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Berwick 'On the Road Again' with CMS Appointment Apparently in the Offing

By John Reichard, CQ HealthBeat Editor

March 28, 2010 -- With the expected nomination this week of Donald M. Berwick to become the new administrator of the Centers for Medicare and Medicaid Services (CMS), the Harvard professor and quality improvement expert begins the new phase of a career marked by ever more ambitious goals and a level of enthusiasm to match.

"Just can't wait to get on the road again" is the fitting closing quotation of the 2009 annual report of Berwick's Institute for Healthcare Quality and Improvement, a reference to a line from a song written by country singer Willie Nelson.

Well, now Berwick's taking his quality improvement ideas south from the ivory tower of Cambridge, Massachusetts to the gritty world of Medicare, Medicaid and the 531 members of Congress who make up its "board of directors."

Berwick has a passion for setting measurable goals and for partnering with a wide array of organizations that make him far more than an impractical academic, however. A clinical professor of pediatrics and health policy at Harvard Medical School, Berwick founded the Institute for Healthcare Improvement (IHI) in 1991 to identify and foster best practices in medicine that would save lives and reduce suffering.

If confirmed he would take over the long vacant CMS post with just the right message for an agency on the threshold of hundreds of billions of dollars of Medicare cuts that will stir anxiety about resulting harm to patients and quality of care.

Berwick preaches that imbuing health care organizations with a culture of thinking through how to deliver care more safely and efficiently not only saves lives but reduces wasteful spending.

Berwick predicts in IHI's annual report that wasteful practices in health care "will become even less tolerable" and says "we can't whistle in the dark about this any more. That's not going to work. We have to bring total spending on health care down . . . way down."

Berwick is perhaps best known for his "100,000 Lives" campaign built around the idea that certain specific practices can eliminate that number of deaths — which is the estimated number of deaths from medical errors that occur in the hospital each year.

According to information on the IHI site, more than 3,000 hospitals representing more than 90 percent of the hospital beds in America have signed on to the campaign, savings tens of thousands of lives.

Hospitals in the campaign commit to deploying rapid-response teams; delivering evidence-based care for heart attacks; preventing medication errors by following specific practices; preventing surgical site infections; implementing the "ventilator bundle," a series of specific practices to prevent pneumonia in patients on ventilators; and implementing the "central line bundle," specific steps to prevent infections associated with intravenous tubing kept in the patient's body to deliver drugs.

The rapid response teams, for example, deploy on a moment's notice when patients show early signs of trouble. They work with bedside nurses to stabilize patients and intervene before deterioration become irreversible.

In running the campaign Berwick has convinced hospitals to report deaths from medical errors. Among other participating organizations recruited by Berwick are the American Medical Association and the American Nurses Association.

The campaign has since spread to other parts of the world, and Berwick also has formed partnerships with health systems in Britain and Africa to improve quality of care.

Berwick speaks of the "globalization of our shared health problems" including common responses to disease outbreaks and sees parallels between creating a more efficient and effective health system "and what we need to do to save the planet" from global warming.

Berwick also speaks of an emerging era that entails not "caring for patients" but "caring with patients." In other words, patients will be much more involved with designing their care and doctors will support them in that, Berwick predicts.

How much opportunity he would have as CMS administrator to pursue such goals and even to further some of the more specific goals he has set is unclear given the many challenges he will face dealing with Congress on health overhaul implementation issues.

Sen. Charles E. Grassley of Iowa, the top Republican on the Senate Finance Committee, clarified Sunday that Berwick is going to get a lot of scrutiny.

"This is always a big job, but the administration of health care reform, which includes implementing the hundreds of billions of dollars in Medicare cuts and the biggest expansion of Medicaid in its history, will make it more challenging than ever," Grassley said in a statement. "The Finance Committee vetting will need to explore the nominee's preparedness for the enormous challenges that face the agency."

But as much as any recent CMS administrator, Berwick would come to the position with good relationships and the good will of many of the various health care organizations whose members are the key constituents of the agency.

The Medical Group Management Association, which represents big medical groups, said that as "health care organizations and professionals shape a reformed health care delivery system, [Berwick's] knowledge and proven leadership will be critical to success. His knowledge of quality improvement also offers great opportunities for improving the efficiency of CMS' internal operations – a critical factor in reducing administrative costs."

But for all his quality improvement expertise, Berwick will have to prove himself in dealing with the many different types of Medicare and Medicaid issues that come before the agency, and in managing relationships with Capitol Hill while keeping his eye on the lofty quality and safety goals for which he is best known.

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