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D M Berwick

Publications and source records attributed to D M Berwick.

At least 55 records · Page 3Linked to original sources
PubMed1995

The toxicity of pay for performance.

Despite their superficial logic, systems of merit pay or pay for performance have features that are toxic to systemic improvement. Contingent rewards doled out by supervisors cause decreased focus on customer needs, loss of accurate information about defects and improvement opportunities, avoidance of stretch goals, and decreased innovation. They may also erode teamwork. Pay for performance may mark a naive understanding of the complexity of human motivation.

Creativity↗
PubMed1994

Eleven worthy aims for clinical leadership of health system reform.

Clinicians ought to be playing a central role in making the changes in the health care system that will allow the system to offer better outcomes, greater ease of use, lower cost, and more social justice in health status. Instead, most of the proposed changes that are today called "health care reform" are actually changes in the surroundings of care rather than changes in the care itself. Clinicians have an opportunity to exercise leadership for the improvement of care, but they must 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 identifying promising improvement aims for clinician-led reform. Eleven plausible aims are these: (1) reducing inappropriate surgery, hospital admissions, and diagnostic tests; (2) reducing key underlying root causes of illness (especially smoking, handgun violence, preventable childhood injuries, and alcohol and cocaine abuse); (3) reducing cesarean section rates to pre-1980 levels; (4) reducing the use of unwanted medical procedures at the end of life; (5) simplifying pharmaceutical use, especially for antibiotics and medication of the elderly; (6) increasing active patient participation in therapeutic decision making; (7) decreasing waiting times in health care settings; (8) reducing inventory levels in health care organizations; (9) recording only useful information only once; (10) consolidating and reducing the total supply of high-technology medical and surgical care; and (11) reducing the racial gap in infant mortality and low birth weight. Health care professions and their professional organizations in concert should embrace these 11 aims, establish measurements of progress toward them, and commit to continuous and fundamental changes in their pursuit.

Delivery of Health Care↗
PubMed1994

Measuring public priorities for insurable health care.

The goal of this research was to develop and evaluate a way to measure the value people place on various medical services in their decisions about what health insurance should cover. A vignette approach to measuring consumer values was developed. People were asked to assign priority and desire to have insurance cover 64 different services. A national probability sample of 206 adults was interviewed by telephone. Their ratings were compared with those of a sample of 47 corporate benefits officers of Fortune 500 companies. Priorities were not significantly associated with respondent characteristics. They were positively correlated with independent assessments of the seriousness of the patient's condition and the likely efficacy of the services. Priorities and desire to cover were virtually the same when respondents were asked about insurance for a low-income population as for a general population. Two-thirds of the ratings of the public were the same as those of benefit officers. The public gave higher ratings than benefits officers to long-term care and services to relieve worries, and the public gave lower ratings to the value of treatment of substance abuse and services when the patient could be viewed as at fault. This pilot test indicates this is an efficient, feasible, useful strategy for measuring the extent to which people value various medical services that could contribute to the process of making decisions about health insurance coverage.

Adult↗
PubMed1993

Quality health care.

Explore the source record for details and available documents.

Health Services Research↗
PubMed1993

TQM: redefining doctoring.

The physician many consider to be the father of "total quality management" in health care explains the philosophy behind the theory. He believes TQM has created a new job description for physicians--one that involves working on a team to improve the system for providing care.

Delivery of Health Care↗
PubMed1992

The clinical process and the quality process.

Quality management methods in health care organizations require the active participation of physicians. Many organizations are successfully using a variety of methods to support this involvement, building on the underlying intellectual similarity between clinical practice to improve the health of individuals and quality management to improve processes of work. Important similarities include the scientific combination of theory and fact, the avoidance of blaming, the systematic analysis of variation, the use of experiments, the refinement and use of measurement, and the development of an extended professional community.

Clinical Medicine↗
PubMed1992

The state of quality management in HMOs.

