How 'The Berwick Report' May Play Out In Massachusetts

Don Berwick, a Democrat, is running for Governor of Massachusetts. But yesterday, he issued a "Letter to the people of England." The subject? Britain's National Health Service (NHS) and Berwick's recommendations for improving safety and restoring confidence after higher than expected death rates at one hospital rocked the country.

Berwick conducted his review and issued his report, pro bono, at the request of Prime Minister David Cameron. Today, he spoke with reporters in Boston about the health care and political lessons his work in the UK offers for Massachusetts.

Q: How do you think this report relates to people in Massachusetts. What do they take away from it?

A: Well…this report is not part of the campaign; I had agreed to do it prior to the announcement and getting people involved with the campaign, and the work does come to a close now, except for perhaps occasional advisory interactions. But this is about large system change, I mean, here you have a system with 1.4 million employees. That’s the size of the National Health Service, spending 100 billion pounds. And it’s a good example of how a very large system constantly needs the attention of leaders to the continual improvement of whatever it’s trying to accomplish. It’s an example of how the field I’ve been investigating for 30 years now, continuous improvement in quality, can be brought to scale.

One of my really big hopes should I be able to become Governor is to take this kind of capability; the ability to help a large workforce rediscover its mission, its purpose, connect to the meaning of the work of our lives, to acquire the skills, to improve continually and invest in your development. For the purpose of better service to customers. In this case patients, that applies to any large agency. That’s one of my big agendas in this campaign is to try and raise the understanding and the investment that we have in making government really work well. So it’s a very relevant experience. I obviously was dealing with very senior leaders in a politicized environment, which of course as governor I would be doing constantly and helping build consensus. The committee that I formed and led consisted of people with many many backgrounds, all the way from patients who had lost loved ones to injuries, to hospital executives who have been running large organizations, scientists who have knowledge and need to find a way to get that knowledge into the system. That ability to build consensus, to keep people with different backgrounds on the same page, to help them discover shared intent to work well together. I think that has a lot to do with the kind of leadership I’d like to bring to the state. Working across boundaries toward a common goal.

Q: The Mass. Nurses Association are proposing a ballot question that would set nurse-to- patient ratios. What’s your position on whether that’s a good move?

A: Well I certainly want to talk with, and will be talking with, the nurses association about [the] ballot initiative and about the overall issue. I think it is absolutely essential to patient safety and quality of care that sufficient staffing be present. Not just in-patient services but across the healthcare system. And this goes way beyond nursing. This has to do with the supply of primary care physicians and others to give primary care with specialists and technicians. Laboratory technicians, radiology technicians, therapists of various types. You can’t get the work done without adequate staffing. We know that.  Indeed, the study was done in the UK while we were doing this work of 14 hospitals, like Mid Staffordshire, that had high mortality rates. And across the waterfront a majority of them did have short staff problems.

The question about a legislative staff ratio to me is a more complex one. My preference right now and what we advocated in the report in England, there should be an absolute expectation requirement on managers and leaders in clinical settings to constantly monitor the adequacy of staffing with real time data, with an immediate response, they understand the kinds of stress that the staff are under and are doing something about it. And they respond to changing demand because equity changes are hour to hour, not just day to day or week to week. Epidemics could happen, there could be lull periods when there is less demand on staff. And I think a responsive staffing agenda is an agile and scientifically informed one.

I don’t think it’s necessarily the case that a legislated number like so many patients-per-nurse- but-no-more is the right way to deal with making sure that staff have all the support that they want, need, and should have. In England what we have done is just that the scientific agency that oversees some of the principles in the NHS take on the project of really looking hard at the formulas, the algorithms that should be used to determine what adequate staffing is in any particular time. And I prefer that kind of dynamic approach to staff.

On the ACA: "...for reasons that are not clear to me, something was missed in terms of explaining to the public, and helping the average person in the public understand how good this thing is, how much benefit this is going to bring to our nation, to our neighbors, to each individual."

Don Berwick

Q: In terms of the Affordable Care Act [President Obama's federal health law] do you believe there is room... to give Massachusetts an exemption or a waiver from the ratings factor (as applied to small business insurance premuims)?

A: Yeah, that’s beyond the scope of this call but let me answer anyway. That is not something I looked at or got legal counsel opinion on when I was in office there. And as you may know for two years after departure, I left December 2, 2011, and I have a two-year prohibition, under severe penalties, from contacting HHS for any purpose on any matter of substance. So I can’t speak for them. I have great respect for the Office of General Counsel in HHS. I think they do a very good job, they are diligent people. And if they have determined and advised the secretary, the governor has reported that this is not something they feel they have the latitude to do, then I would have to respect their judgment. I just don’t have any first-hand information about it. I would say in principle, I think Massachusetts is on the right track for doing a really terrific job showing the country how to get universal care and head towards the kind of health care reform we need, and I would like Massachusetts to get all the latitude it could possibly get to craft a system that works here.

