Special Communication

Eleven Worthy Aims for Clinicai

Leadership of Health System Reform
Oonald M. Berwick, MO

Clinicians ought to be playing a central role in making the changes in the health Even in their own local organizations,
care system that will allow the system to offer better outcomes, greater ease of such as hospitaIs anel group practices,
use, lower cost, and more social justice in health status. Instead, most of the physicians are feeling less anel less in
proposed changes that are today called "health care reform" are actually changes control of the circumstances of proviel-
in the surroundings of care rather than changes in the care itself. Clinicians have ing care as they are asked to accept
protocols, guielelines, criticaI paths, anel
an opportunity to exercise leadership for the improvement of care, but they must
new management systems. 1,2
first agree to address the aims of reform and to adopt an agenda of specific
changes in their own work that are likely to meet the social needs driving the
reform movement. Health services research offers a sound scientific basis for See also p 803.
identifying promising improvement aims for clinician-Ied reformo Eleven plausible
aims are these: (1) reducing inappropriate surgery, hospital admissions, and di- Notwithstanding the resulting sense
agnostic tests; (2) reducing key underlying root causes of i1lness (especially of helplessness among so many profes-
smoking, handgun violence, preventable childhood injuries, and alcohol and co- sionals, the central premise ofthis artiele
caine abuse); (3) reducing cesarean section rates to pre-1980 leveis; (4) reduc- is this: only those who proviele care can in
ing the use of unwanted medicai procedures at the end of life; (5) simplifying the enel change care. Efforts to reform
pharmaceutical use, especially for antibiotics and medication of the elderly; (6) the health care system from the outsiele
increasing active patient participation in therapeutic decision making; (7) de- through revisions in payment, corporate
relationships, regulation, anel reporting
creasing waiting times in health care settings; (8) reducing inventory leveis in
of outcomes can help motivate and set
health care organizations; (9) recording only useful information only once; (10) the stage for improvement. Yet, if phy-
consolidating and reducing the total supply of high-technology medicai and sur- sicians, nurses, pharmacists, clinicaI tech-
gical care; and (11) reducing the racial gap in infant mortality and low birth weight. nicians, operating managers, anel others
Health care professions and their professional organizations in concert should at the front line ofhealth care elo not wish
embrace these 11 aims, establish measurements of progress toward them, and to make specific changes in their own
commit to continuous and fundamental changes in their pursuit. work to better meet society's neeels for
(JAMA. 1994;272:797-802) better outcomes and Iower cost, no one
outsiele the health care system can be
eleveI' enough OI' powerful enough to make
PHYSICIANS, in conce1t with others ofthe changes proposeel are not really in them do it-at least not well 01' for very
who provide care, can themselves achieve the ways we give health care; they are longo What will happen instead is simple
the purposes ofhealth system reformo In insteael changes in the environment of anel bael: less care anel worse care.
