The term health care reform has diverse meanings for the many stakeholders involved in the US health care system. The underlying issues associated with implementing such reforms are quite complex, but pressures for reform are high. In this context, such reforms are similar in nature to many large improvement initiatives which are pursued within large businesses (though these are each dramatically different in scale).

In 2005 alone, the United States spent more than two trillion dollars on health care, or over $7,100 per person, and are growing at over twice the rate of growth of our overall economy. Government and private insurance fund about 80 percent of those costs, and the rest largely comes directly (rather than indirectly) out of our pockets. About a third of these expenditures occur within hospitals; clinicians get another third, and the rest is spread across nursing homes, prescription drugs, and the costs of administering our insurance system.

While people are generally satisfied with the health care they receive, they also are usually not aware of how well the current system works, or how it has been improving over time. People generally have a sense of fairness, would like everyone to have access to health care, and feel compassion towards others who do not have access; yet when you ask them what they would be willing to give up in order to provide this access, their commitment to universal health care often disappears.

Yet the public generally recognizes that should current cost escalation trends in health care continue, delays in implementing systematic improvements to this system could provide many different kinds of risks for it's consumers. Mistakes in implementing reforms could lead to limitations on our lifestyle choices, employment options, and financial prlorities. Businesses could also have their competitiveness, employee job satisfaction, and ability to attract and retain the best available talent seriously impacted. Finally, the costs of health care has collateral impacts on the overall economy and funds available for other purposes. All of this creates an environment for reform which is ripe for political and media exploitation, pressure for change, and a rush to judgment. All of that can, of course, play a role in producing suboptimal outcomes.

The front line of health care is the practicing physician. Physicians’ after-expense incomes are a relatively small percentage of these total medical costs, but like other solution designers (engineering, architecture, etc), they initiate most of health care spending. Their collective efforts in execution and improvement are thus critical to changing this system. In this context, during 2006 and 2007, the privately funded Institute for Healthcare Improvement set out to pursue a Big Hairy Audacious Goal - to save 100,000 lives which would otherwise have been lost due to health care quality problems. IHI's improvement efforts were rolled out in a campaign to catalyze action around six specific system interventions throughout hospitals in the United States. While the relationship between costs and these outcomes is complex, there are underlying drivers which affect both cost and outcomes. Their efforts thus present an interesting opportunity to study systematic improvements 'in the large'. Their effort is analagous to what many describe in corporate improvement programs as 'risk avoidance strategies'. Such strategies can be a challenge to demonstrate the benefits of, since it is difficult to substantiate what the world would truly be like under alternative scenarios.

Despite this, Initial indications are that IHI's efforts, in concert with other systemic improvements that had already been previously set in motion, have actually exceeded IHI's extremely ambitious targets - a monumental achievement, especially in such a short period of time. This article summarizes how these results were achieved, with the hope that their underlying approaches and lessons learned can be leveraged by others with similar challenges in implementing complex, systematic improvements in high pressure situations.