideological insulation created by the profession is
being peeled away. No longer is the physician, paternalistically committed to the patient, the driving
force in medical care. Health care is being rationalized through critical pathways and guidelines, and
integrated business structures can increasingly define the care they want to buy. In these circumstances,
the espoused central guarantee of quality of care, the ethical commitment of doctors, may weaken.
Hence as the market develops, we may find a greater need for regulation, not a lesser one.‖44

―It is inappropriate to ask people to make judgments about the effectiveness of alternative treatment
protocols. Those judgments are clearly the responsibility of professionals. Moreover, the determination
of appropriate costs for a service is not a proper task of a general population survey.‖45

―The other part of this problem is competition. The reliance on competition as the remedy for
improvement is failing in health care.‖46

―I am not a fan of competition and market forces as a route to improvements, but the [British]
government is insisting that they be tried…I wish the NHS would cease experimenting with additional
suppliers of care. They lead to rapidly rising costs without much value for patients.‖47

―No successful health care system in a western democracy is relying primarily on markets to produce
excellence. Some are trying to now, but frankly, the changes we are seeing are screwing things up.
They are making things worse. I think you will see smart countries say, ‗Oops, that was a bad idea,‘ and
go bad to what they had...We have human rights at stake here that are not a commodity…I think that
markets, bluntly used, are just not going to work.‖48

41
―The Total Customer Relationship in Health Care: Broadening the Bandwidth‖ by Donald Berwick, Journal on Quality
Improvement May 1997, p. 246
42
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 392
43
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 15
44
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 24
45
―Measuring Public Priorities for Insurable Health Care‖ by Floyd Fowler, Donald Berwick, et al., Medical Care June 1994,
p. 633
46
―QMHC Interview: Donald M. Berwick, MD,‖ Quality Management in Health Care Fall 1993, p. 76
47
―One Year to Save the NHS: What Would You Do?‖ interviews by Zosia Kmietowicz, BMJ January 27, 2007, p. 180
48
―Wanted: A Health Care System that Has Your Back,‖ interview with Chris Salazar, DocTalk June/July 2008, p. 43
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―The one part of the plan that I am absolutely against at the moment is the shifting of burden to
individual patients. I do not believe that making the individual American patient more ‗cost-sensitive‘
has any rationale in science, ethics, or evidence. It will fail, and it will fail miserably…The idea that [a
patient] will now be more sensitive because she pays an extra ten bucks out of pocket is, to me, nearly
stupid...
Internationally, when one looks at high performing systems around the world—and ours is
nowhere near the highest-performing one—it is almost a routine characteristic of the best systems that
they have first-dollar coverage, and there is no attempt to make patients pay more when they‘re sick,
which is a stupid thing to do.‖49

―Much of the health care industry is ripped apart by its payment structures—a monstrous collection of
contradictory signals that Paul Batalden has called ‗the payment system from hell.‘…VHA has what it
takes to make finance and systemness align: it has a single budget. The internal squabbles are
inevitable, but when the day is done, the money comes from all one pot, and robbing Peter to pay Paul
means Paul pays Peter too. I admit to my own devotion to a single-payer mechanism as the only
sensible approach to health care finance I can think of.‖50

Caps on Health Care Expenditures


―Align financing with purpose. We must test payment methods that include features that reorient us
toward systemness. And that, I suggest, means we must have absolute caps on healthcare expenditures
at some level in this country. So long as we continue to believe that the survival of our organizations
depends on finding additional revenues, we will not reorient ourselves to the internal restructuring that is
so crucial.‖51

―The hallmarks of proper financial management in a system pursuing the Triple Aim, we suspect, are
government policies, purchasing contracts, or market mechanisms that lead to a cap on total spending,
with strictly limited year-on-year growth targets.‖52

―The integrator would be responsible for deploying resources to the population, or for specifying to
others how resources should be deployed. Segmentation of the population, perhaps according to health
status, level of support from family or others, and socioeconomic status, will facilitate efficient and
equitable resource allocation.‖53

―Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless,
through rational collective action overriding some individual self-interest, we can reduce per capita
costs.‖54

―If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics
such as the following, purveyed by governments and payers, would accelerate interest in the Triple Aim

49
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-4
50
Foreword to Quality in the Veterans Health Administration: Lessons from People Who Changed the System (Jossey-Bass,
1996) by Donald Berwick, p. xi
51
―Seeking Systemness‖ by Donald Berwick, Healthcare Forum Journal March/April 1992, p. 28
52
―The Triple Aim: Care, Health, and Cost‖ by Donald Berwick, Thomas Nolan, and John Whittington, Health Affairs
May/June 2008, p. 765
53
―The Triple Aim: Care, Health, and Cost‖ by Donald Berwick, Thomas Nolan, and John Whittington, Health Affairs
May/June 2008, p. 764
54
―The Triple Aim: Care, Health, and Cost‖ by Donald Berwick, Thomas Nolan, and John Whittington, Health Affairs
May/June 2008, p. 761
Page 7 of 28
and progress toward it: 1) global budget caps on health care spending for designated populations…With
some risk, we note that the simplest way to establish many of these environmental conditions is a single-
payer system, hiring integrators with prospective, global budgets to take care of the health needs of a
defined population, without permission to exclude any member of the population.‖55

―The third principle is that we need to control costs and the way to do that is probably not through price
controls at the level of individual deeds or actions or resources, but rather thinking about population-
based payment, the idea of controlling costs per capita, for a population. It‘s sort of the same idea as
establishing a budget for the population that can then be rationally spent, optimizing the use of
resources. That will require an integrator, somebody that can be [a] steward of a population-based
budget.‖56

―It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage
points below currently projected increases and to grant the federal government the authority to reduce
updates in Medicare fees if the target is exceeded.‖57

―Factors to consider in a policy regime—costs. Supply drives demand, without apparent limit. About
8% of GDP is plenty for ‗best known‘ care.‖58

―A progressive policy regime will…control and rationalize financing—control supply.‖59

―Conditions for pursuing the triple aim: population budget; discipline of a cap on total budget.‖60

―What disruptions are you willing to embrace to achieve a transition to the triple aim? For
example…Controlling supply?...Capping total expenditure?‖61

―If I could wave a wand…


 Health care can and should find a route to both higher quality and lower cost—‗The budget is
now capped‘‖62

Health Care as a Universal Right


―Americans have no right to health care. In this respect, we stand almost alone among the industrialized
nations of the world…Committing ourselves to health insurance for our entire citizenry would be a start

55
―The Triple Aim: Care, Health, and Cost‖ by Donald Berwick, Thomas Nolan, and John Whittington, Health Affairs
May/June 2008, pp. 767-78
56
―Health Policy and Quality Principles,‖ Health Care Reinvented: Discussions with Don Berwick, Institute for Healthcare
Improvement, June 2008,
http://www.ihi.org/ihi/files/Promotions/ProfilesInImprovement/Berwick/Health_Policy_and_Quality_Principles.wma
57
―Achieving Health Care Reform—How Physicians Can Help‖ by Elliott Fisher, Donald Berwick, and Karen Davis, New
England Journal of Medicine June 11, 2009, p. 2497
58
―Take Two Policies and Call Me in the Morning‖ by Donald Berwick, speech to Healthcare Management Association and
Massachusetts Hospital Association, October 22, 2008
59
―Take Two Policies and Call Me in the Morning‖ by Donald Berwick, speech to Healthcare Management Association and
Massachusetts Hospital Association, October 22, 2008
60
―Improving Health Care Quality and Value‖ by Donald Berwick, speech to Families USA Health Action 2008 Conference,
January 25, 2008
61
―Improving Care for Populations‖ by Donald Berwick, John Kitzhaber Lecture on Health Care Policy, October 17, 2007
62
―Take Two Policies and Call Me in the Morning‖ by Donald Berwick, speech to Healthcare Management Association and
Massachusetts Hospital Association, October 22, 2008
Page 8 of 28
in addressing a much larger agenda of change, one that would identify health as a basic American right
at last—a right that, if met, would do much for the nation‘s security.‖63

―Any health care funding plan that is just, equitable, civilized, and humane must—must—redistribute
wealth from the richer among us to the poorer and less fortunate.‖64

―Caring for sick people is a social obligation that extends beyond the commercial realm. While
ownership of institutions or other organizations that deliver medical care may be appropriate, care itself
cannot be owned and must be viewed as a service that is rendered and remunerated under the
stewardship of those in the healthcare system, rather than merely sold to individuals or communities.‖65