fact, we should; alI of the visible alterna- health care-the regulations, the pay- The reverse is also true. If the clini-
tives are worse. Clinician-Ied refonn, how- ment, anel the corporate structures un- cians ofthe nation ever see fit collectively
ever, would require that we establish elear der which the work is done. It is as ifwe to eleelare the aims of health system re-
improvement aims, monitor our progress, were trying to improve skiing by chang- form to be thei1' aims anel shoulel they
and above all willingly make changes in ing the rules of competition, the color of ever set about enthusiastically to improve
the way we do our work in an effort to the meelals, anel the location of the hill their own work with the objectives of
better meet the aims. A true commit- without spending much time at all on reform fully in minel, they coulel not easily
ment to improvement would be manifest changes in skiing itself. be stopped. If clinicians want to stop feel-
in our willingness to change. The preelictable result is fear within ing battereel by health system refonn,
Instead, we are struggling for stabil- the health care professions. We experi- they can elo so by achieving the aims of
ity. That is no surprise given the pre- ence the changes as outsiele not inside health system reform themselves. It
vailing approaches to change in health our work. Most physicians feellike pas- woulel be the best solution, but it cannot
care. The rhetoric of "health care re- sive witnesses to corporate restructur- be elone by fighting for the pasto
form" often mentions change, but most ing of health care organizations, merg- Motivating health system reform are
ers and acquisitions among them, new social neeels in four basic categories: (1) to
financiaI relationships between physi- improve the health status of populations
From the Institute for Healthcare Improvement, 80s- cian groups and hospitaIs, continuing anel to achieve better clinicaI outcomes of
ton, Mass. shifts of care from inpatient to outpa- care; (2) to improve the experience of
8ased on a paper presented at the Fifth Annual Na-
tional Forum on Quality Improvement in Health Care tient settings, anel gl'owth in the pro- care for patients, families, anel communi-
sponsored by the Institute for Healthcare Improvement, portion of prepaiel anel managed care. ties; (3) to reeluce the total economic bur-
Orlando, Fia, Oecember 8, 1993. Governments and business alliances are den of care anel illness beginning with the
Repnnt requests to Institute for Healthcare Improve-
ment, 1 Exeter Plaza, Floar 9, Boston, MA 02116 (Or threatening 01' actually enforcing new price of health care coverage; anel (4) to
Berwick). performance measurement systems. improve social justice anel equity in the

JAMA, September 14, 1994-Vol 272, No. 10 Aims for Health System Reform-Berwick 797
health status of Americans.
Breakthroughs are unlikely through
the prevailing, blunt, across-the-board
budget cuts and organizational down-
sizing now under way, but at bottom,
the social demands that motivate the
call for reform are reasonable. Decades
of sound health services research leave
litt1e doubt that clinicians themselves
could make great progress in every one
of these areas.
ELEVEN WORTHY AIMS
Imagine that the leading organizations
in American medicine, nursing, and re-
lated professions (in a community, a state,
01' the nation as a whole) declared un-
equivocally that the aims ofreform-bet-
ter outcomes, better experiences, lower
cost, and more justice-were indeed their
aims, that the professions were ready and
willing to make substantial changes in
their work to achieve those aims, and
that they intended to do it together, in
coliective stewardship of the health and
health care of Americans.
The next step after such a commit-
ment would be to translate the broad
goals of reform into a specific agenda-
the insiders' agenda-{)fimprovements,
just as a skier who intends to race faster
must focus attention on specific, improv-
able elements of skiing, such as edging,
body position, waxes, timing, and per-
sonal endurance.
Selecting foci in health care is diffi-
cult, in part because so many opportu-
nities for specific improvement appear
in the research literature. As a staI'ting
point, the following 11 aims are particu-
larly promising. For each, research
hows a large gap between ouI' current
performance and what is within our
reach if we are willing to change.
Aim 1: Reduce the Use 01
Inappropriate Surgery, Hospital
Admissions, and Diagnostic Tests
Important initial targets include man-
agement of stage I and stage II breast
cancer,3-5 prostatectomy,6 carotid en-
darterectomy,7 coronary artery bypass
surgery, treatment of low-back pain,9
hysterectomy,1O endoscopy, li blood trans-
fusion, 12 chest roentgenograms, 13and pre-
natal ultrasound. U
Aprocedure i "inappropriate" in a par-
ticular patient if there is no scientific ba-
sis on which to predict benefit. The re-
lationship between variation in practice
and inappropriate care is far from
straightforward; high-use areas are not
necessarily areas of high inappropriate-
ness. l 5-17 However, research consistent1y
shows that inappropriate surgel)', 15-20 ad-
missions,21 and testing2223 are common;
for a group of carefully studied surgical
procedm'e ,the rate of inappropriate use
798 JAMA, September 14, 1994-Vol 272. No. 10
ranges between 20% and 70%.16 Thanks
to a decade of development by scholars at
RAND and elsewhere, simple and reli-
able procedm-es exist for assessing the
appropriateness of care, and these pro-
cedures can be adapted for use by phy-
sicians in community settings. 24 Specific,
targeted efforts to involve clinicians in
peer-comparison studies, education, and
coliaborative guideline development of-
ten result in substantial declines in pro-
cedm'e rates, with a consequent reduc-
tion in both costs and hazards to patients. 25
Those who regulate, measure, or pur-
chase health care understandably tend
to treat this problem of inappropriate-
ness from their own outside perspec-
tive-hence the current infatuation with
protocols, guidelines, algorithms, and
criticai paths. The trend is worrisome.
