I was reminded recently with unwelcome vividness what constancy we really need—what, behind the chaos of mergers and acquisitions, downsizing and layoffs, budget cuts and price slashing, integrating and competing, is worth the trouble. It involved my father.

My father was a retired physician in rural Connecticut. For 42 years, he provided care as a general practitioner in the tiny town in which I grew up. Then he retired and found himself no longer giving care but receiving it. I do not know what he thought of health care reform. By the time the national issue became popular, my father was mentally unable to comprehend the debate. I don't think he knew what TQM stands for, and he probably would have defined "reengineering" as changing the person who drives a freight train.

Of course, he did know quality. He was the guy who got up in the middle of the night because Jimmy had a high fever, or Mr. Bernstein had a heart attack, or an awful car accident occurred at the drawbridge. I heard him speak rudely to patients sometimes, but I never saw him unconcerned. And, when I attended my 30th high school reunion in 1994, I was still Dr. Berwick's boy. People could not wait to remind me of the time my father delivered their baby or themselves, or sewed a wound, or answered a tough question. They called him a great doctor. He was always there, they said. You could count on him.

My father retired in 1984 and not long afterward began developing symptoms of Parkinson disease and mild dementia from small, multiple strokes. He remained alert but became progressively weaker until he fell at home and broke his hip in June of 1994. His housekeeper found him and called the ambulance.

One of my brothers, who lives an hour from our father's home, rushed to the local hospital to meet him in the emergency department. He was told—in error—that our father was not there. Panicked telephone calls followed as my brother searched anxiously for our father's whereabouts until, finally, someone told him that our father was there, after all, and was about to be wheeled into the operating room.

After surgery, my father lay sedated on a special mattress containing sections that alternately inflated and deflated. Within a week, he had a deep pressure ulcer on his right heel. It was painful and interrupted his early ambulation therapy. He became restricted to a wheelchair for most of the day and gradually refused to walk at all. Unable to return home, my father needed to go to a rehabilitation facility, and my brothers and I searched hard for the best one. The signs pointed to a facility 20 miles from his home.

I visited him there on the morning after his admission. He was lying stuporous in the bed, on his back, with his ulcerated heel pressing into the sheets. His mouth was hanging open, and his eyes were rolled back into his head. I asked the nurse for an explanation. "We sedated him," she said. "He was combative. He hit a staff member." For 10 years, my father had had severe Parkinson disease, and for most of that time he had been unable to voluntarily extend his own arm, much less throw a roundhouse punch. My father had undoubtedly been angry, yes. But a punch ... no. I demanded that the sedation be stopped.

Not that it mattered much. For reasons that never became clear, the medication he took for Parkinson disease, meticulously adjusted for 2 years by his physician at home, was summarily stopped when he was admitted to the rehabilitation facility. This resulted in a 2-week siege of spasm and much decreased mobility. Not that that mattered much, either. By then, the pressure sore on his right heel had opened again, causing pain that prevented him from walking or even spending much time in a wheelchair.

Not that it mattered, because when my brothers and I asked that our father be placed in a wheelchair whenever possible, the nurses on the weekend shift told us that no wheelchairs could be found. They asked that we bring in his rickety old wheelchair from home. They eventually did find a wheelchair, but it was missing the footrest plate that would have protected his injured heel from bruising.

My father spent 6 weeks in the rehabilitation facility and then gave up, as did the staff. He returned home to a hospital bed and around-the-clock housekeeper coverage. Two weeks after he returned home—almost entirely bedridden and almost certainly never to walk again—a wheelchair finally came: the latest model, with postural supports, custom back rests, and hand controls he could never use. It was beautiful. The price: $6000. It sat proudly and nearly totally unused in the corner of his bedroom.