Q: You know that your work in the UK was thrown back at you as a critique in Washington. I wonder how you read the climate in Massachusetts for drawing lessons from work, like what you’ve done in this report?

A: Well first the critique in Washington always felt to me, more or less hogwash. It was more demagogic than informed. I did work with the National Health Service, I’m proud to have done that, it’s a good system with flaws; they brought me there because of their flaws and what they wanted is to continually improve. It is not the case that you can take a system from one country, or from one state, let alone the country, and just import it to another one so that was pretty much fabricated, the idea that somehow I had a plot with the NHS. I’m proud of that work.

I think Massachusetts is a state that has a history of learning and growth and development and one of the ways you do that is by reaching out and learning what others are doing. We don’t have a Mid Staffordshire problem of that exact type here in Massachusetts. Then again I think there are things we can learn in this state from that study and that event, and I think any collective, any state is stronger when it reaches all over the world for information on how it can be better when it’s hungry for ideas. I think we are that kind of state and I believe that the people of Massachusetts I’m talking to would not want to walk away from any information that might be available somewhere in the world that could help our state do better.

Q: Any other broad takeaways that a democratic primary voter who might be looking at the field should take away from this?

A: Well, hopefully people will see in this evidence of my investment in helping large systems get better, that I’ve done that for decades. It was not a small thing for the prime minister of another country to come to that country, to advise as an outsider on how to take one of the most important and valuable systems they’ve got and make it even better. Perhaps that kind of trust in me as an advisor would be interpreted by people in this state as evidence of some of the confidence and interest I have in helping us do better as a society.

Q: Was this a pro-bono thing (the work for NHS), or did you get a substantial sum for---

A: It was pro-bono, I got no fee for this at all. I felt it was an honor to be able to do it, and this is a very valued system in that country and I was happy to be asked. Indeed, the whole committee worked pro-bono, that’s very important to know.

Q: I’d love to get your take on the state of play of the Affordable Care Act now. On the one hand, you have predictions of disaster, on the other hand, you have the administration saying, “It’s going to work, we’re going to wait and see.” And people will see once it’s implemented. I’d like your critique –

A: I’d like to remind you of what I said earlier, it really is true that I do not have an inside wire to information from CMS or for that matter, the White House. In many cases, you know more than I do. But my feelings right now, two things – first is, the Affordable Care Act has already done very important things for millions and millions of Americans. People have prevention coverage they never would’ve had without this bill, people can get access to prescription drugs they couldn’t have had, insurance companies are under more and proper surveillance, kids no longer have pre-existing condition threat when getting insurance, and as of next year, that’ll be true for anyone that wants insurance.

Massachusetts itself has gotten millions of dollars for prevention funds, for maternal and child care, for people to get access to better care. It’s a lot, it’s already working, and if the Republicans or anyone tried to take this law away, I think there’d be a sudden outpouring of rage as people realized what they were losing, what they’ve already gotten. For the future, it’s a complex endeavor, we’re taking a 2.6 trillion dollar system that serves the entire nation and trying to turn it into something that is universal, that is higher quality, that is more accountable, that is oriented toward outcome not volume. That’s a big deal, and of course there’ll be adjustments.

As I watch – as an outsider now – the President make decisions about changes in timing, the delay of the employer mandates, for example, I don’t – of course there’ll be adjustments, they’re making decisions about how to help a very complicated thing get done well, I can’t second guess that. I think one of the good news stories that’s going on here is what the rates increases, or, what the premiums look like – as the best exchanges get set up, I’ve seen the California data for the actual premium levels for the California exchange, are way below what was predicted by OMB and CBO, I believe. And the same now is happening now that there are exchanges. I think this story is going to play out over time as a very important positive move for the country, and that the people who are trying to take the law away are not going to meet a happy public.

Q: The administration’s posture seems to be, “Well, we will let the people judge for themselves as it takes effect’, and I’ve been struck by, they don’t seem to, they never seem to have done a very good sales job explaining how the benefits work, why you need universal care or a mandate if you’re going to get rid of preexisting conditions, any of those tensions, do you feel that they have sold this thing well?

A: I agree with your point, I think there was, for reasons that are not clear to me, something was missed in terms of explaining to the public, and helping the average person in the public understand how good this thing is, how much benefit this is going to bring to our nation, to our neighbors, to each individual. Why I don’t know, the story is a very important story. When I was able to get out and about, when I traveled the country as CMS administrator, and went into town hall meetings and meetings with providers or beneficiaries, it took 5 minutes to be able to bring them around and help them see what they were really getting because of this law. It’s a very, very good piece of legislation despite the inevitable changes and tweaks that are going to be needed over time.

I think some opportunity was missed. I’ve seen in the efforts of the secretary over the past year, and the outreach now to get people enrolled, a really great story in terms of helping people understand what’s possible, but if we could go back to square one, I think a different, better messaging effort would’ve taken off.