Under-Visioning Professionalism: Deming, Berwick, & Sensemaking

Mike Magee MD

The question: Can a health professional be “professional”  in a fundamentally misaligned health system? If not, does a health professional have to contribute to health system transformation to behave professionally?

Professionals are generally members of a vocation with special training, highly educated, enjoy special trust and work autonomy, abide by strict moral and ethical obligations, and in return are generally self-regulating. Their academic training is expected to reliably provide those they serve with special skills, judgement, and services. When they deliver, society responds with confidence and trust and durable long-term relationships. (1,2)

Studies of the critical elements of the patient-professional relationship, both from the patients’ and the professionals’ point of view, are well aligned. The relationship must deliver compassion, understanding and partnership. Beyond nuts and bolts health care, they must also manage fear, reinforce important familiy and community linkages, and support hope-filled futures. The consummation of such relationships is heavily reliant on the consistent presense and interest of professionals in patients’ and families’ lives, their home settings and the many integrated variables that effect their human potentials and their futures. The ability of professionals to exhibit consistently such interest and presense is in term determined by the design, processes, reliability and accessibilty and value center of the health care system itself. (3,4)

W. Edward Deming, the father of Quality Control Management, credited with assisting the Japanese in transforming their auto industry into the leader in automotive innovation today, had this to say about transformation: “The prevailing style of management must undergo transformation. A system cannot understand itself. The transformation requires a view from outside… The first step is transformation of the individual. The individual, transformed, will perceive new meaning to his life, to events, to numbers, to interactions between people… The individual, once transformed, will: set an example; be a good listener, but will not compromise; continually teach other people; and help people to pull away from their current practices and beliefs and move into the new philosophy without a feeling of guilt about the past.” (5)

This well describes the life and work of Don Berwick MD, President of the Institute For Healthcare Improvement, who is widely recognized as the premier thought leader in health care quality improvement today. In 1999, in a classic speech, “Escape Fire: Lessons For The Future of Health Care”,  sponsored by the Commonwealth Foundation, Don recounted the events surrounding the tragic fire at Mann Gulch, Montana which claimed the lives of 13 “smokejumpers” on August 5, 1949. (6) He reviewed the lessons learned in a system analysis by Professor Karl E.Weick, of the University of Michigan, in his paper titled,“The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster.”

Berwick explains in his speech, “Sensemaking is the process through which the fluid, multilayered world is given order, within which people can orient themselves, find purpose, and take effective action. Weick is a postmodern thinker. He believes that there is little or no preexisting sense of organization in the world—that is, no order that comes before the definition of order. Organizations don’t discover sense, they create it…In groups of interdependent people, organizations create sense out of possible chaos. Organizations unravel when sensemaking collapses, when they can no longer supply meaning, when they cling to interpretations that no longer work.”

Berwick then goes on to recount the difficult and personal journey of he and his wife as they struggle with her serious and life-threatening illness and the broken health care system that was attempting to support them. He then concludes, “I love medicine. I love the purpose of our work. But we are unraveling, I think. Sense is collapsing… We need to face reality…Why did it take the Mann Gulch crew so long to realize they were in trouble? The soundest explanation is not that the threat was too small to see; it is that it was too big. Some problems are too overwhelming to name. I now think that that is where we have come in health care; I have been radicalized.”

Berwick lays out the primary pillars of a new design: access, science, and relationships. He concludes: “I envision a system in which we promise those who depend on us total access to the help they need, in the form they need, when they need it. Our system will promise freedom from the tyranny of individual visits with overburdened professionals as the only way to find a healing relationship; will promise excellence as the standard, valuing such excellence over ill-considered autonomy; will promise safety; and will be capable of nourishing interactions in which information is central, quality is individually defined, control resides with patients, and trust blooms in an open environment that the old order could never have imagined.”

That was 1999. And over the past 10 years, Don at the IHI and others have with great energy and resolve fought to realize these gains. (7) And yet, the system has not “bloomed” and professionalism remains under siege. So I continue to probe, “Why has health professionalism not advanced?”

I believe the answer is that the visions we have been using are under-powered. Here are my three pillars, 10 years after Don’s, which I believe could support “Advanced Professionalism”:

1. Health Equals Customized Strategic Planning: Health is about reaching full human potential and is fundamentally driven by personalized and prospective short and long term strategic health planning. (8)

2. Home-Centered Health Care System: For strategic plans to be well integrated and successful, the health system must be re-centered around healthy homes, not around hospitals or doctors’ offices. (9) This is not to be confused with the new “Medical Home” concept, which provides some marginal improvement, but as I have said is “too much medical, not enough home”. (10)

3. Health Care Team Home Engagement: To efficiently and effectively manage resources wisely and advantage science, care teams must move aggressively, both physically and virtually, into the home. This will require leveraging technology, redefining all health professionals job descriptions including physicians, inclusion of informal family caregivers as bona fide members of the health care team, re-engineering homes for health and connectivity, reconnecting the now 4 and 5 generation American family and harnessing existing family social capital, and moving from backward facing PHR’s (Personal Health Records) to forward facing LPR’s (Lifespan Planning Records). (11)

Next week we’ll take a close look at the the FACCT Innovators and Visionaries Report of 2003, FACCT’s absorption into Markle, and explore the role that dampening of expectations has on professionalism.

For Health Commentary, I’m Mike Magee.

References:

1. Beeghley, L. (2004). The Structure of Social Stratification in the United States. Boston: Allyn & Bacon.

2. About Professionalism: ABIM Foundation.http://www.abimfoundation.org/en/Professionalism/About%20Professionalism.aspx

3. Magee M. Relationship Based Health Care in the United States, United Kingdom, Canada, Germany, South Africa and Japan: A Comparative Study of Patient and Physician Perceptions Wordwide. The Journal of Biolaw and Business, Vol. 7, 2003. www.mikemagee.org. (access publications)

4. Magee M. “The Patient – Provider Relationship” in Connecting With The New Healthcare Consumer, D. Nash, Ed. McGraw Hill, 1999.

5. Deming, W. Edwards. 1993. The New Economics for Industry, Government, Education, second edition.

6. Berwick DM. Escape Fire. December 9, 1999. 11th Annual National Forum on Quality Improvement in Health Care. Commonwealth Foundation. http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf

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