A guideline enforced from outside may
lead to more predictable care, but it can-
not lead to the continuai improvement
of care. The outsider can judge care, but
only the insider can improve it.
The commitment to improving the
match between scientific knowledge and
actual practice, the commitment to "appro-
priateness," must come from the profes-
sionals-nm'Ses, physicians, and manag-
ers-whose actions constitute the care.
To improve appropriateness, we must
begin with a clearheaded understanding
that in our hands unnecessary care does
exist; it is our well-meaning inappropri-
ateness, it is pervasive, and physician by
physician, organization by organization,
we can reduce it without guilt, censm'e,
01' severe externai controls.
Aim 2: Improve Health Status
Through Reduction in Underlying
Root Causes 01 IIIness
The underlying root causes of illness
include smoking,26-31 handgun violence,22-35
preventable injuries in children,'l&-38 and
alcohop9 and cocaine abuse. 40 The causes
of the majority of both deaths and years
of potentiallife lost in the United States
are preventable.41.42 McGinnis and Foege43
have recent1y offered a brilliant reclas-
sification of "actual causes of death" in
the United States, showing that tobacco,
diet and activity patterns, toxic agents,
firearms, sexual behavior, motor vehicles,
and illicit use of drugs account collectively
for 50% of ali deaths each year in the
United States. Unintentional injuries, sui-
cide, and homicide account for 30% of all
years of potential life lost under the age
of 65 years. 44
In their own office-based practices,
clinicians have substantial opportunities
to affect some of the behavioral causes
of illness. Skilled counseling by physi-
cians can reduce smoking, high-risk
sexual activities, and some forms of un-
intentional injury. With simpie question-
naires, clinicians can detect alcohol abuse
and depression in earlier and less haz-
ardous tages. 45 In large measm'e, how-
ever, knowledge about the social, be-
havioral, and environmental causes of
disease frustrates physicians. How can
we, trained as we are in curative care
and palliative care after the fact, ever
really reach the sources of the illnesses
we treat? Is it, after all, our job to do so?
Strong social currents suggest that it
may be. Social support is resurging for
public health and prevention,45 reflected
in governrnental budgets, community-
wide health status improvement efforts,
and an emphasis on primary care in many
health system reform proposals. Of
course, so far the signals are still rnixed,
as every physician knows. No one pays
yet for a physician to become a leader in
community-wide prevention of automo-
bile accidents, smoking cessation pro-
grams, or handgun control. A specialist
paid thousands of dollars for the termi-
nal care of a cirrhotic patient is paid
little or nothing for community work to
prevent alcohol abuse. A hospital, like
the Magic Valley MedicaI Center in Twin
Falls, Idaho, that successfully reduce .
head injuries in children by leading com-
munity-wide bicycle safety efforts 46 still
takes a significant negative strike to its
bottom line, because it loses emergency
department revenues as a result. No
one yet totaIs and adjusts the economics
to encourage more and more preventive
activity in the nation.
Yet, the duty remains. Even though
health care financing current1y works
against it, a commitment to improve-
ment requires that clinicians carry their
work effort to the sources of disease.
Physicians strongly influence commu-
nity attitudes toward appropriate health
investments, and it is therefore impor-
tant for physicians not just to counte-
nance prevention, but also to lead it.
Aim 3: Reduce Cesarean Section
Rates to Below 10% Without
Compromise in Maternal
or Fetal Outcomes
Cesarean section rates in the United
States have risen from 5% to 25% over
two decadesY Rates well below 10%
have been maintained in some other de-
veloped nations48 (and as low as 1.3% in
certain practice settings49) without any
demonstrated compromise in maternal
and fetal outcomes.
