In 2014, Dr. Donald Berwick was the keynote speaker at the National Council Conference for Behavioral Health in Washington, DC. After his speech, he was asked about his impact upon suicide prevention. Was he aware of the transformation that the Institute for Healthcare Improvement had sparked in 2001?
He quickly acknowledged, “Oh, you’re talking about Henry Ford Health System, and the work of Ed and Justin Coffey.” And, he began rubbing his hands together and talking about hand-washing. He saw suicide as similar to other complex and wicked problems that healthcare has tackled. When he led the Saving 100,000 Lives campaign, the data showed that hospital-acquired infections were the top culprit. An analysis of causes demonstrated that many lives could be saved by more rigorous practice of routine hand-washing protocols. Follow the data. Study the causes. Develop and implement interventions. Track the success. Repeat.
In 2001, Health Affairs described the common approach to quality in healthcare: “The current US system produces exactly what it produces exactly what it was designed to … highly variable care, widespread failures to implement best practices, and inability practices, and inability to change patterns of practice.”
But, Dr. Berwick and the Institute for Healthcare Improvement consulted the world’s top quality gurus, including NASA and lean experts in leading telecom companies, to learn what worked to create highly reliable results.
HFHS Back to the Drawing Board
When the National Action Alliance for Suicide Prevention task force that published the Suicide Care in Systems Framework was meeting in early 2011, Dr. Ed Coffey related the moments that created the Perfect Depression Care initiative back in 2001. Dr. Berwick and the Institute for Healthcare Improvement team were visiting Detroit to hear a presentation from the Henry Ford Health System who were finalists in an innovations grant program offered through IHI. Early in the morning, Dr. Berwick cut off the team from Henry Ford and asked to speak with Dr. Coffey in the hall.
Dr. Berwick explained his belief that what Henry Ford was aspiring to do in their response to reduce depression was likely very progressive for mental health. Henry Ford proposed that the would routinely measure outcomes and track progress for success, revolutionary in a large mental health system at the time. But… that was not the essence of robust performance improvement, which called for targets like perfect care and zero events. It lacked the urgency IHI was seeking, and Dr. Berwick and team left.
Days later, the Henry Ford team convened to review what had occurred, still reeling from the abrupt exit. What was it that IHI wanted? It didn’t seem clear. Feeling stuck, the group paused, and a nurse, mostly thinking out loud, said… “Hmmm…”
“If we were providing perfect care, then no one would die of suicide.”
A leading psychiatrist in the program stood to his feet and used an expletive to describe his response to such a statement. “If someone is going to kill himself, then he will kill himself,” he said (expressing a common fatalistic view among medical and clinical leaders). There’s nothing really that can be done to prevent these tragedies the thinking goes. But, a seed had been planted, and Henry Ford started down a different path that would produce different outcomes and spark a global movement.