It is very hard to convey the special sense of helplessness I felt as a participant in this. In a journal article 2 years ago [2], I proposed 11 aims for clinical leadership of change that would really matter. "Aim 5" called for more appropriate use of pharmaceutical agents, especially in the elderly, but I found my own father heavily oversedated with sleeping pills he did not need and dramatically undermedicated with the anti-Parkinson agents that he did need. "Aim 8" was for the appropriate use of technology, especially in the last stages of life, but I found an excessively complex and nearly useless $6000 wheelchair freighted to my father's home; a far simpler one could not be found during the week in which it would have made a real difference. "Aim 7" asked that we decrease the amount of time spent waiting, but my brother sat uninformed and confused for too long in the waiting area of an emergency department. "Aim 2" involved prevention, including prevention of injuries, but my own father, inevitably, fell at home. And, inevitably, he acquired a debilitating and totally preventable pressure ulcer that interrupted his rehabilitation irreversibly. I felt helpless. So did he.

Some Success Stories

Yet, behind my father's story, and beyond the anger, I now feel a sense of possibility. In the course of my work, I am privileged to see good news as well as bad. In place after place, I see throughout the health care systems of the United States and Canada an ever-increasing collection of glowing successes that rivet my attention. Some examples follow.

My father was oversedated; it did not need to be that way. At Intermountain Health Care's LDS Hospital in Salt Lake City, Utah, the director of critical care medicine, Dr. Terry Clemmer; the nurse manager of that unit, Vicki Jensen Spuhler; and their colleagues worked for 2 years on safe sedation, substituting for new, expensive drugs a class of older, safer, and less costly agents. Total savings for Intermountain Health Care have been $209 000, and far safer levels of sedation have been achieved for the patients in the intensive care unit.

Dr. Ken Petersen and his colleagues in pediatrics at the Alaska Native Medical Center in Anchorage have been working on improving sedation in children having computed tomography. As a result of their efforts, the rate of rescheduling procedures because of ineffective sedation decreased from 40% in May 1993 to less than 1% in September 1994.

Improvement in medication has been a goal of the infectious disease group at LDS Hospital since the mid-1980s. Through the group's work during the past 8 years, antibiotic costs are down almost $50 000 per year and have decreased from 46% to 13% of the pharmacy budget. Duration of therapy has been shortened, and outcomes from infections have improved [3, 4].

My father was never successfully rehabilitated from his hip fracture because the rehabilitation system failed him at crucial points. It didn't need to be that way. Dr. Bill Nugent, chair of cardiovascular surgery at Dartmouth Medical School, Lebanon, New Hampshire, and his team have reduced the median length of hospital stay after surgery and mortality rates from heart surgery by carefully preparing patients for postoperative care and rehabilitation.

Drs. Michael Morris and Peter Mandt, orthopedic surgeons at Virginia Mason Medical Center's Sports Medicine Clinic in Seattle, Washington, redesigned their repairs of anterior cruciate ligaments tears. Between 1993 and 1995, they reduced actual costs of care by $1500 per patient, from $4278 to $2777, while sustaining clinical success rates of 93% and a rate of returning to work at 1 year of 100%.

My father's rehabilitation was permanently stalled by a pressure ulcer on his foot. It did not need to be that way. Prevention of pressure ulcers has been the subject of a major guideline by the Agency for Health Care Policy and Research. This guideline was studied and used by a team at LDS Hospital under the leadership of Carol Ashton. The team celebrated a decrease in ulcer rates on the medicine service—from 24% in July to December 1992 to 2% in July to December 1993. For the patients at highest risk, the rate of ulcers in that period decreased from 37% to less than 10% [5].

For my brother, the emergency department was a place to wait, questions unanswered, misinformed, anxious, but it didn't need to be that way. Carolyn Jackson and Dr. Andrew Greene at Bethany-EHS Hospital near Chicago converted their emergency care for adults with asthma into the first step in a carefully designed sequence of patient and family education, evaluation, and support. Between 1992 and 1994, returns to the emergency department decreased from 11.6 patients per month to 2.3 patients per month; rehospitalization rates were cut by 60%; and inpatient length of stay decreased by 30%. In Terry Clemmer's intensive care unit, careful work on improving communications with families over 3 years increased the rate of orientation of families within 24 hours of a patient's admission to the intensive care unit from 30% to 98%.

