By 2004, Don Berwick realized he had reached a crossroads. His organization, the Institute for Healthcare Improvement (IHI) had been working since the late 80s to promote the quality methods that had transformed manufacturing to do the same for medicine. He had made some headway, but felt that progress had been to slow.
Things changed when he visited his son, who had been working on John Kerry's presidential campaign at the time. Impressed, Berwick invited some of the political operatives to hold a day-long seminar and train the IHI staff on how a campaign operates. That, in essence, is how The 100,000 Lives Campaign was born.
In his plenary address at the IHI Forum later that year, he declared, "I think we should save 100,000 lives. And I think we should do that by June 14, 2006--18 months from today." What followed was a movement that not only achieved its seemingly impossible goals, but serves as a model for anybody who wants to create transformational change. Here's how they did it.
Forming Common Purpose
Berwick's vision of healthcare as essentially a production system was, in many ways, a hard sell. Doctors are high status professionals and many, at least at the time, weren't enthusiastic about concepts like checklists and tracking "defects." However, at the time the error rate in healthcare was about 10% and one report showed that as many as 98,000 people were dying in hospitals due to medical errors, more than those who died from car crashes.
First, Berwick and his team got critical support from key institutions, such as government agencies and the American Medical Association, as well as insurance companies and hospitals that were already engaged on the issue. However, for the campaign to be successful, it had to move far beyond those early advocates.
Maureen Bisognano, former President of IHI, told me that building an emotional connection was essential to building support. "We had to build the will for change. We would tell about a patient who experienced an error or contracted an infection. That engages them and gets to their heart. Then we would walk them through the numbers and get to their heads."
"We were able to show how quality problems touched every part of the healthcare system," she continued. "The human cost, the financial cost. Everything. That's how we got a diverse set of stakeholders to buy in and say 'we want to solve this problem.'"
Creating a Bias for Action
Another key factor to success was to ensure that barriers to participation were kept as low as possible. So instead of requiring an extensive application, a simple fax from the Hospital CEO, along with a commitment to share mortality data, was enough to join the movement. The team also put a lot of thought into the changes it was asking hospitals to make.
"Throughout IHI's history we had been identifying evidence based protocols that could really make a difference," Joe McCannon, a former Vice President at IHI told me. "We chose six that we thought would relatively turnkey, that most hospitals would be able to run with, but also have enough impact to give the movement were were trying to build momentum."
For example, one of the procedures that the team identified was to keep the heads of patients on ventilators elevated at a 45-degree angle to reduce the risk of pneumonia. IHI suggested drawing a line on the wall behind the patient's bed so that it would be obvious when it dipped below that level, which enabled not only doctors and nurses, but families, orderlies and even janitors to monitor the 45-degree standard.
For each protocol, IHI provided "change kits" complete with how-to-guides, to ease the transition and gain maximum adherence. Also the participating hospitals were not required to adopt all six procedures, but were free to choose those best suited to their organization. In every aspect, IHI sought to empower, rather than to overpower or shame.
Networking the Movement
IHI is not a large organization. In fact, at the time of the campaign it had a staff of less than 100 and, it should be noted, the campaign wasn't its only activity at the time. So to drive change at thousands of hospitals all across the country, it needed to find a way to leverage its resources to create an asymmetric impact.
"We had to figure out how to support their learning," McCannon remembers. "So we identified certain facilities that could act as nodes and help support local initiatives for improvement. That's how we built scale. It was less about broadcasting information and more about harvesting the good work that was going on."
Besides helping IHI to leverage its resources, designating selected institutions as "nodes" allowed them to take ownership of the campaign. It wasn't just IHI's movement anymore, it was theirs and they internalized its goals as much as they would have if they had started it themselves.
Perhaps most of all, the network that formed built personal relationships that transcended traditional institutional barriers. When you work directly with someone to achieve a common goal, that bond doesn't just dissipate after the initial objective has been achieved, but forms a basis for future collaboration.
In his 2004 speech, Don Berwick set out the goals for the campaign as saving 100,000 lives at 1600 hospitals in 18 months. By the deadline, the participating hospitals saved an estimated 122,000 lives at 3100 institutions, which accounted for about 75% of US hospital beds. Clearly, The 100,000 Lives Campaign was a major success.
Still if they had stopped there, the impact would have been somewhat limited. "The lasting achievement of the 100,000 lives campaign wasn't the immediate objectives we attained. We wanted to shift values in a way that would lead to institutional change at insurance companies, medical schools and government to improve healthcare in a lasting way," McCannon says.
So IHI followed up with a 5 Million Lives campaign and then a 100 Million Healthier Lives campaign. It also created an Open School for health professionals, to continue to promote improving the quality of healthcare practices and runs numerous other programs. It also helped to inspire many of the improved regulations in the Affordable Care Act.
Yet at the core of its continued success is the shared values and extensive network of personal bonds built during the 100,000 lives campaign. A successful movement, as the name implies, is kinetic and is defined less by how or where it starts, but where it goes and the people it attracts to take it there.