Interest in total quality management (TQM) in health care is increasing rapidly as leaders search for positive strategies to deal with both costs and quality. We conducted a national telephone survey of 200 HMO medical directors, 451 physicians affiliated with managed care organizations, and 550 corporate health benefits officers to obtain their reports of the potential contributions, the current interest in, and the degree of implementation of TQM activities in their own managed care systems. A large majority of all respondents felt that TQM could help greatly in health care, as it has in other industries. Among HMO medical directors, 81% claimed that their organizations placed "a great deal of emphasis" on TQM, while only 34% of physicians and 35% of benefits officers agreed. Areas of implementation claimed by the HMOs tended to involve abstract matters such as mission statements and leadership commitment, while technical components of TQM, including data systems, training, and supplier management, appeared much less well-developed. The managed care organizations surveyed seem to be in the early phases of commitment to TQM. To achieve the results seen in other industries, these organizations will need much deeper levels of investment, understanding, and deployment of TQM than this survey reveals.

Attitude of Health Personnel↗
PubMed1991

Uncovering psychiatric test information with graphical techniques of Exploratory Data Analysis.

This article illustrates how Exploratory Data Analysis (EDA) can complement conventional statistical methods in evaluating psychiatric tests. Using one recent EDA computer program, we evaluated the ability of repeated psychiatric screening tests (the General Health Questionnaire [GHQ]) to predict medical and psychiatric service use in a Health Maintenance Organization (HMO), the Harvard Community Health Plan (HCHP). Using a stratified random sample of 244 new HCHP enrollees and viewing three-dimensional graphs of their data from multiple perspectives, we found two subpopulations: low GHQ scorers, for whom the tests did not predict service use; and high scorers, for whom they did. Surprisingly, improving scores forecast increased use and chronically high scores predicted diminished use. Using another stratified random sample of 213 new HCHP enrollees, and with scatterplot matrices from another interactive computer program, we found that high and unchanging GHQ scores forecast HMO dropout. We examine possible interpretations--for example, that chronically distressed patients may become immobilized, diminish service use, and ultimately leave the HMO. We also explain how EDA methods may help uncover elusive results in other data (e.g., mental health outcomes).

Adult↗
PubMed1991

Performance of a five-item mental health screening test.

We compared the screening accuracy of a short, five-item version of the Mental Health Inventory (MHI-5) with that of the 18-item MHI, the 30-item version of the General Health Questionnaire (GHQ-30), and a 28-item Somatic Symptom Inventory (SSI-28). Subjects were newly enrolled members of a health maintenance organization (HMO), and the criterion diagnoses were those found through use of the Diagnostic Interview Schedule (DIS) in a stratified sample of respondents to an initial, mailed GHQ. To compare questionnaires, we used receiver operating characteristic analysis, comparing areas under curves through the method of Hanley and McNeil. The MHI-5 was as good as the MHI-18 and the GHQ-30, and better than the SSI-28, for detecting most significant DIS disorders, including major depression, affective disorders generally, and anxiety disorders. Areas under curve for the MHI-5 ranged from 0.739 (for anxiety disorders) to 0.892 (for major depression). Single items from the MHI also performed well. In this population, short screening questionnaires, and even single items, may detect the majority of people with DIS disorders while incurring acceptably low false-positive rates. Perhaps such extremely short questionnaires could more commonly reach use in actual practice than the longer versions have so far, permitting earlier assessment and more appropriate treatment of psychiatrically troubled patients in primary care settings.

Adult↗
PubMed1991

Controlling variation in health care: a consultation from Walter Shewhart.

The control of unintended variation is an objective central to modern industrial quality management methods, based largely on the theoretical work of Walter A. Shewhart. As industrial quality management techniques find their place in health care, professionals may feel threatened by the effort to reduce variation. Understanding may reduce this fear. Variation of the types addressed in quality control efforts erodes quality and reliability, and adds unnecessarily to costs. Such undesirable variation derives, for example, from misinterpretation of random noise in clinical data, from unreliability in the performance of clinical and support systems intended to support care, from habitual differences in practice style that are not grounded in knowledge or reason, and from the failure to integrate care across the boundaries of components of the health care system. Quality management efforts can successfully reduce each of these forms of variation without insult to the professional autonomy, dignity, or purpose of health care professionals. Professionals need to embrace the scientific control of variation in the service of their patients and themselves.

Attitude of Health Personnel↗