Through systematic improvement efforts, committed persons have achieved stunning success in areas ripe for clinical breakthrough. I have suggested that we can, if we wish, safely reduce the rate of cesarean section in the United States from the current 24% to less than 10% [2]. Many health care professionals have doubted that this is possible, citing threats of malpractice suits and patient expectations. However, Drs. Robert DeMott and Herbert Sandmire from Green Bay, Wisconsin, reduced the community-wide rate of cesarean sections from 16.3% in 1986 to 10.4% in 1993 [6]. Dr. Charles Guise, from the obstetrics services at the U.S. Air Force Academy Hospital, reports that the rate of this procedure decreased from 17% in 1989 to 6% in 1993; during the same interval, the rate of vaginal birth after cesarean section increased from 30% to 85%.

Steps to Improvement

Improvement is within our reach. Not marginal improvement, but fundamental, breakthrough-level changes that are better for patients, families, clinicians, and payers. My father need not have fallen, suffered, lain in bed, and never walked again. What will it take? As a start, I suggest five changes.

1. Change Our Focus from Integrating Structures to Integrating Experiences

I have serious doubts as to whether the current wave of mergers, acquisitions, and reorganizations now sweeping into almost every large market in health care in 1996 will matter at all to persons like my father unless the leaders so engaged build on their new structures by asking themselves a simple question: "Why should the people of this community—those who are sick or those who may become sick—care that this change in structure or ownership has occurred?" The answer, if it is honest, must relate to improving the experiences of care. As structures, our new "integrated delivery systems" should not be end points in themselves. They matter in the long run only as foundations for redesigning the processes of care so that patients get better help. In my father's transition among facilities—from hospital to nursing home to rehabilitation facility to his home—he was in the care of five different teams of physical therapists. Five different evaluation forms were completed, with five different recommendations for five separate fees. The only evident transfer of evaluation documents occurred when I drove to the hospital, picked up a copy of the evaluation, and took it to the nursing home. There I was told, "We never use outside evaluations."

By contrast, integrating appointment processes in one portion of one region of Kaiser Permanente has reduced the waiting list for healthy-adult appointments from 2000 to 0 in 3 months, while the total clinical staff required to supply those appointments decreased by 4%.

2. Learn To Use Measurement for Improvement, Not Just Measurement for Judgment

The dominant use of measurement in health care systems is what I call "measurement for judgment," not "measurement for improvement." Report cards, benchmark comparisons, accreditation processes, and employer-based performance surveys are all inspection-based systems, seeking data that can be used to make choices. The underlying strategy is to improve through culling, and it is a distant second-best to the real improvement that comes only through continuous effort and pervasive change. I fear the rush to collect information whose main effect will be to quell aspiration and invite dishonesty. Learning begins with curiosity, and curiosity is never totally safe. Public reports on health care performance may help to motivate change, but the responsibility to make changes that will actually help patients cannot be placed outside the system; it is we, inside, who must change.

Contrast reliance on culling with the approach that Bill Nugent describes as a support system for his team's dramatic improvements in cardiac outcomes over the past 2 years. In a recent letter to me, Nugent wrote,

By continuously tracking our outcomes, we have found it much easier to organize ourselves. ... We needed earlier warnings of statistically real problems. ... We now rely on control charts ... used to track input variables (e.g., patient demographics), process variables (e.g., intubation and length of stay), and outcome variables (e.g., mortality, morbidity, patient satisfaction, functional health). All this is now reported back in the form of a cardiac surgical instrument panel ... In sum, I have worked to develop effective ways to collect high-quality clinical data and, more importantly, to use that data to improve outcomes.