―People living in poverty being denied access to modern health care is a form of violent, systematic
social deprivation that we, as a civilized global community, ought not to accept.‖66

―One e-mail correspondent asked why he should care about AIDS in Africa. ‗What does this have to do
with me?‘ he asked. ‗I deeply believe we are one world,‘ I responded, ‗and all humankind are
connected.‘ He replied instantly with a further question, which haunts me still. ‗Where did you get that
idea?‘ he asked.‖67

―I would say there are three or four initiatives or points of view that I hope all serious candidates take.
The first is the most important, which is to make health care in America a human right. It isn‘t; we
never declared it to be, and we certainly don‘t deliver on that. I have come to think until we say, ‗You
have a right to health care because you live in this country,‘ we probably won‘t get off the dime on some
of the other changes we need to make. So I think, to me, that would be, that‘s a litmus test.‖68

―Already, it is clear that the country lacks sufficient redistributive impulse to guarantee access to care
for the poor.‖69

―We are nearly alone among developed nations in our failure to commit to health care as a human right.
Our will does look a little shabby.‖70

―Those who know Berwick well will recognize that he uses this address to promote his deeply held
belief that health care is a right of every individual everywhere.‖71

63
―Who Pays?‖ by Donald Berwick and Howard Hiatt, New England Journal of Medicine August 24, 1989, p. 541
64
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008; Emphasis original
65
―A Shared Statement of Ethical Principles‖ by Donald Berwick et al. in Tavistock Group, Nursing Standard January 27,
1999, p. 35
66
―‗We all have AIDS:‘ Case for Reducing the Cost of HIV Drugs to Zero,‖ by Donald Berwick, BMJ January 26, 2002, p.
214
67
―‗We all have AIDS:‘ Case for Reducing the Cost of HIV Drugs to Zero,‖ by Donald Berwick, BMJ January 26, 2002, p.
216
68
―The Triple Aim: Global Health, Governance, and Dialoging with Skeptics,‖ Health Care Reinvented: Discussions with
Don Berwick, Institute for Healthcare Improvement, December 2006,
http://www.ihi.org/ihi/files/Promotions/ProfilesInImprovement/Berwick/The_Way_Things_Are.wma
69
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 25
70
―Eagles and Weasels,‖ speech to 10th annual National Forum on Quality Improvement in Health Care, December 1998, in
Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 174
71
Howard Hiatt, commentary on ―Every Single One,‖ speech to 13 th annual National Forum on Quality Improvement in
Health Care, December 2001, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass,
2004), p. 241
Page 9 of 28
―The shadow of September 11 reaches across time and space into this room at this hour…I do not for
one instant believe that injustice is an excuse for the violence or even for the hatred behind the violence.
But I do believe that injustice—exclusion—nourishes hatred. In its deepest core, the pursuit of
perfection is to forget no one. And to forget no one is to pursue justice. And to pursue justice is to
pursue love. And to pursue love is to pursue peace. And that is why we are here.‖72

―America spends 40 percent more dollars per capita on its health care than the next most expensive
nation, and more than twice as much as most. For this glut of funding, it gets nowhere near the top
health status in the world—we are maybe tenth or twentieth, depending on how you count it. We are the
only developed nation on Earth that does not guarantee health care to its people—the only one. At
$5,000 per person per year, we leave 45 million souls without health insurance. At under $3,000 per
person per year, the United Kingdom leaves no one out—no one—not even illegal immigrants.‖73

―We need a national government and a president that commits to universal health care as a
nonnegotiable feature of American society. A promise. Now, not later. It is an embarrassment to our
country that we have neither declared health care to be a human right nor delivered on that. To me, that
is not in the arena of quality improvement, but in the arena of social justice. So I put that challenge out
to the next U.S. Congress and the next president: Get us there. No excuses or wringing our hands about
costs. To me that is an escape from duty, so I say, ‗Universal care is a human right; promise it and take
us there.‘‖74

―If I could wave a wand…


 Health care is a common good – single payer, speaking and buying for the common good;
 Health care is a human right – universality is a non-negotiable starting place;
 Justice is a prerequisite to health – equity is a primary quality goal‖75

―This seventh suggestion leads me far afield for a minute, because I have come to think that we cannot
possible finally accept as a nation that health care is a human right for Americans unless and until we
acknowledge it as a human right globally, and shoulder the implications of doing that.‖76

―I believe now that the duty to help the world‘s poor nations is everyone‘s. I wish my own nation were
in the lead, and someday maybe it will be.‖77

―The United States cannot achieve the triple aim without health insurance for everyone.‖78

―To have an America that tolerates an American that cannot get health care is unconscionable; it is
immoral. Health insurance coverage must be a human right in this country; until we do that, the rest
would not matter that much.‖79

72
―Every Single One,‖ speech to 13th annual National Forum on Quality Improvement in Health Care, December 2001, in
Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 266-67
73
―Plenty,‖ speech to 14th annual National Forum on Quality Improvement in Health Care, December 2002, in Escape Fire:
Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 293-94
74
―An Interview with Donald Berwick,‖ Joint Commission Journal on Patient Quality and Safety December 2006, p. 665
75
―Take Two Policies and Call Me in the Morning‖ by Donald Berwick, speech to Healthcare Management Association and
Massachusetts Hospital Association, October 22, 2008
76
Donald Berwick, Speech to Jewish Alliance for Law and Social Action, May 22, 2006
77
―Lessons from Developing Nations on Improving Health Care‖ by Donald Berwick, BMJ May 8, 2004, p. 1128
78
―Achieving Health Care Reform—How Physicians Can Help‖ by Elliott Fisher, Donald Berwick, and Karen Davis, New
England Journal of Medicine June 11, 2009, p. 2496
Page 10 of 28
―Health care in America is a human right; it is universal. We need to decide that you cannot be an
American and not have it, that we will not allow that to happen.‖80

―Make Health Care in America a Human Right: The US spends almost twice as much in health care [sic]
as the next most costly nation, and our system is not even close to the best on earth. The assertion that
making health care a human right isn‘t feasible—isn‘t affordable—nearly makes me mad. It‘s just not
true; in fact, we are the only developed Western country that fails to view health care as a human right.
Leadership for change must come from the President and Congress. Without the promise of health care
for all, we aren‘t likely to muster the energy and political will we need to meet the needs of our entire
population. We‘ll limp along, instead, with defects in care and gaps in management that we have trained
ourselves to regard as inevitable.‖81

―As I said, the US spends almost twice as much in health care as the next most costly nation, and our
system is not even close to the best on earth. The assertion that making health care a human right isn't
feasible—isn't affordable—nearly drives me crazy. It's just not true. In fact, we are the only developed
Western country that fails to view health care as a human right. Leadership for change must come from
the President and Congress. Without the promise of health care for all, we aren't likely to muster the
energy and political will we need to meet the needs of our entire population. We'll limp along, instead,
with defects in care and gaps in management that we have trained ourselves to regard as inevitable. And,
here in Massachusetts, where we have made one legislative step toward that vision, let me tell you—we
had better mean it, because without committed, courageous political and social leadership, we can easily
lose track of that dramatic promise when the going gets rough. And, it will get rough. We have yet to be
tested.‖82

―By making health and health care a right…we gain people‘s attention: a debate begins on who might
have the duty to try to achieve health and health care for everybody…And it‘s important also to make
health a human right because the main health determinants are not health care but sanitation, nutrition,
housing, social justice, employment, and the like.‖83

―Any institution adopting the Tavistock principles would be accepting the imperfect obligation to bring
health and health care to everybody. That would create a tension in institutions that provide care only
for those who can afford it.‖84

HMOs and Managed Care


―The closest you can come to heresy in today‘s healthcare policy debate is to suggest that managed care
can help and that capitation is the best way to pay for it. No presidential candidate even whispers the
terms. What a shame.‖85

79
―Wanted: A Health Care System that Has Your Back,‖ interview with Chris Salazar, DocTalk June/July 2008, p. 39
80
―Wanted: A Health Care System that Has Your Back,‖ interview with Chris Salazar, DocTalk June/July 2008, p. 42
81
―How to Fix the System‖ by Donald Berwick, Time April 24, 2006
82
Donald Berwick, Speech to Jewish Alliance for Law and Social Action, May 22, 2006
83
―Refining and Implementing the Tavistock Principles for Everybody in Health Care‖ by Donald Berwick et al., BMJ
September 15, 2001, p. 617
84
―Refining and Implementing the Tavistock Principles for Everybody in Health Care‖ by Donald Berwick et al., BMJ
September 15, 2001, p. 617
85
―Dirty Words in Healthcare‖ by Joseph Dorsey and Donald Berwick, Boston Globe February 27, 2008, p. A9
Page 11 of 28
―I think we need to find a way in public policy to resurrect integrated care systems as a mainstay in
every form of American health economies that we can. Now I‘ll say it outright: What I‘m talking about
is HMOs.‖86

