Daniela Levi “every single one” Don Berwick “in its deepest core, the pursuit of perfection is to forget no one. And to forget no one is to pursue justice…”

Daniela Levi IOM report on HC quality Need major systemic effort to overhaul how –Deliver care –Educate and train clinicians –Assess and improve quality

Daniela Levi quality problems: Overuse of procedures and interventions Underuse of treatments that are known scientifically to be helpful Misuse- errors in execution

Daniela Levi aims for improvement Safety Effectiveness Patient- centered Timeliness Efficiency Equity

Daniela Levi The problem is design- 4 segments of HC Level 1- patient and community –Purpose –Aims –Quality is defined here Level 2- The microsystem –Encounters the suffering, need and tries to heal Level 3- organizational context –Information, financing, architecture, rules, personnel Level 4- environmental context –HC financing, regulations, accreditations, tort, education, market

Daniela Levi Microsystem redesign- 10 rules Base care in healing not visits Customize to individual Patient in control Share knowledge Evidence –based decisions Safety as a system property Transparent Anticipate not react Reduce waste Foster cooperation

Daniela Levi Berwick’s famous quotes Whom do we serve? Fundamental assumptions Every defect is a treasure Medicine as a social act Never-ever loose sight of the patient Becoming something we are not today

Daniela Levi “Learn how to heal systems” Open access Health information Patient decisions 24/7 visiting for ICUs Patient and family advisory councils Community members on patient safety committee Sharing clinical pathways with patients Reduce unwanted and ineffective medical procedures at the end of life Consolidate high- technology services into regional and community-wide centers

Daniela Levi Berwick’s on innovation: “Change agents often have a deep understanding of the system they wish to change” “People who lead change must usually leave their current environment in order to grasp what others cannot see”

Daniela Levi Quality improvement: Tenacity and tension needs to be applied today to: –Insisting on better outcomes –Insisting on more dignity in care –Insisting on less waste –Insisting on more safety –Insisting on more listening