In industries other than health care,
dramatic improvements have sometimes
been motivated by the setting of"stretch
goals," goals so demanding that they chal-
lenge prevailing assumptions and auto-
matically require reconsideration of the
system as a whole. A stretch goal makes
the need for fundamental change clear,
Aims for Health System Reform--8erwick
because it is absolutely unattainable
within the existing work proces . The
cesarean section rate is a candidate for
stretch goals. Returning safely to the US
rates of the mid 1970s (well below
10%) will require fundamental system
changes. 50·51 What we do know is that it
can be done, because others have done it.
Aim 4: Reduce the Use of Unwanted
and Ineftective Medicai Procedures
at the End of Life
Only a minority of patients, families,
and clinicians support prolonged use of
life-sustaining procedures and dramatic
interventions in the terminal stages of
illness,52.53 yet substantial use ofthese pro-
cedures continues.iH In human terms, us-
ing unwanted procedures in terminal ill-
ness is a form of assault. In economic
terms, it is waste. Several techniques,
including advance clirectives55 and involve-
ment of patients and families in decision
making,56.57 have been shown to reduce
inappropriate care at the end of life, re-
sulting in both lower cost and more hu-
mane care from the patients' point ofview.
lt is, of course, hard to know in ad-
vance that this month 01' this week is the
last month 01' week of a patient's life.
That is, in fact, one of the main reasons
why this particular improvement chal-
lenge rests squarely on the shoulders of
clinicians. lt requires OUl' highest skills to
help patients and familie balance the fac-
tors ofuncertainty, clignity, risk, and re-
ward involved in using meclical proce-
dUl'es appropriately as life ends. We must
begin by recognizing that today the ap-
propriate balance is badly missing.
Aim 5: Adopt Simplified Formularies
and Streamline Pharmaceutical Use
This aim applies e pecially for anti-
biotics and for drug prescriptions for
the elderly and chronically ill. Medica-
tion prescribing elTors,óll,5!l overuse of
antibiotics 60 (especially broad-spectrum
antibiotics), and inappropriate polyphar-
macy in the elderly and chronically
illUl ,52 are well documented. Simplified
formularies and educational interven-
tions among cliniciansl' 1•64 lead to safer
and less expensive prescribing practices.
In addition, simplifying the processes
by which we order, prepare, and deliver
meclications should reduce errar rates.
One hospital system has reported re-
current annual savings of nearly $1 mil-
lion by using simple ways to ensure the
timely administration of correct peri-
operative prophylactic antibiotics. 65
This aim is given special Ul'gency by
the early warnings we now have about
new strains of organisms resistant to
multiple antibiotics. 60•56 The wisest pos-
sible use of antibiotics may help to slow
the emergence of resistance.
JAMA, September 14, 1994-Vol 272, No. 10
Aim 6: Increase the Frequency
With Which Patients Participate
Actively in Decision Making
About Medicai Interventions
A growing amount of experimental lit-
erature documents the payoff from help-
ing patients to consider explicitly their
own values and goals in the context of
difficult treatment decisions. "Activated
patients" encoUl'aged to ask questions and
to participate with theÍl' physicians in
reaching the best plan of diagnosis and
therapy often achieve better outcomes at
lower cost than patients in more passive
modes. 67.68 Thi approach does not work
for all patients, but it does for many, and
it challenges clinicians and organizations
to develop new skills and processes for
interacting with patient .
The financiaI gains are substantial.