3. Move Beyond a Naive Search for "Best Practices" to a Much Healthier Mode of Learning from Each Other

I recently asked my 15-year-old daughter, Jessica, an avid horseback rider, whether it would help her to see a video of the Olympic gold medalist in dressage so that she could copy her. "I'd enjoy it," said Jessica, "but it wouldn't help me much." Why? "Because what I need to learn right now isn't what she would show me."

This sensibility—seeing learning as a process, not a goal—characterizes the persons involved in the best improvements in health care. In reducing the rate of pressure sores by 80% at LDS Hospital, Carol Ashton did not begin by seeking the lowest rates in the nation and then simply copying the practices used to achieve these. She began by seeking knowledge, help, and insights and by involving her own colleagues in that undertaking. Hers was a step-by-step process, with infinite respect for the imagination and wisdom of the other adults with whom she worked. Members of Ashton's team avidly looked for ideas from outside their own system, but the solutions were inevitably and powerfully their own. And because the solutions were their own, they worked.

4. Shift Our Thinking from Reduction of Local Cost to Reduction of Total Cost

At Bethany Hospital, the dramatic gains outcomes for adults with asthma were accomplished in a resource-starved institution that treats the poorest of populations. Ask Carolyn Jackson how it was done, and she will begin by describing new initiatives in patient education, testing, and information systems. It will at first be impossible to understand how this inner-city hospital could possibly find the resources to improve until you hear Jackson make the case, as she did to her own managers and clinicians, on hard facts about total costs and benefits. "We pay now," she says, "or we definitely pay later." This was the argument, supported by data inside the hospital, that her team developed, but putting it into practice required a leadership that listened and was able to think about now and later at the same time.

I am troubled by the focus on reducing lengths of hospital stay as an end in itself. Deming [1] warned against numerical goals, and this is one. We need to keep our minds on total costs, and it may even be that an extra day in the hospital is the best investment. We will miss that possibility if we fail to look. Integrated delivery systems may have a better chance at unifying views of cost, but that unifying will require many departures from classic, fragmenting assumptions about how budgets are made and monitored.

5. Compete against Disease, Not against Each Other

We have very little to rely on nowadays other than each other. I called a hospital in Houston, Texas, last year to learn about its allegedly successful innovations in pneumonia care and was told that the gains were enormous but that the methods could not be reported in public—excellent pneumonia care offered the hospital local competitive advantage. No wonder people feel confused! The enemy is disease. The competition that matters is against disease, not each other (a phrase I borrow from Dr. Paul Batalden of Dartmouth Medical School). The purpose is healing.

On my drive to work, I see billboard after billboard with silly rhymes urging me to join one health maintenance organization or another; many of these organizations are distinguishable only by their logos, and they often use the very same physicians and hospitals. Every dollar of this meaningless, competitive showmanship is waste. Every beautifully printed sales brochure is care denied someone. The greatest confusion in this terribly confused year of market reform is that we think we will succeed by overcoming each other. My father did not care. He was in bed with a pressure sore, staring at a wheelchair he did not need and living with the undeserved memory of insult, delay, and medically induced coma.

If we cannot work together on improvements that matter to those who call on us for help, then we have no cause to take pride in our restructuring, our mergers, our integrated systems, or our report cards. I propose that we take aim where it matters. Pressure sores are the enemy. Stop them. Errors in drug use are the enemy. Stop them. Fragmentation is the enemy. It creates waste, cost, and disrespect. Stop it. It was my father this time, but next time it will be your father, and then you, and then your child. I have heard it said by cynics that the quality of medical care would be far better and the hazards far less if physicians, like pilots, were passengers in their own airplanes. We are.

Postscript: My father, Dr. Philip Berwick, died at home on 6 November 1995. His physician, Dr. Malcolm Gourley, was at his side at the end, as he was so often and so helpfully in my father's final years.

This paper was based on an address to the Institute for Healthcare Improvement's Sixth Annual National Forum on Quality Improvement in Health Care held in San Diego, California, on 7 December 1994.