This chapter has touched on many areas important in QI to promote and deliver better ACP and EOL care. It has been written by a U.K. health care leader who has had the benefit of time studying the U.S. health care system and the challenges it faces. U.S. clinical leaders tend to promote their optimism and positive belief that they can effect change in some states and health care organizations. This external optimism may well be real and unfettered, or perhaps we must remember the commercial pressure of competing for the patient dollar. It is at this last section of the chapter I would like to introduce the “Moral Test.”

Dr. Donald Berwick, the founder and former CEO of the IHI and former Administrator of the Centers for Medicare & Medicaid Services in the United States, presented a keynote speech at the IHI National Forum conference in 2011. He presented his personal view about the approach to and resistance of change he has faced, as well as more public, professional, and political pressures. I have provided an edited excerpt from this address covering key aspects of EOL care. Readers are encouraged to go to the full text available online (Berwick, 2011).

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels”—the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight of our lives when our health fades and our need for help grows and changes. Luckily, palliative care—care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families—has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight. (Berwick, 2011, p. 9)

Berwick recommended five principles to guide efforts to transform our health care system:

1. Put the patient first. Every single deed—every single change—should protect, preserve, and enhance the well-being of the people who need us. That way—and only that way—will we know waste when we see it.

2. Among patients, put the poor and disadvantaged first—those in the beginning, the end, and the shadows of life. Let us meet the moral test. 3. Start at scale. There is no more time left for timidity. Pilots will not suffice. The time has come, to use Göran Henrik's scary phase, to do everything. In basketball, they call it “flooding the zone.” It's time to flood the Triple Aim zone.

4. Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter.

5. Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization—nothing less (Berwick, 2011, pp. 22–23).

Clearly Berwick made this speech during the political turmoil of U.S. health care reform, as he was leaving his role as the Administrator of the Centers for Medicare and Medicaid Services. The negativism he was facing included reform to EOL care. His eloquent soliloquy emphasizes the last simple principle “that we can and should offer people the very best of care at all stages of their lives, including the twilight” (Berwick, 2011, p. 9).

Leadership and the Commitment to Change

As a clinical leader driven by my vocation to effect positive change, I use this question at key times to test myself or to help colleagues, “Do you have the commitment, competence, confidence, and clarity of purpose to deliver excellence reliably?” This, I find, is a good way to build will and motivation and be action focused.

Finally, this is my last personal reflection dedicated to all those converted to change management and improvement science: I don't pretend to have all the answers because I haven't finished learning yet. What I do know is that I have the confidence to lead a coalition of passionate believers with the tools of improvement science to make positive change. Most importantly I am not afraid to demand change and get people to do the right thing, do it better and do it for less, and give patients a good death.


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