Prostatectomy candidates who actively
help decide between medicaI and sur-
gical treatment choose surgery as much
as 50% less often than those for whom
the physician alone makes the choice. 1m
Diabetic patients coached by nonphysi-
cians to ask questions when they see
their physicians have lower glycohemo-
globin leveIs and higher functional sta-
tus than those who are not coached. 70
Chronically ill adults who develop simpIe
self-efficacy skills show subsequent
medicaI utilization pattern 50% lower
than matched controls. 71
Aim 7: Decrease Uninformative
Waiting of Ali Types
In health care, experienced physicians
sometimes use "watchfu1 waiting" to gain
information and to allow natUl'al healing
to proceed. This is a sound strategy,
often preferable to aggressive clinicai
intervention. However, a large propor-
tion of the waiting that occurs in health
care is not of this informative type; it
adds no value for either the caregiver 01'
the consumer of care. In fact, rapid ac-
cess and high responsiveness are among
the major quality characteristics desired
by the beneficiaries ofhealth care. 72 Mod-
ern companies outside the health care
system devote a great deal of attention
to reducing such waits throughout the
chain of production of a product 01' ser-
vice. They aim for continuous flow; they
reject batching in favor of more agile,
stream1ined manufacturing processes.7:l
Constructing feasible wait-ft'ee pro-
cesses under constrained reSOUl'ces de-
mand high leveis of process redesign
and invention, but it lead to markedly
improved quality at much lower cost.
In the buffeted health care economy,
with wholesale budget cuts now common,
more waiting may appear to be inevi-
table as a device for rationing scarce ser-
vices. 74 The vocabulary of limitation be-
comes an acceptable and common fOIm of
adjustment to resource constraints. lt is
precisely at such times, however, that
waiting must be UIUnasked as the thief it
really is. Often queues add cost and rob
opportunities as more and more time and
energy pOUl' into managing waiting lists
and enforcing rules of access. Patients
who fear that they will be denied care are
often thereby induced to demand it, if
only to test for theÍl' own security. The
anger of someone denied access wastes
time in apology, defense, and repaÍl'.
Organizations and physician who find
new ways to minimize delays, produce
continuous flows, and decrease waiting,
even while reSOUl'ces are more and more
limited, will also find themselves devel-
oping innovations that please patients
more while stressing and demoralizing
caregivers less. The precondition to suc-
cess is that caregivers suspend their clis-
belieflong enough to join wholeheartedly
in trying out ways to reduce waiting un-
der conditions of severe reSOUl'ce con-
straint. Testing different ways to reduce
01' eliminate waiting may be ft'uitful in
appointment-scheduling systems, refer-
ral patterns, gatekeeping habits, and ad-
ministrative barriers to utilization. Sev-
eral group practices have already had ex-
citing successes with open-access primary
care systems in which the patient, not the
system, chooses the exact appointment
date and time. A hospital committed to
reducing waits might refuse to delay ad-
missions pending prospective certifica-
tion by payers, but guarantee repayment
of any charges from admissions that are
decertified after the facto
Aim 8: Reduce Inventory Leveis
Other industries have dramatically re-
duced their inventory leveis through the
u e of "just-in-time" process flows, im-
proved supplier management, and pro-
cess simplification.72 By comparison,
health care organizations maintain high
inventory leveIs and tend to underuse
capital equipment. 75.n
At first glance, inventory alone may
seem to explain so little ofthe cost struc-
ture of health care that its reduction
would not be a significant gain; but look
again. Inventory recluction to 10% of
historicallevels, which other industries
have achieved, saves money in obvious
ways by ft'eeing capital, decreasing stor-
age space, and simplifying record keep-
ing, for example. However, in less ob-
vious and even more important ways, a
system that can minimize it own in-
ventory leveis may well be fundamen-
tally less expensive to manage and more
adaptive to changing needs. If we must
tore 1000 copies of a form, because we
cannot be sure that one will be delivered
when we need it, we must either throw
Aims for Health System Reform-Berwick 799
away 01' use up our stocks when we neeel
a new version. A system that coulel ele-
Iiver forms to us reliably, exactly when
neeeleel, woulel by its nature have to be
in c10se communication with us anel
thereby better able to unelerstanel our
neeels anel more Iikely to change quickly
when necessary.
What elo physicians have to elo with so
aelministrative a matter as inventory lev-
eIs? A great eleal. By stanelarelizing their
requests for materiaIs anel services, anel
by taking the time to explain their neeels
carefully to their suppliers, physicians
can help smooth the flow of supplies
through their own system of work anel,
as a happy by-proeluct, reeluce both waits
anel waste.