―It seems safe at this point to predict that the managed care organization—or its offspring, the integrated
delivery system…—will be the dominant model of health care delivery in the early years of the twenty-
first century.‖87

―We will create a high-performing health care system only if integrated delivery systems become the
mainstay of organizational design.‖88

On the policy priorities of the incoming Obama Administration: ―The most important policy changes
would be those that would allow us to pay for care in integrated forms. Right now we‘re paying for
fragments, and we need to find a way to rediscover the payment of care over time and space, integrating
care for populations. That‘s going to take some very clever policy leadership. We need to avoid the bad
forms of managed care, but we should return somehow to population-based treatment, care, and
payment. I think it can be done.‖89

―We need ‗managed care‘ as it was originally intended to be—the good kind, not the evil, mutant twin
that just tried to cut costs, restrict choice, and limit available care. Correctly conceived, "managed care"
addresses the real needs of patients over time and place, guiding them through the technological thicket
of modern medicine, and making sure that they get exactly what they want and need, exactly when and
how they want and need it. You heard me: We threw out HMO‘s—the good kind—as the route to better,
rational, integrated care. We were wrong.‖90

―In general, the literature in this area…consistently shows that costs are lower in managed care systems,
with quality equal to or better than that in fee-for-service care.‖91

―Who may (now or soon) have the triple aim on their screen?...Classical HMOs; single-payer European
systems.‖92

―If responsible cost consciousness is to be integrated into health care, managed care will have to do the
heavy lifting.…We must emphasize a culture of parsimony in day-to-day medical practice, and managed
care does this.…If an organization is to be held responsible for the quality and costs of the care it
delivers, then it must be able to exercise responsibility for the choice of physicians on whom it will rely

86
―True Health Care Reform,‖ Health Care Reinvented: Discussions with Don Berwick, Institute for Healthcare
Improvement, February 2008,
http://www.ihi.org/ihi/files/Promotions/ProfilesInImprovement/Berwick/True_Health_Care_Reform.wma
87
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 156
88
―Achieving Health Care Reform—How Physicians Can Help‖ by Elliott Fisher, Donald Berwick, and Karen Davis, New
England Journal of Medicine June 11, 2009, p. 2496
89
―Donald Berwick, MD: Connecting Finance and Quality,‖ interview in hfm, October 2008, p. 55
90
Donald Berwick, Speech to Jewish Alliance for Law and Social Action, May 22, 2006
91
―Quality of Health Care, Part 5: Payment by Capitation and the Quality of Care‖ by Donald Berwick, New England
Journal of Medicine October 17, 1996, p. 1228
92
―Improving Health Care Quality and Value‖ by Donald Berwick, speech to Families USA Health Action 2008 Conference,
January 25, 2008
Page 12 of 28
to deliver that care. Networks should not be opened. If they are, quality is just as likely to deteriorate as
to improve.‖93

―Excuse me if I draw from examples on the section of health care I know best: HMOs. I am confident
that HMOs do represent in these respects a vanguard: what happens in them today is likely to happen in
much more of health care tomorrow.‖94

―Some have questioned [the Administration‘s] choice to concentrate its review in the managed care
sector, believing, as I do, that the average managed care system probably has a higher level of quality
than does the remainder of health care. But I, for one…believe that, as HMOs were in the vanguard of
cost-containment in medicine, so they may be best suited to be in the vanguard of efforts to improve
quality.‖95

The Needs of Society versus The Needs of the Patient


―Limited resources require decisions about who will have access to care and the extent of their coverage.
The complexity and cost of healthcare delivery systems may set up a tension between what is good for
the society as a whole and what is best for an individual patient…Hence, those working in health care
delivery may be faced with situations in which it seems that the best course is to manipulate the flawed
system for the benefit of a specific patient or segment of the population, rather than to work to improve
the delivery of care for all. Such manipulation produces more flaws, and the downward spiral
continues.‖96

―Doctors and other clinicians should be advocates for patients or the populations they service, but should
refrain from manipulating the system to obtain benefits for them to the substantial disadvantage of
others.‖97

―Individual clinicians should not impede improvements in patient care because the financial implications
of the improvements may affect them adversely. Individual clinicians have an obligation to change
practices that may serve their interests but are costly to the system as a whole.‖98

―The physician‘s first responsibility is to the patient: to apply appropriate current medical knowledge to
treat and prevent illness…Physicians have a stake in society as well, however, and this implies prudent
use of health care dollars...Often new technologies pose a dilemma for physicians in society. Health
benefits come with a price tag. The benefit to the individual patient results in more costs in an already
overburdened health care budget. When better health costs extra, how can we make rational choices?‖99

93
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick (Jossey-
Bass, 1996), p. 378
94
―The Society for Medical Decision Making: The Right Place at the Right Time‖ by Donald Berwick, Medical Decision
Making April-June 1998, p. 78
95
Statement of Donald Berwick, House Energy and Commerce Health Subcommittee hearing on H.R. 1145 and H.R. 2116,
October 26, 1987, Serial No. 100-85, p. 253
96
―A Shared Statement of Ethical Principles‖ by Donald Berwick et al. in Tavistock Group, Nursing Standard January 27,
1999, p. 34
97
―A Shared Statement of Ethical Principles‖ by Donald Berwick et al. in Tavistock Group, Nursing Standard January 27,
1999, p. 35
98
―A Shared Statement of Ethical Principles‖ by Donald Berwick et al. in Tavistock Group, Nursing Standard January 27,
1999, p. 36
99
―Cost-Effectiveness Analysis in Pediatric Practice‖ by Robert Pantell and Donald Berwick, Pediatrics March 1990, p. 361
Page 13 of 28
―In the developed nations of the world, and increasingly in the developing ones, there is a growing
social insistence that health care costs are unsupportable at current levels. Influential people in many
countries today think that health care is robbing productive resources from other useful social and
commercial aims.‖100

―I have dealt with healthcare leaders who are ethically offended by the level of cost in this industry at
this moment and by its rate of rise, because it drains from society other opportunities equally as
important as those it fulfills.‖101

―[People] know full well that unneeded expenditures for health care are expenditures denied to other
useful social sectors—education, housing, and environment, for example—or at the very least, crassly,
profits denied to stockholders.‖102

―The social budget is limited—we have a limited resource pool. It makes terribly good sense to at least
know the price of an added benefit, and at some point we might say…that we wish we could afford it,
but we can‘t.‖103

―How to judge a health care policy…Will it nurture the young? Will it increase joy in work?...Will it
yield justice? Will it craft value over time and place…Will it control supply?...Will it limit health care
to a fair and wise share of the social commons?‖104

―Other critics, concerned about the increasing cost of health services, question the efficacy of extending
expensive health care services to individuals with distressing emotional symptoms and psychosocial
problems without physical pathology or serious psychiatric illness.‖105

―The tension between caring for individuals and populations. Sometimes no tension exists, but often—
particularly with resources—there is tension. Resources devoted to one patient will be denied to
another, or they will be denied to an enterprise that might promote public health…This principle calls on
institutions and individuals within them to think beyond individuals to populations.‖106

