This is a collection of 11 speeches that Dr Donald Berwick, cofounder and president of the US Institute for Healthcare Improvement, delivered to the annual meetings of the National Forum on Quality Improvement in Health Care between 1992 and 2002.
Figure 1.
Donald M Berwick
Jossey Bass, $30, pp 352 ISBN 0 7879 7217 7
Also available as an e-book www.josseybass.com
Rating: ★★★
Berwick is modest about his institute and his work, asking in the preface to this anthology, “With so much different, why do these speeches strike me as so repetitive? Metaphor after metaphor, list after list, story after story—but always the same. Year after year I can find only three messages at the core: focus on the suffering, build and use knowledge, and cooperate.”
But he's also a realist. For more than a decade Berwick has been pushing for a US healthcare system that puts patients' needs above those of doctors and insurers; that eliminates or substantially reduces ineffectiveness, inefficiency, waste, disorganisation, and error; that embraces cohesiveness and purpose; and that becomes less inbred—learning to learn from such outside organisations as the airline industry, General Motors, and the US Forest Service. However, he admits that little of this has come to pass.
It's from the Forest Service that the book's cryptic title comes. Escape Fire refers to a 1949 tragedy in Montana in which 13 young firefighters died in a wildfire that was sweeping up a hillside. Their leader found what seemed at first to be an unorthodox solution. As Berwick described it in the 1999 speech: “He did a strange and marvelous thing... [He] set fire to the grass directly in front of him. The new fire spread quickly uphill ahead of him and he stepped into the middle of the newly burnt area. He called to his crew to join him as he lay down in the middle of the burnt ground.” But the firefighters ignored him or didn't hear him, and “ran right past the answer” and perished. Berwick's lesson for health care: don't be bound by traditional or “accepted” modes of thinking.
As well as using metaphors—and the book is full of them—to explain the ills of US health care, Berwick recounts a harrowing personal experience. In 1999 (the year of the escape fire speech) his wife, Ann, developed a rare and serious autoimmune spinal cord problem. She lost the ability to walk and was hospitalised for more than 60 days. Berwick told his audience that not a day passed without a medication error, and in only two instances did someone seek feedback on the care his wife received. The ordeal was marked by waste, unnecessary procedures, delays, and lack of communication.
Berwick ruefully concludes that, far from escaping the fire, he felt it licking at his heels during his wife's experience. And until the healthcare system is radically overhauled, he implies, it will continue to burn.