Take, for example, the inventory ofhip
prostheses in an Olthopeclic unit. Imag-
ine that eight surgeons in a group ele-
manel that a total of a elozen elifferent
prostheses be available. To have suffi-
cient back up stocks ofprostheses on hanel,
the purchasing office must maintain 12
processes for orelering anel storage--one
per prosthesis type. The purchasing
office must manage multipIe outsiele
supplier contracts with attenelant legal,
accounting, anel clerical costs. The oper-
ating room central supply service must
maintain a complex storage anel retrieval
system so that Dl' Jones always receives
his proper tray anel Dl' Smith, hers. If
there are 10 technicians in central supply,
each of whom must be traineel in the pre-
fen'eel setup for each of the 12 prosthe-
ses, then 120 prosthesis-technician elyaels
existo Even if each elyael functions per-
fectly with 99% probability, the probabil-
ity of systemic perfection (ali 120 elyaels
correct) is approximately 0.99 120 01' 0.30.
(This is the joint probability of 120 inele-
penelent events ali occurring together if
each has a 99% chance of occw·ring.)
Compare this system with one in
which eight sW'geons agree, through con-
versation, research, anel compromise, to
elemanel only three prostheses in stock
insteael of 12. Inventory e1ecreases, as
elo the costs of accounting, contracting,
storage, tracing, anel staff training.
Higher-volume purchases from a single
supplier will earn price breaks for the
hospital. Insteael of 120 prosthesis-tech-
nician elyaels to maintain, there are now
only 30, anel the probability that ali will
function correctly is 0.99'JO 01' 0.74, a250%
improvement. The reeluceel complexity
also creates the oppol'tunity to learn
more quickly about the outcomes fi'om
the chosen prostheses (it is easier to
stuely three than 12 in a single ortho-
peelic unit), setting the stage for scien-
tifically informeel changes in the future
selection of prostheses. By exactly this
change (reelucing the numbel' ofhip pros-
theses in use), one hospital system has
800 JAMA, September 14. 1994-Vol 272, No. 10
saveel almost $1 million per year while
improving functional status outcomes for
total hip replacement patients (M. Weeel,
written communication, February 1994).
The key point is that physician anel
nW'ses themselves must unelerstanel anel
drive this movement towm'elreeluceel com-
plexity anel lower inventory. Simplifica-
tion wiU make the most sense not when
thrust on them, but when sought anel
planneel with anel by them. What applies
to hip prostheses applies equally well to
many types ofelwable meelical equipment,
consumable supplies, examining room
stocks anel elesigns, papel' forms, anel pro-
ceelw'e-manual specifications. In a gl'OUp
of eight peeliatrician " how many types of
standing orelen; shoulel there be accorel-
ing to which the support staff prepm'e a
toelcUer for examination? The common an-
swer is, "Eight." The correct answer if
we truly value both quality anel efficiency
is, "One."
Aim 9: Record Only Useful
Information Only Once
Let us define "useful" as "Iikely to be
used by someone, sometime." By this
measure, medicaI recorels, aelministrative
habits, anel regulatory history require
extraorelinary leveIs of"useless"-waste-
fuI, eluplicative, anel unused-record keep-
ing, both clinicaI and aelministrative.'''''-'l
Decreasing eluplicate elata entry anel ceas-
ing the recoreling of information that is
never used woulel both reeluce costs anel
improve cm·e. To accomplish this goal re-
quil'es rational changes in l'egulation anel,
even more important, changes in out-
moeleel habits and information manage-
ment systems. Some changes may be out-
siele the jW'iseliction of physicians anel
nw'ses, but many useless habits are pre-
served by aelministrative fiat 01' by in-
ternaI governance committees on forms
anel meelical recorels. In ali m'enas, nurs-
ing anel physician leaelers shoulel insist on
rational parsimony anel shoulel eliscm'elre-
coreling practices honoreel by time but
not by logic. How often elo we recorel vital
signs anel why? Why cio separate sections
of the medicaI record contain virtually
the same information? How many times
do patients have to teU us their telephone
numbers? Do we record quantitative in-
formation in claunting tables or in infor-
mative gl'aphs? Simply substituting
graphs for tables anellists of numbers in
our meelical recorels woulel be a big step
forward.