Supply of Technology and Rising Costs


―Whereas competition eliminates excess capacity in other markets, in health care, supply creates
demand. The excess capacity remains available, increasing fixed costs and encouraging greater use of
services. Many communities are characterized by a wasteful duplication of medical services. Costly
new technology is frequently adopted even when it cannot be shown to improve health outcomes
compared with older technology.‖107
100
―Crossing the Boundary: Changing Mental Models in the Service of Improvement‖ by Donald Berwick, International
Journal for Quality in Health Care October 1998, p. 437
101
―Seeking Systemness‖ by Donald Berwick, Healthcare Forum Journal March/April 1992, p. 24
102
Foreword to Organizational Transformation in Health Care: A Work in Progress (Jossey-Bass, 1994) by Donald Berwick,
p. xvii
103
―Rethinking Comparative Effectiveness Research,‖ An Interview with Dr. Donald Berwick, Biotechnology Healthcare
June 2009, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799075/pdf/bth06_2p035.pdf
104
―Take Two Policies and Call Me in the Morning‖ by Donald Berwick, speech to Healthcare Management Association and
Massachusetts Hospital Association, October 22, 2008
105
―Efficacy of a Brief Psychosocial Intervention for Symptoms of Stress and Distress Among Patients in Primary Care‖ by
Gerald Klerman, Donald Berwick, et al., Medical Care November 1987, pp. 1078-79.
106
―Refining and Implementing the Tavistock Principles for Everybody in Health Care‖ by Donald Berwick et al., BMJ
September 15, 2001, p. 617
107
―A Health Care Agenda for Business‖ by Leonard Barry, Ann Mirabito, and Donald Berwick, MIT Sloan Management
Review Summer 2004, p. 62
Page 14 of 28
―Aim 10: Reduce the total supply of high-technology medical and surgical care and consolidate high-
technology services into regional and community-wide centers…Most metropolitan areas in the United
States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal
intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology
imaging.
This is not an easy change for physicians to accept. Some physicians in high-technology
specialties will lose income and job opportunities as a result. For-profit, entrepreneurial providers of
medical imaging, renal dialysis, and outpatient surgery, for example, may find their business
opportunities constrained. It will be necessary for other physicians, who see the benefits of
consolidation of services, to insist on sensible reorganization nonetheless, even at the risk of internal
professional conflicts.‖108

―Imagine that I could wave a wand tomorrow and import the Swedish system to America. Well, I told
you that would cut our costs in half. That is the good news. The bad news is how many jobs would be
at stake. How many supply chain products would be at stake? The system we need would be a less
wealthy system for some people. Still, I am absolutely confident that we are a smart enough country to
be able to reinvest those energies and that money, eventually in the long run, into what we need, maybe
better roads, maybe better education.‖109

―We face an oversupply of both doctors and hospital beds in many health care markets.‖110

―Unfortunately—and likely unexpectedly—with federal funding in hand and continued importation of


expensive technology into a variety of specialties, the stage was set for unabated health care
inflation.‖111

―A health care system whose capital formation and growth are largely unregulated has produced an
excess supply that society cannot now afford.‖112

―Not many American cities need more than a single cardiac surgery unit, and most would have better
outcomes if units now operating separately were combined. In the service of improvement of the system
as a whole, consolidation of high technology units is desirable.…If, in a small city, two hospitals can
make a deal whereby one closes its duplicative neurosurgery service while the other closes its
duplicative cardiac surgery suite…we believe this should not only be permitted by the regulatory
framework but encouraged. American medicine is too large, but survival of the fittest is among the
silliest ways to shrink it.‖113

―Strong research suggests that the key cost driver is the supply of services. Unlike other industries, in
which costs tend to fall as supply increases, the dynamics of health care produce an upward cost spiral

108
―Buckling Down to Change,‖ speech to 5th annual National Forum on Quality Improvement in Health Care, December
1993, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 28-29
109
―Wanted: A Health Care System that Has Your Back,‖ interview with Chris Salazar, DocTalk June/July 2008, p. 38
110
Statement of Donald Berwick, House Energy and Commerce Health Subcommittee hearing on H.R. 1145 and H.R. 2116,
October 26, 1987, Serial No. 100-85, p. 257
111
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 37
112
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 338
113
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 363
Page 15 of 28
as more doctors, more hospitals, and more technologies become available. Supply one Magnetic
Resonance Imager, and community use will be x. Supply two, and the use will rise to 2x. Three
scanners make 3x, and so on, without much apparent limit. If we double the number of hospital beds per
capita, we harvest nearly double the hospital bed-days of care, other factors being equal.‖114

On problems in a typical American city‘s health care system: ―The city remains overbuilt in inpatient
services, especially in high technology, with too many angiography suites, three organ transplant units
when one would do, extra obstetrical beds and more being built.‖115

Ideal solutions to the city‘s problems: ―High technology being in oversupply, the trustees of the
community agree upon the appropriate level of supply to meet the community need, and downsize the
elements accordingly. To minimize the pain of downsizing, and to take the fullest possible advantage of
attrition and personal growth, arrangements are made for transfer of staff and professionals wherever
possible.‖116

―It‘s scary to see how easy it would be for Cedar Rapids today to become McAllen tomorrow—in a
heartbeat, actually. The physician group is building its own 180,000 square foot, $40 million medical
building—right between the two hospitals. Will they do a little ambulatory surgery there? And then
more? And then a whole lot more? The hospitals have different ownership structures. Will their
Boards go along with shared services? Or will they say, ‗Wait a minute, my father helped build this
place! We need one of our own.‘ When a new group comes into town and revs up its own CT scanner,
will the people of Cedar Rapids say, ‗Finally. We can get a scan anytime we want—that‘s quality,‘ and
go there, forcing the hospital and the doctors to do more scans themselves to keep up? Or, will the
medical leaders speak up, earn trust, and explain to the people of Cedar Rapids that more is not always
better in health care. Will they tell them that one CT scan of the abdomen is the same radiation
exposure as 400 chest X-rays, and that maybe less, not more, is better?‖117

―Avoid supply-driven care like the plague. Unfettered growth and pursuit of institutional self-interest
has been the engine of low value for the US health care system. It has made it unaffordable, and hasn‘t
helped patients at all.‖118

―There have been few whole-hearted efforts to change demand in safe and respectful ways. We haven‘t
developed sound methods to help our patients seek their own self-interest, but instead have allowed the
public to proceed on the dangerous and expensive assumption that more care is better care.‖119

―I want to see that in the city of San Diego or Seattle there are exactly as many MRI units as needed
when operating at full capacity. Not less and not more.‖120

114
Foreword to Organizational Transformation in Health Care: A Work in Progress (Jossey-Bass, 1994) by Donald Berwick,
p. xvi
115
―Run to Space,‖ speech to 7th annual National Forum on Quality Improvement in Health Care, December 1995, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 86
116
―Run to Space,‖ speech to 7th annual National Forum on Quality Improvement in Health Care, December 1995, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 89-90
117
―Squirrel‖ by Donald Berwick, speech to 21 st annual National Forum on Quality Improvement in Health Care, December
2009
118
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
119
―We Can Cut Costs and Improve Care at the Same Time‖ by Donald Berwick, Medical Economics August 12, 1996, pp.
185-86
120
―QMHC Interview: Donald M. Berwick, MD,‖ Quality Management in Health Care Fall 1993, p. 76
Page 16 of 28
―Although most discussion of rationing is stimulated by an interest in reducing costs, some observers
cite physician uncertainty and excessive health system supply as more appropriate targets than patient
access to beneficial services.‖121

―One of the drivers of low value in health care today is the continuous entrance of new technologies,
devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know
the difference.‖122

―Is this idea of rationing a stealth agenda item that could come in again under sort of a more popular
notion of more is not better? First, if you‘re on the supply side and you want to sell your machine, one
way to defend its sale is to put up the specter of rationing, when that‘s not what‘s happening. What‘s
happening is excess is being offered and should be not offered. So let‘s not be dupes here. Not
everything called rationing is rationing; there‘s such a thing as parsimony, as wisdom, as judgment, as
frugality, all of which are good things.‖123

Preventive Screening Measures


―Reduce demand…We have not developed sound ways to help our patients seek their own self-interest,
and we have allowed the public to proceed on the dangerous, toxic, and expensive assumption that more
is better. The evidence is often otherwise. I have had the pleasure for the past five years of serving as
vice chair of the U.S. Preventive Services Task Force [from 1990-96]…with the sole charge of
reviewing…almost two hundred clinical preventive practices.‖124

―Leaders at Group Health Cooperative of Puget Sound took managing demand seriously when they
noted the overuse of PSA (prostate-specific antigen) screening tests compared to recommendations of
the U.S. Preventive Services Task Force. With a carefully crafted combination of education, feedback,
and so-called academic detailing, they reduced the proportion of their own primary care providers
misusing the test to 3 percent.‖125

―The U.S. Preventive Services Task Force, of which I was vice chair, reviewed preventive and screening
technologies and found many that were growing rapidly in use without any scientific proof of their
merit—and often with some proof of their harm. These include techniques such as continuous
monitoring for preterm labor, prostatic ultrasound tests, and exercise stress testing in normal adults to
screen for coronary disease.‖126

―Take, for example, the recently published second edition of the Guide to Clinical Preventive Services
from the U.S. Preventive Services Task Force…A preventive services package for a group practice or a

