Intended for healthcare professionals

Education And Debate

A primer on leading the improvement of systems

BMJ 1996; 312 doi: (Published 09 March 1996) Cite this as: BMJ 1996;312:619
  1. Donald M Berwick, president and chief executive officera
  1. a Institute for Healthcare Improvement, Boston, MA 02215, USA

    The nurse called me urgently into the room. The child, she said, was in acute respiratory distress.

    I had never met either Jimmy (the 6 year old boy) or his mother (an inner city single teenage parent) before. His asthma attack was severe, his peak expiratory flow rate only 35% of normal. Twenty years ago my next steps would have been to begin bronchodilator treatment, call an ambulance, and send the boy to hospital. That also would have been the story 10 years ago, or five, or two.

    But today, when I entered the room, the mother handed me her up to date list of treatments, including nebuliser treatment with β2 agonists, that she had administered with equipment that had been installed in her home. It continued with her graph of Jimmy's slowly improving peak flow levels, which she had measured and charted at home, having been trained by the asthma outreach nurse. She then gave me the nurse's cellular telephone number, along with a specific recommendation on the next medication to try for her son, one that had worked in the past but was not yet available for her to use at home.

    My reply was interrupted by a knock on my door. It was the chief of the allergy department in my health maintenance organisation. He worked one floor above me in the health centre and, having been phoned by the outreach nurse, had decided to “pop down” to see if he could help. He also handed me a phial of the same new medication that the mother had just mentioned, suggesting that we try it.

    Two hours later Jimmy was not in a hospital bed; he was at home breathing comfortably. Just to be safe the allergy nurse would be paying him a visit later that afternoon. …

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