As they seek simplifiecl and less waste-
fulrecord keeping, clinicians shoulcl ques-
tion the ever-present, intimidating trump
cm'cI of "medicaI-legaI requirements."
Some of these requil'ements m'e indeed
wOlth wOl'rying about, but many m'e
myths-Dw'able but Wl'ong. In some
cases, the risks of nomecording may be
weU justified by the savings in both time
and money. An automated medicaI recorel
may provicle a pmtial solution, but it will
be little help if it merely stores magneti-
cally the waste formerly stored on papel'.
Aim 10: Reduce the Total Supply
of High-Technology Medicai
and Surgical Care and
Consolidate High-Technology
Services Into Regional and
Community-wide Centers
The largest single eleterminant ofthe
rate of high-technology care anel inva-
sive proceelures is the leveI of local sup-
ply of those services,tI.XH"; For many
high-technology practices, reduction in
the total supply is an effective and safe
way to reeluce costs and limit aelverse,
meelically ineluceel outcomes.
When this reeluction is achieveel
through con olielation, we can expect out-
comes to improve. Encouraging elata sug-
gest a positive relationship between "vol-
ume" and "outcomes," especially with re-
gm'el to high-technology services, although
the ful! profile of this l'elationship is not
yet known.N-X~ Duplication ofservices re-
suIts in higher costs, higher use mtes,
anel inefficient use of capital. Some ben-
efits from regional consolidation have been
elocumented for cm'e of very low-birth-
weight infants!JO anel for aelult cm'eliac sw'-
gery.91 Most metropolitan m'eas in the
United States should reduce the number
of centers engaging in careliac sw'gery,
high-risk obstetrics, neonatal intensive
cm'e, organ transplantation, tertiary can-
cer care, high-Ievel trauma cm'e, anel high-
technology imaging.
This is not an easy change for physi-
cians to accept. Some physicians in high-
technology specialties willlose income and
job OPPOltunities as a resulto For-profit,
entreprenew'ial provielers of meclical im-
aging, renal elialysis, and outpatient sw'-
gery, for example, may finel their busi-
ness oppOltw'Úties constraineel. It wiil be
necessal'Y for other physicians, who see
the benefits of consolielation of services,
to insist on sensible regionalization none-
theless, even at the risk of internaI pro-
fessional conÍlicts, Com'age in meelicine
now inclueles the courage not to elemanel
the highest leveI oftechnology "right here,
on site," but to seek insteael the more
challenging forms of integrateel, intel1n-
stitutional relationship that, in the long
run, achieve more for less.
Aim 11: Reduce the Racial Gap in
Health Status Beginning With Infant
Mortality and Low Birth Weight
Extreme elifferences remain in the in-
fant morbielity anel mortality rates for
minorities anel low-income populations
compm'eel with whites ofhigher economic
status in the Uniteel States.~t.!l:; The
Alms for Health System Reform-Berwick
causes are multifactorial,!>l anel so mul-
tiple system improvements ",'iU be re-
quireel to reduce the gap.
Perinatal outcomes are only the tip of
the iceberg of social inequity in the health
status ofAmerican .!';'!l7 ot only are black
infants 240% more likely than whites to
die in the perinatal perioel, but they also
face a far more uncertain futul'e if they
live. A black male bom toelay in the Uniteel
States has the foUowing exces risks of
eleath compared with a white male: 150%
for hemt clisease, 190% for stroke, 280%
for renal elisease, 340% for human immu-
nodeficiency vim -relateel eleath, anel
680% for homicide.!JS Life expectancy for
a black male at birth toelay is 8 yem . less
than for a white male; for a black female,
it i 6 years lessY'
These eliscrepancies are not only of-
fen ive, they are insupportable. Any na-
tional OI' regional changes worth caUing
"reform" in health care, any agenela
worth caUing "improvement," must in-
tend explicitly to reeluce this injustice.