121
―Measuring Public Priorities for Insurable Health Care‖ by Floyd Fowler, Donald Berwick, et al., Medical Care June
1994, p. 625
122
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-7
123
―Reform Means Wisdom, Not Rationing,‖ Health Care Reinvented: Discussions with Don Berwick, Institute for
Healthcare Improvement, July 2008,
http://www.ihi.org/ihi/files/Promotions/ProfilesInImprovement/Berwick/WisdomNotRationing.wma
124
―Run to Space,‖ speech to 7th annual National Forum on Quality Improvement in Health Care, December 1995, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 81
125
―Run to Space,‖ speech to 7th annual National Forum on Quality Improvement in Health Care, December 1995, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 81-82
126
―Sauerkraut, Sobriety, and the Spread of Change,‖ speech to 8 th annual National Forum on Quality Improvement in Health
Care, December 1996, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 102
Page 17 of 28
managed care system modeled on the recommendations of the USPSTF would be both more effective
and less expensive overall than the informal packages that abound today.‖127

―The second U.S. Preventive Services Task Force spent over five years reviewing well over 6,000
published research articles on the effectiveness of clinical preventive practices, such as screening tests,
counseling, and immunizations. The Task Force found good evidence behind many forms of
prevention, but it also found that many allegedly preventive services, such as screening urinalyses in
well populations, ultrasound tests in normal pregnancies, and screening electrocardiograms, had no
scientific support and in some cases lead to harm from meddlesome and unnecessary follow-up
procedures. And yet many of these wasteful practices remain in widespread use.‖128

―One over-demanded service is prevention: annual physicals, screening tests, and other measures that
supposedly help catch diseases early.‖129

―The problems of random abnormalities, the cost of false positives, the false reassurance of those with
intermediate screening results, and the dubious benefit of early detection of many conditions cast
significant doubt on the wisdom of including multiple blood chemistry tests in health fairs as a strategy
for disease detection.‖130

―When the burden of anxiety and subsequent medical care of the transient or asymptomatic ocular
hypertensiveness is weighed against the equivocal benefit to the infrequent glaucoma victim, the value
of unselected screening in health fairs seems worth questioning.‖131

―Is any screening procedure appropriate for a health fair even though that same procedure lacks merit in
a physician‘s office?...At the moment, we lack sufficient information to make such a judgment.‖132

―The medical director of an HMO knows that routine colonoscopy as part of well-adult physical
examinations can occasionally save the life of a colon cancer victim. She also knows that, to serve her
enrolled population, she would have to hire eight specialists to perform the needed colonoscopies. If she
did that, the resulting premium increase would be so great that the HMO would without doubt lose many
employee accounts and its economic future would be at risk. Are routine colonoscopies a social good?
What about routine pap smears? Routine smoking cessation counseling? Routine well-baby visits?‖133

127
―The Total Customer Relationship in Health Care: Broadening the Bandwidth‖ by Donald Berwick, Journal on Quality
Improvement May 1997, pp. 247-48
128
―As Good As It Should Get: Making Health Care Better in the New Millennium‖ by Donald Berwick, Institute for
Healthcare Improvement publication, 1998, p. 4
129
―We Can Cut Costs and Improve Care at the Same Time‖ by Donald Berwick, Medical Economics August 12, 1996, p.
186
130
―Screening in Health Fairs: A Critical Review of Benefits, Risks, and Costs‖ by Donald Berwick Journal of the American
Medical Association September 20, 1985, p. 1495
131
―Screening in Health Fairs: A Critical Review of Benefits, Risks, and Costs‖ by Donald Berwick Journal of the American
Medical Association September 20, 1985, p. 1496
132
―Screening in Health Fairs: A Critical Review of Benefits, Risks, and Costs‖ by Donald Berwick Journal of the American
Medical Association September 20, 1985, p. 1498
133
―Health Services Research and Quality of Care: Assignments for the 1990s‖ by Donald Berwick, Medical Care August
1989, pp. 769-770
Page 18 of 28
―Our study suggests that, even if customers had to pay out of pocket for their ultrasound tests, the excess
of willingness to pay over price—i.e., consumer‘s surplus—could provide some of the momentum
behind rapidly rising health costs.‖134

End of Life Care


―Only a minority of patients, families, and clinicians support prolonged use of life-sustaining procedures
and dramatic interventions in the terminal stages of illness, yet substantial use of these procedures
continues. In human terms, using unwanted procedures in terminal illness is a form of assault. In
economic terms, it is waste. Several techniques, including advance directives and involvement of
patients and families in decision making, have been shown to reduce inappropriate care at the end of
life, leading to both lower cost and more humane care from the patients‘ point of view.‖135

―A growing amount of experimental literature documents the payoff from helping patients consider
explicitly their own values and goals in the context of difficult treatment decisions. ‗Activated patients‘
encouraged to ask questions and to participate with their physicians in reaching the best plan of
diagnosis and therapy often achieve better outcomes at lower cost than patients in more passive modes.
This approach does not work for all patients, but it does for many…‖136

―Joanne Lynn [of the Center to Improve Care of the Dying] will tell you that end-of-life care in the
United States is far, far from what it could be. Hundreds of thousands of patients die in pain that they do
not need to suffer, and millions more have futile, unwanted, and costly treatments in stages of illness
where those treatments make no sense at all.‖137

―Most people who have serious pain do not need advanced methods; they just need the morphine and
counseling that have been available for centuries.‖138

―One health care system was having trouble encouraging doctors to make earlier referrals for patients
who could benefit from palliative and hospice care…The group decided to ask doctors a different
question. Instead of asking doctors, ‗Which of your patients are dying?‘ the team began to ask, ‗Would
you be surprised if this patient were to die this year?‘ Changing the question changed the results.
Doctors began to review patients in a different light…‖139

―Measurement forces upon us some uncomfortable awareness that in our multi-attribute world we face
choice:
An 84-year-old man lies in intensive care on a respirator, the victim of his fourth heart attack. ‗It
is time,‘ says the surgeon, ‗for a tracheostomy.‘ ‗What are his chances?‘ asks his wife. ‗One in
a hundred,‘ the surgeon replies. ‗Please go ahead then,‘ she decides, ‗he‘s all I‘ve got.‘ …
What do we want? Is it better not to measure, we are tempted to say.‖140

134
―What Do Patients Value? Willingness to Pay for Ultrasound in Normal Pregnancy‖ by Donald Berwick and Milton
Weinstein, Medical Care July 1985, pp. 889-90
135
―Buckling Down to Change,‖ speech to 5th annual National Forum on Quality Improvement in Health Care, December
1993, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 22
136
―Buckling Down to Change,‖ speech to 5th annual National Forum on Quality Improvement in Health Care, December
1993, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 23-24
137
―Eagles and Weasels,‖ speech to 10th annual National Forum on Quality Improvement in Health Care, December 1998, in
Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 172
138
―Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement‖ by Joanne Lynn, Donald
Berwick, et al., Annals of Internal Medicine July 16, 2002, p. E-118
139
Foreword to Improving Care for the End of Life (Oxford University Press, 2000) by Donald Berwick, p. viii
140
―E.A. Codman and the Rhetoric of Battle: A Commentary‖ by Donald Berwick, Milbank Quarterly 1989, p. 264
Page 19 of 28
“Unnecessary” Treatments and Services
―Here is the challenge: for useless care, develop and improve methods to help the public understand the
futility and, in view of the possibility of error, the complications and hazards that unneeded care can
introduce.‖141

―As many as 80 percent of hysterectomies are scientifically unnecessary. So are more than a quarter of
the drugs used for ear infections, most of the ultrasound tests done in normal pregnancies, and almost
half of the cesarean sections in the United States. Isn‘t this, with all due respect, some form of assault
and battery, however unintended?‖142

―Half or more of our patient encounters—maybe as many as 80 percent of them—are neither wanted by
patients nor deeply believed in by professionals.‖143

―Evidence of variable quality and widespread ‗inappropriateness‘ in the medical care of both countries
has cast doubt on the competence of the producers of medical care—doctors, hospitals, and others.‖144

―There is a widespread (but not well documented) opinion in America that many patients demand tests,
treatments, and procedures that their doctors know will not help them.‖145

―We know that our infatuation with technologies has led us to forms of invasive medicine that, upon
quiet reflection, our patients do not want to get and that our doctors, in their hearts, do not really want to
give.‖146

―Clinicians may have an inherent bias toward action, particularly in the case of therapeutic procedures
with relatively low risks…This bias may arise from a cultural pattern in American medicine, namely,
both patients and physicians often prefer to pursue a test or therapy that might have some benefit, even if
the indications are questionable…Unfortunately, the pursuit of tests or procedures of questionable value
may trigger a cascade of unanticipated negative consequences for patients, including anxiety,
complications, and direct and indirect costs.‖147

