Cooperating, not competing, to improve health care

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6991.1349 (Published 27 May 1995) Cite this as: BMJ 1995;310:1349
  1. Don Berwick,
  2. Richard Smith
  1. Director Institute for Health Care Improvement, Boston, MA 02116, USA
  2. Editor BMJ, London WC1H 9JR

    The first European forum on quality improvement in health care will provide a way

    Cooperation may become most difficult just when it is most needed. When stress is high, fear develops; and fear fragments us. Health care leaders should now be working more and more closely with each other, seeking systemic solutions for systemic problems, but the opposite is happening. As demands to cut costs increase and as governments and other groups paying for health care probe the system for evidence of safety and effectiveness, professions tend to retreat within their own walls, organisations become increasingly secretive, and individuals struggle against their interdependencies.

    We have seen this in the United States as reform of health care has gained momentum, mostly induced by large corporate purchasers of care, which provide most of the health care insurance for the American population. These purchasers have been angered by the steady growth in American health care costs—almost three times the rate of inflation for over two decades—without strong evidence either of added benefit to the population or of effective efforts by health care organisations to control their own costs. Trust has been broken, and those paying for health care are now more assertive than ever before. They are requiring organisations to provide data on their performance, including data not only on costs but also on health status outcomes, rates of use of diagnostic and therapeutic procedures, and patients' satisfaction. Standardised scoring systems—so called “report cards”—are appearing more and more frequently, and the demise of the federal government's efforts to enact health reform has not slowed these moves by the private sector towards accountability and measurement of performance.

    American health …

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