Infant mortality anellow birth weight
is a fine place to begin. The potential
gains are large, the measurement sys-
tems to support tests of change are fea-
sible, and the implications for cost, as
weU as for outcomes, are favorable. Re-
sults "viU come only from highly inte-
gI'ated, coUaborative action at the com-
munity levei, anel solutions wiU vary
ba eel on local conditions. Meelicalleael-
ership of this community-wiele activity
is essential, notjust to ensure that health
care organization allocate their 0W11re-
sources where they will do the most
good, but also to stimulate the conscience
of the public and to convene organiza-
tion and indivieluals in pursuit of com-
mon goals. The increasing investment
in severe competition in many local medi-
caI markets will prevent such col!abo-
rative action unless clinicaI leaelers,
driven by their ethical duty, insist on it.
CONCLUSIONS
These 11 aims define an action plan for
clinicians who wish to leael effective
change in US health cm'e. Any hospital,
integrateel system, 01' community that
made substantial gains in even half of
these m'eas woulel be easily distinguish-
able in cost, outcome, and satisfaction.
Co ts would elecrease dramaticaUy as a
result of decreases in inappropriate and
unwanted care, simplified pharmaceuti-
cal use, less supply-ell'iven use ofmeelical
proceelures, reeluceelrecord keeping, anel
less complex inventory. Health status in-
elicators woulel reveal elecreases in pre-
ventable morbidity anel mOltality, more
inclivielualized patient care elecisions, anel
fewer complications of clmgs, invasive
tests, anel sw'gica1 procedmes, ]f com-
munity-wiele action were taken, the gaps
JAMA. September 14, 1994-Vol 272, No. 10
between white anel minority health sta-
tus woulel begin to c1ose. Patients woulel
repOlt shorter waiting times, more re-
spectfu1 dialogues with theu' health cm'e
provielers, anel less duplicative anel elis-
organizeel cm'e. In short, such a system of
cm'e woulel be better, cheaper, and inci-
elentaUy more satisfying to \Vork ",'ithin.
A gooel case exists for other aims as
weU, but the real point i . for physicians
to get starteel anel to engage in improving
specific dimensions of care as quick1y as
we cano Physicians who wish to help leael
systemic change towarel aims like these
wiUlikely have to cultivate new personal
skills. To accomplish each of these im-
provements, the heroic image ofinelivielu-
alist physicians each doing the best he OI'
she can anel each bem1ng fuU anel per-
sonal responsibility for the care of the
patient cannot possibly suffice. These aim
reflect the performance of system . of in-
terelepenelency, not of inelividuals acting
alone. They wiU be accomplisheel by those
who proviele health care, 01' they will not
be accomplisheel at alI. Physicians who
wish to help must lem'n more than how to
heal patients, they must lem'n how to heal
system.
Healing systems ",,'iU require skills not
customm'ily taught in meclical training.
Progre 'ive meelical eelucation in the fu-
tW'e shoulel help physicians, nurses, and
administrators participate fuUy in chang-
ing the systems in which they do theu'
work. Relevant skills incluele the fol!ow-
ing: the ability to understanel the health
care system as a whole, not merely one's
own profession; the ability to gather anel
interpret elata on outcomes of cm'e; the
ability to work eEfectiyely acro's elis-
plinary bounelm'ies anel, when neeeled, to
pmticipate in fonTIal ÍlTIprovement teams;
the ability to tmst generaUy in the mo-
tives anel intelligence of people of eliffer-
ent professional roles, geneler, anel life
experience; the skill anel willingTIess to
test new approaches to work instead of
clinging to the status quo as the safest
option; anel the ability to interpret the
unelerlyi.ng neeels of patients anel others
who elepenel on physicians, so the elefini-
tion of "needeel il11provements" ",riU be
placeel firm1y in the hanel of those who
are served by the health care system?'
"Reform" seem so confusing, The
frenzy invites a sense of helplessness,
but we need not feel helpless. Clinicians
who do not wish to feel victimized shoulel
specify the improvements they intend
to initiate to help better meet social
neeels anel then shoulel welcome changes
in pursuit of those improvements.
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