Reclaiming Health Care’s Fundamental Purpose

 In his powerful plenary session speech at the 2017 IHI National Forum, Dr. Don Berwick mentioned untamed chronic illness, inadequate patient safety, insufficient investment in disease prevention and the social determinants of health, high costs, over-emphasis on technology, and too little joy in work. His conclusion: “Our care is not fit for use.” “We need,” he stated, “a fundamentally different system.” I agree.

I am a business school professor who believes that striving to make American health care more “businesslike” squashes its soul. The fundamental purpose of health care is to enhance quality of life by enhancing health. Commercial businesses focus on creating financial profit to support their valuation and remain viable. Health care must focus on creating social profit to fulfill its promise to society. Yes, health care needs to be efficient and productive and earn a sufficient margin to continue to serve and to improve. But when financial metrics rule the day in health care, we sacrifice its fundamental purpose. Our best companies have a social conscience, which contributes to their financial success. But most businesses emphasize margin over mission, and health care must emphasize mission over margin.

Dr. Berwick and other keynoters at the 2017 Forum highlighted several elements essential for creating a fundamentally different health care system. They spoke of proximity, humility, shared purpose, trust, transparency, inclusion, empowered execution, and joy. Embracing these concepts will take health care much further than RVUs, incentive payments, and multi-layered documentation.

Bryan Stevenson, a social justice lawyer who founded the Equal Justice Initiative, stressed the importance of being proximate to the poor to effectively advocate for them. “There is power in proximity,” he said. “We see things you can’t see from a distance.” We need more proximity in health care. Government officials, politicians, hospital administrators, and others need to be more proximate to what happens on the frontlines of health care delivery — and to what impedes effective and efficient care. Clinicians need to be more proximate to their patients’ emotions, fears, preferences, and limitations. Just as I believe that airline executives should periodically fly in coach class (in the middle seat) to better understand customer experience, so do I believe that senior health care administrators should spend more time on the floor where care is delivered to learn what they cannot from their offices.

The opening plenary session featured Derek Feeley, president and CEO of IHI, Dr. Rana Awdish, a critical care physician at Henry Ford Health System, and Tiffany Christensen, a professional patient advocate with The Beryl Institute. Awdish and Christensen spoke from their experiences as patients so ill they nearly died. Proximity changed the way Awdish practices medicine, and it turned Christensen into a fierce defender of patient rights. In her Forum remarks, Awdish commented, “Medical education trains us to see the pathology, not our patients. Before I got sick I hadn’t seen the person behind the disease. Being sick I had the opportunity to reflect on what medicine had given me and what it had not.”

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Awdish’s and Christensen’s stories reinforced Feeley’s opening theme of “mutuality” — shared purpose, partnership, distributed power. No one has all the answers; no one owns all the knowledge. Pooling knowledge towards a shared purpose in a climate of trust, respect, transparency, and humility is what health care must embrace to transform, to move beyond incremental improvement, to shed enormous waste, to become not only more effective technically but also more humane for patients and more joyful for clinicians.

“Mutuality transformed how we engage our enemies,” was the strong message from General Stanley McChrystal, commander of America’s Joint Special Operations Task Force in Iraq. The organizational structure looked like a corporation’s when McChrystal took the reins: multiple layers of management and clear reporting relationships. The Task Force was stable and orderly but slow to adapt to fast-moving events because ground forces closest to the action were not privy to critical information or had to await approval to act. The enemy — Al-Qaeda — was unencumbered by such a structure. The old way of waging war was not working; just as in health care, the military needed “a fundamentally different system.” As described in his speech, McChrystal realized, “We had to change the way we interacted, the way we operate. We lacked a shared consciousness.”