Standard Guidelines versus Individualized Care


―I would place a commitment to excellence—standardization to the best-known method—above
clinician autonomy as a rule for care.‖148

141
―Run to Space,‖ speech to 7th annual National Forum on Quality Improvement in Health Care, December 1995, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 82
142
―Why the Vasa Sank,‖ speech to 9th annual National Forum on Quality Improvement in Health Care, December 1997, in
Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 129-130
143
―Escape Fire,‖ speech to 11th annual National Forum on Quality Improvement in Health Care, December 1999, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 203
144
―Quality Management in the NHS: The Doctor‘s Role—I‖ by Donald Berwick et al., BMJ January 25, 1992, p. 236
145
―Quality Management in the NHS: The Doctor‘s Role—I‖ by Donald Berwick et al., BMJ January 25, 1992, p. 235
146
―Peer Review and Quality Management: Are They Compatible?‖ by Donald Berwick, Quality Review Bulletin July 1990,
p. 246
147
―Do Physicians Have a Bias Toward Action? A Classic Study Revisited‖ by John Ayanian and Donald Berwick, Medical
Decision Making July-September 1991, p. 157
148
―Escape Fire,‖ speech to 11th annual National Forum on Quality Improvement in Health Care, December 1999, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 205-06
Page 20 of 28
―Frederick Taylor knew absolutely that the human spirit requires an opportunity to think, learn, and
invent, and he really did want workers to do all those things—but he wanted them to do those things at
home in their leisure time, not at work. Design belonged in the design shop. To work was to follow
rules, not to make rules. Certainly not to break rules. Health care has taken a century to learn how
badly we need the best of Frederick Taylor. If we can‘t standardize appropriate parts of our processes to
absolute reliability, we cannot approach perfection. So we have become very interested in guidelines,
protocols, and standards so we can be reliable.‖149

―Our current health care system is essentially a cottage industry of non-integrated, dedicated artisans
who eschew standardization.‖150

On his greatest deficiencies: ―I don‘t feel like a leader, so it‘s very hard for me to project myself into
that situation. But inattention to detail is my biggest defect. I‘m always leaning forward into something
new. I can create a mess. Luckily, I have people who are willing to create the detail around the idea or,
if they‘re really smart, know which ideas to ignore.‖151

―Although [an individualized] approach [to patient care] may offer ideal care for some, it has limited
ability to promote continual learning and improvement, because each patient‘s circumstances are unique.
Yet with increasing clinical knowledge and expertise, patients‘ responses to treatment can often be
predicted. In such cases, the elements of care should be standardized, disseminated, monitored, and
constantly improved.‖152

―Why is the understanding and control of variation so central to improving quality? The answer, simply
put, is that variation is a thief. It robs from processes, products, and services the qualities that they are
intended to have. Variation is in processes what heat is in mechanical systems: evidence of wasted
energy.‖153

―Because decision making in health care has traditionally been decentralized and uncoordinated,
collective values may have suffered and may need correction through regulation. In this light, we
suggest the following as a reasonable list of the primary functions of regulation in health care, especially
as they affect the quality of medical care: 1) To constrain decentralized, individual decision making so
as to achieve the efficiencies of a more coordinated, cohesive approach…‖154

―Young doctors and nurses should emerge from training understanding the values of standardization and
the risks of too great an emphasis on individual autonomy.‖155

―Reaping the harvest of standardization is possible only when people can trust each other…‖156

149
―Plenty,‖ speech to 14th annual National Forum on Quality Improvement in Health Care, December 2002, in Escape Fire:
Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 283
150
―Cottage Industry to Post-Industrial Care‖ by Donald Berwick et al., New England Journal of Medicine February 4, 2010
151
―Seeding a Simple Dream: Do No Harm‖ by Avery Comarow, US News October 30, 2006,
http://www.usnews.com/usnews/news/articles/061022/30berwick_print.htm
152
―Cottage Industry to Post-Industrial Care‖ by Donald Berwick et al., New England Journal of Medicine February 4, 2010
153
―Controlling Variation in Health Care: A Consultation from Walter Shewhart‖ by Donald Berwick, Medical Care
December 1991, p. 1218
154
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 17
155
―The John Eisenberg Lecture: Health Services Research as a Citizen in Improvement‖ by Donald Berwick, Health
Services Research April 2005, p. 334
156
―Overview: Cooperating for Improvement‖ by Donald Berwick, Journal on Quality Improvement November 1995, p. 575
Page 21 of 28
―The belief in standardization is a challenge. We have romanticized the autonomy of every individual
clinician. We say: It‘s an art, not a science. We have, for some good reason, encouraged doctors and
nurses and others to think in terms of themselves as the heroes. Everyone has to do it their own way.
That‘s not a formula for reliability. To be reliable, you have to, in a sense, get the human mind out of
the system. Some things should be done the same way every time. That‘s why pilots use checklists.
That‘s why we automate safety systems. In health care, we have to change our mentality to one of wise
standardization rather than chaotic autonomy.‖157

―We have to encourage nurses and doctors to embrace standardization by letting go of the idea that
everyone has to do everything their own way all the time.‖158

Cost Effectiveness Research


―Decision analysis and cost-effectiveness analysis have reached new levels of scientific maturity, and
their products now appear frequently in clinical publications. For reasons unclear to us, these analytic
methods are relatively underrepresented in the pediatric literature…‖159

―In a full cost-effectiveness analysis, the decision maker compares options to each other through ratios
such as costs per case treated, cost per case prevented, or cost per additional year of life added. When
resources are limited, it makes logical sense to invest first in options that buy desired outcomes at the
lowest price available; that strategy assures that the greatest achievable good comes from the available
resources.‖160

―Neonatal intensive care, like every other part of American medicine, has been swept into the rising tide
of concern for health care costs. The need to balance effectiveness against cost has shifted the burden of
proof onto the shoulders of those who use or propose to use expensive technologies.‖161

―An important recent study estimated that adding a year of life, adjusting for the quality of life, cost
about $22,000 for newborns weighing 500 to 999 grams and $3,200 for those weighing 1,000 to 1,499
grams. By comparison, quality adjusted life years added by screening procedures for coronary artery
disease commonly cost about $10,000…‖162

―Patients and doctors often seem willing to pay money and to take risks to produce information with
very little potential impact on therapy…It remains to be seen whether a cost-containing medical
economy will continue to be willing to pay for such valued attributes of test information, or whether we
will be required increasingly to demonstrate that a proposed test could really affect therapy more than
once in a blue moon.‖163

157
―Back to Basics Measures Save Lives,‖ interview by John DiConsiglio, Hospitals and Health Networks November 2006,
pp. 63-64
158
―Back to Basics Measures Save Lives,‖ interview by John DiConsiglio, Hospitals and Health Networks November 2006,
p. 64
159
―Cost-Effectiveness Analysis in Pediatric Practice‖ by Robert Pantell and Donald Berwick, Pediatrics March 1990, p. 361
160
―Cost-Effectiveness Analysis in Pediatric Practice‖ by Robert Pantell and Donald Berwick, Pediatrics March 1990, p. 361
161
―Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit‖ by Donald Berwick,
Respiratory Care June 1986, p. 524
162
―Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit‖ by Donald Berwick,
Respiratory Care June 1986, p. 524
163
―Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit‖ by Donald Berwick,
Respiratory Care June 1986, p. 527
Page 22 of 28
―The seventh and last level of evaluation is often called the societal level. Here we deal with both
medical effectiveness and with cost. Usually, studies at this level use the techniques of cost-
effectiveness analysis (CEA). Simply stated, CEA is a search for a price—the price at which a desired
good (like an extra year of life) is available for purchase.‖164

―While we continue to believe in the usefulness of formal, quantitative analyses in medical decision
making, we suggest that decision analyses or cost-effectiveness analyses that neglect non-medical and
non-decisional uses of diagnostic information may fail to represent patients‘ values accurately.‖165

―Major comparisons of program performance are based mainly on the dollar cost per year of life saved.
This measure describes the expected cost of adding one additional person-year of life to the population
as a whole, and provides a useful common denominator for comparison. The screening programs are
assumed to use an ‗optimal cutoff level‘ in selecting those subjects who should receive the intervention.
This ‗optimal cutoff‘ results in the lowest achievable cost per year of life saved.‖166

―The approach used here, detailed cost-effectiveness analysis, can help to organize a large body of
technical information, putting that information to work for those policy decisions that we are ready to
make.‖167

