Donald M. Berwick, MD, MPP
Note: This paper is based on a plenary address, “My Right Knee,” delivered at the Institute for Healthcare Improvement's 15th Annual National Forum on Quality Improvement in Health Care, New Orleans, Louisiana, on 4 December 2003.
Acknowledgments: The author thanks Jane Roessner, Valerie Weber, and Frank Davidoff for their extraordinary help in preparing this manuscript.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Donald M. Berwick, MD, MPP, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138; e-mail, firstname.lastname@example.org.
Despite some impressive recent gains, improving the glaring deficiencies in health care quality is proving to be very hard. Improvement is local, rather than system-wide, and is sustained with difficulty, rather than becoming an intrinsic feature of care.
My right knee will probably need to be replaced soon. This has given me the opportunity to define, in very personal terms, 5 specific dimensions of “total quality” that I will require from the medical institution that does my surgery and that every patient has the right to require of their encounters with the health care system. Don't kill me (no needless deaths). Do help me, and don't hurt me (no needless pain). Don't make me feel helpless. Don't keep me waiting. And don't waste resources, mine or anyone else's.
Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient. Although at this point individual institutions can meet some of these requirements, no single institution can deliver on all of them. Generating the energy, insight, and courage we need to get to “total quality” may require those of us who work in health care to get much better at seeing images of ourselves in the people we help. As Gandhi said, “You must be the change you wish to see in the world.”
Donald M. Berwick. My Right Knee. Ann Intern Med. 2005;142:121–125. doi: 10.7326/0003-4819-142-2-200501180-00011
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Published: Ann Intern Med. 2005;142(2):121-125.
Healthcare Delivery and Policy, Hospital Medicine, Osteoarthritis, Pulmonary/Critical Care, Rheumatology.
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