―At the Harvard School of Public Health, Hiatt created a new ‗Center for the Evaluation of Clinical
Practices‘ and attracted the interests and attention of some young and some not-so-young
mavericks…[including] me…From that era at Harvard and elsewhere came the foundations of a new
wave of clinical epidemiology, cost-effectiveness analysis, decision analysis, and health services
research that matured fully in the few decades that followed.‖168

―For comparison, a recent cost-effectiveness analysis of cholesterol screening in children estimated that
such a screening program could prolong life at a cost of only $10,000 per year of life added…Other
studies have evaluated preventive practices that could in effect purchase extra years of life for as little as
$1,000 per year. Therefore, in communities with a very low prevalence of lead poisoning, lead-
screening programs seem less advantageous than other options available for investment in the
prevention of disease, such as some types of programs for cancer screening and prevention of heart
disease…
When comparing programs, one must always look beyond the simple cost-effectiveness ratio to
judge social impact. Since lead screening especially benefits disadvantaged children, a caring society
may attach special value to it and may therefore adopt lead screening even over programs that are more
cost effective but benefit a less needy population.‖169

Accountability through the Political System

164
―Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit‖ by Donald Berwick,
Respiratory Care June 1986, p. 528
165
―What Do Patients Value? Willingness to Pay for Ultrasound in Normal Pregnancy‖ by Donald Berwick and Milton
Weinstein, Medical Care July 1985, p. 891
166
―Cholesterol, Children, and Heart Disease: An Analysis of Alternatives‖ by Donald Berwick, Shan Cretin, and Emmett
Keeler, Pediatrics November 1981, p. 724
167
―Cholesterol, Children, and Heart Disease: An Analysis of Alternatives‖ by Donald Berwick, Shan Cretin, and Emmett
Keeler, Pediatrics November 1981, p. 729
168
Foreword to Focused Operations Management for Health Services Organizations by Donald Berwick (Jossey-Bass,
2006), pp. xvi-xvii
169
―Cost Effectiveness of Lead Screening‖ by Donald Berwick and Anthony Komaroff, New England Journal of Medicine
June 10, 1982, p. 1397
Page 23 of 28
On factors that make change in health care ―problematic:‖ ―In American Culture, Election. Leaders who
hold their positions only so long as they remain fully accountable to the society that chooses them
sometimes find in that a source of purpose. Executives in this country are not elected. To a growing
degree, in fact, they aren‘t even accountable any longer to their customers or their workforce. And
that‘s a troubling source of lack of purpose.‖170

―Political leaders in the Labour Government have become more enamored of the use of market forces
and choice as an engine for change, rather than planned, centrally coordinated technical support.‖ 171

―Why would I bet on success in the UK over the US? The biggest reason is simple: the UK has people
in charge of its health care—people with the clear authority to take on the challenge of changing the
system as a whole. The US does not. When it comes to health care as a nation, the US is leaderless. An
immense resource for progress in improving the NHS—the key resource, in my view—has been the
consistent focus of government, emanating from the Prime Minister personally, on raising the bar for
NHS performance. The modernization process sought to establish accountabilities, structures,
resources, and schedules in the NHS that no one at all is in a position to establish in the pluralistic,
chaotic, leaderless US healthcare system.‖172

―As you know, we in the US are right now in the midst of a great national struggle to hoist our health
care system to a totally new platform. This includes the improvements in the dimensions of care
designated by our Institute of Medicine—safety, effectiveness, patient-centeredness, timelines,
efficiency, and equity—but, more urgently, the changes we are trying to make would close the immoral
gap in my country in insurance, which leaves almost 50 million Americans without health care coverage
and an equal number with insufficient coverage—and to find some way to control the nearly insane rate
of rise of our health care costs—now double yours in per capita terms. This passage is turning out to be
very difficult in the US, not because we do not know what a better system would look like, but because
we don‘t yet quite have the political will to change in the face of the vested interests in the enormously
expensive status quo. What is waste for our society as a whole is income and profit for vocal subgroups.
And our populace continues to believe that more care is better care, despite the evidence to the
contrary.‖173

―Congress hasn‘t led us to a new care system, and I don‘t think it will. Congress won‘t give America
even a vague prescription, much less a detailed set of rules, for that. How could they? How could
Congress possibly know enough to specify, for every community, the exact design for that: care that is
safe, effective, patient-centered, timely, efficient, and equitable?‖174

―I don‘t blame Washington for leaving health care redesign to us. I don‘t think it‘s Washington‘s job. I
think it‘s ours. The care we need—the system we want—will not come from what they do; it will come
from what we do.‖175

170
―Seeking Systemness‖ by Donald Berwick, Healthcare Forum Journal March/April 1992, p. 25
171
―What Can the UK Learn from the USA about Improving the Quality and Safety of Healthcare?‖ by Charles Tomson and
Donald Berwick¸ Clinical Medicine November/December 2006, p. 552
172
―The Improvement Horse Race: Bet on the UK‖ by Donald Berwick, Quality and Safety in Health Care 2004; 13, p. 408
173
―System Sciences and Better Care‖ by Donald Berwick, speech in Gothenberg, Sweden, November 17, 2009
174
―Squirrel‖ by Donald Berwick, speech to 21st annual National Forum on Quality Improvement in Health Care, December
2009
175
―Squirrel‖ by Donald Berwick, speech to 21 st annual National Forum on Quality Improvement in Health Care, December
2009
Page 24 of 28
―First, your nation set aims. They came, frankly, (for better or worse—I think for better) from the top—
from Number 10 Downing Street. They came from political imperatives that a master politician had no
trouble deciphering. Whatever you think of Tony Blair, no one can gainsay his read—his accurate
read—that, in the view of his bosses, the people of the UK, something was awry with their most valued
public institution. His job was to translate their concern into remedy in two steps: give it a name, and
then fix it. Naming was crucial. You cannot improve what you do not name. Blair‘s charter to all
relevant stakeholders, governmental, NHS executive, the Modernisation Board, and more, came in the
form of specific goals for improvement: access, personalization of care, clinical reliability, and
expanded manpower. National Service Frameworks developed, specifying details of the levels and
forms of excellence sought. And the dreaded ‗targets‘ were born – government‘s blunt tool for
describing what it wanted…
In the year 2000, about the time the new Modernisation Plan appeared, I remember meeting in London
with a group of distinguished surgeons. One asked, in effect and irately, ‗Who does he (Tony Blair)
think he is, telling us all to work on access to care as a priority? We have other priorities.‘ I thought to
answer, but I did not, ‗He thinks he is the elected representative of the collective will of 60 million of
your countrymen, who, by the way, pay you. What part of the phrase, ―parliamentary democracy,‖ do
you not understand?‘‖176

―Here, in England, accountability for the NHS is ultimately clear. Ultimately, the buck stops in the
voting booth. You place the politicians between the public served and the people serving them. That is
why Tony Blair commissioned new investment and modernization in the NHS when he took office, it is
why government has repeatedly modified policies in a search for traction, and it is why your new
government chartered the report by Lord Darzi. Government action on the NHS is not mere restlessness
or recreation; it is accountability at work through the maddening, majestic machinery of politics.‖ 177

―Because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn‘t just
technical – it‘s political. It is an arena where the tectonic plates of a society meet: technology,
professionalism, macroeconomics, social diversity, and political ambition. It is a stage on which the
polarizing debates of modern social theory play out: between market theorists and social planning,
between enlightenment science and post-modern skeptics of science, between utilitarianism and
individualism, between the premise that we are all responsible for each other and the premise that we are
each responsible for ourselves, between those for whom government is a source of hope and those for
whom government is hopeless. But, even in these debates, you have agreed hold in trust a commons.
You are unified, movingly and most nobly, by your nation‘s promise to make good on an idea: the idea
that health care is a human right. The NHS is a bridge—a towering bridge—between the rhetoric of
justice and the fact of justice.‖178

Managerial Methods
―One last promising research issue at the organization level involves the question of joy in work. We
have no hope of fundamental solution to the American health care dilemma unless it is fun to work in
health care. By ―fun‖ I mean satisfying, enriching, fulfilling, and inspiriting. ―Joy in work‖ is in short
supply in American health care now, and we know it. The costs of a dispirited workforce are very high.
This ought to become a top-priority research issue. We need to understand far more than we do about
the psychodynamics of work. How else can we begin to make some scientifically grounded changes

176
―Celebrating Quality 1998-2008‖ by Donald Berwick, speech at London Science Museum, September 30, 2008
177
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
178
―A Transatlantic View of the NHS at 60‖ by Donald Berwick, speech at NHS Live, July 1, 2008
Page 25 of 28
that will help our workforce become what they wanted to be when they entered health care: proud,
joyful, interdependent actors getting a good job done well?‖179

―Quality Improvement Methods are Fun to Use: Teams that engage in quality improvement efforts, we
wrote, are embarking ‗on a voyage of discovery, and the pleasures of new understanding and continuous
improvement are theirs to enjoy.‘ This is as true today as it was thirteen years ago—perhaps even truer,
as people search for sources of hope and joy in work within health care. Improvement projects have
given hundreds of organizations, and thousands of people who work in health care, new hope for joy in
work…One of the most important ideas in the movement for quality is joy in work.‖180

―I think we need a national agenda to restore joy in work, and I don‘t see that as the direction we‘re
moving in right now. Ninety-nine out of a hundred people would think that‘s a naïve comment.‖181

―At the individual level, I don‘t trust [pay-for-performance] incentives at all. I do not think it‘s true that
the way to get better doctoring and better nursing is to put money on the table in front of doctors and
nurses…I think people respond to joy and work and love and achievement and learning and appreciation
and gratitude—and a sense of a job well done.‖182

―To be honest, much of this sounds like nonsense, doesn‘t it?‖183

―Linking pay to merit is an absolutely obvious instrument of proper management. Because it is


absolutely obvious, it is difficult in the extreme to see that it is very nearly absolutely wrong. ‗Pay for
performance‘ is as toxic to true organizational reform as any of the perfidious tactics of outmoded
control-based management that enlightened organizations have long since, and much more readily,
abandoned.‖184

Waste and Its Sources


―There is enormous excess in American health care. Health care starts from a platform of such waste
that it is almost literally incredible. Reducing this waste is difficult, in part because the vested interests
in that waste are extremely strong. The U.S. health care system includes organizations that are totally
unnecessary, especially some of those involved in payment. A thoroughly redesigned system would not
need these organizations, and yet their power preserves the waste.‖185
―I stand by my estimate that if we were to use relief of suffering as the primary index of value, 30 to 40
percent of American health expenses are pure waste—$300 billion to $400 billion at a minimum.‖186

―[Berwick‘s wife] Ann‘s care has been billed at perhaps $150,000 so far, at a minimum, and the bare
fact is that, of all that enormous investment, a remarkably small percentage—half at best, probably much
less—stood any chance at all of helping her. The rest has been pure waste.‖187

179
―The John Eisenberg Lecture: Health Services Research as a Citizen in Improvement‖ by Donald Berwick, Health
Services Research April 2005, p. 332
180
Curing Health Care by Donald Berwick, Blanton Godfrey, and Jane Roessner (Jossey-Bass, 2002), p. xxii
181
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-5
182
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-5
183
―Seeking Systemness‖ by Donald Berwick, Healthcare Forum Journal March/April 1992, p. 28
184
―The Toxicity of Pay for Performance‖ by Donald Berwick, Quality Management in Health Care Fall 1995, p. 28
185
Curing Health Care by Donald Berwick, Blanton Godfrey, and Jane Roessner (Jossey-Bass, 2002), p. xxiii
186
―Dirty Words and Magic Spells,‖ speech to 12 th annual National Forum on Quality Improvement in Health Care,
December 2000, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 233
Page 26 of 28
―Like it or not, health care is now a big chapter in the story of global macroeconomics. This isn‘t just
about whether we can afford universal coverage; it‘s about the whole country‘s fate. In 2011, our
national debt is going to surpass our entire gross domestic product: over $15 trillion. We‘re handing
those cards to my grandson. If confidence falls in the economic health of America, then the vast
numbers of American dollars in foreign hands fall in value. Other nations will seek other reserve
currencies. Our standard of living will fall, and so will our capacity to invest – publicly or privately.
And a key culprit, the biggest engine of decline, is the rising cost of health care. Like it or not.‖188

―My personal belief is that waste in health care systems in most developed countries at least surely
exceeds 50% of their total resource use. For the USA, with health care costs 40% higher than the next
highest nation, the figure is probably even greater.‖189

―I have said before, and I‘ll stand behind it, that the waste level in American medicine approaches 50
percent.‖190

―The latest surge in the malpractice premium crisis has deflected interest of lawmakers from error
prevention to an effort to put caps on malpractice settlements.‖191

―Although its somewhat neutral moniker would suggest otherwise, tort reform is chiefly an effort by
chronic defendants to obtain changes in law that will make it more difficult for plaintiffs to bring claims.
Tort reform intends to make claims less valuable for the plaintiff‘s attorney, the critical economic player
in medical malpractice litigation.‖192

―Tort reform does not necessarily promote better quality care; just the opposite may be true. Insofar as
these reforms reduced claims rates, they also reduced the deterrent effect associated with malpractice
litigation, in theory thereby increasing the number of medical injuries due to substandard care.‖ 193

―Most physicians do not understand malpractice litigation as part of the overall system of quality
improvement or as a remedy for social concerns about prevalence of medical injuries. Instead, they
continue to approach medical injury, and the much less frequent malpractice claim, as a random event, a
‗bolt of lightning.‘‖194

Government’s Role in Educating Consumers and Physicians

187
―Escape Fire,‖ speech to 11th annual National Forum on Quality Improvement in Health Care, December 1999, in Escape
Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 195
188
―Squirrel‖ by Donald Berwick, speech to 21 st annual National Forum on Quality Improvement in Health Care, December
2009
189
―Crossing the Boundary: Changing Mental Models in the Service of Improvement‖ by Donald Berwick, International
Journal for Quality in Health Care October 1998, p. 436
190
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-8
191
―Five Years After To Err Is Human: What Have We Learned?‖ by Lucian Leape and Donald Berwick, JAMA May 18,
2005, p. 2384
192
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 187
193
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 188
194
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 190
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―One of the most successful innovation-spread programs ever seen in this country [is] the Agricultural
Extension Service…American health care could benefit greatly from the establishment by the federal
government of a health care extension service modeled on the AES.‖195

―We favor the development, as a matter of public policy, of governmentally supported mechanisms to
collect and disseminate good ideas for change. President Clinton‘s ill-fated Health Security Act
contemplated such a vehicle in the form of ‗regional professional foundations.‘…Without governmental
action, we fear that such collaborations will not build or spread.‖196

―I believe that we should create and offer to any clinical office practice and small hospital in the country
a thoroughly re-designed, computer-based medical record technology for free. It is a mistake for us to
rely on the market for this. The market will only add variation, which is the last thing we need more
of.‖197

About the utopian health system established by a fictional country called ―PeoplePower:‖ ―In an effort
to hold the media accountable, a national program to inform and educate the media has established
guidelines for fairness and accuracy. National and local agencies assist and support the media in
recruiting and retaining experts skilled in interpreting research studies who teach reporters to evaluate
new findings critically. PeoplePower has also established incentives, including national and local
‗health care media award programs,‘ that encourage the media to join in efforts to improve the health of
the nation.‖198

―I am biased toward thinking of knowledge about improvement of care as a public good. I like the idea
of an agricultural extensions service analogue in the government that will help especially small and rural
hospitals and physician practices improve their work—as a national investment, not as a consulting
gig.‖199

―Government is an extraordinarily important player in the American health care scene, and it has
inescapable duties with respect to improvement of care, or we‘re not going to get improved care. Here‘s
some of what really counts: Government remains a major purchaser. It‘s much bigger than GE. So as
CMS goes and as Medicaid goes, so goes the system. CMS needs to continue to develop to be the best
and possible [sic] purchaser of care, on behalf of its beneficiaries. To do that through giving choice to
individuals, as I said earlier, is a very weak lead. To do it as an aggregate purchaser, demanding
performance, is a very strong lead.‖200

195
―Sauerkraut, Sobriety, and the Spread of Change,‖ speech to 8th annual National Forum on Quality Improvement in Health
Care, December 1996, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), p. 121
196
New Rules: Regulation, Markets, and the Quality of American Health Care by Troy Brennan and Donald Berwick
(Jossey-Bass, 1996), p. 393
197
―The John Eisenberg Lecture: Health Services Research as a Citizen in Improvement‖ by Donald Berwick, Health
Services Research April 2005, pp. 329-30.
198
―Healthcare in a Land Called PeoplePower: Nothing About Me Without Me‖ by Tom Delbanco, Donald Berwick, et al.,
Health Expectations September 2001, p. 149
199
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-7
200
―‗A Deficiency of Will and Ambition:‘ A Conversation with Donald Berwick‖ by Robert Galvin, Health Affairs Web
Exclusive January 12, 2005, p. W5-6
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