Into this fray steps Don Berwick, a guy that most people will never heard of, and who didn't even have his own Wikipedia article until I began one for him. But his name just kept popping up in books I was reading (Better and Super Crunchers) and in a presentation I'd seen from Tom Peters. When I dug deeper into what he was doing, I came away believing that his leadership of systematic improvements to health care are a pretty safe bet to win the Nobel Prize in Medicine some day.

Atul Gawande describes Berwick and his efforts this way:

Berwick ... provides multimillion-dollar grants to hospitals that are willing to try his ideas for improving medical practice. ... And among Berwick's key stipulations was that recipients had to open up their information to their patients - to "go naked", as one doctor put it. Berwick is an unusual figure in medicine. In 2002, the industry publication Modern Healthcare listed him as the third most powerful person in American health care. Unlike the others on the list, he is powerful not because of the position he holds.

At a conference in December 1999, Berwick gave a forty-minute speech distilling his ideas about the failings of American health care. Years afterward, people are still talking about the speech. Berwick is middle-aged, soft-spoken, and unprepossessing, and he knows how to use his apparent ordinariness to his advantage. He began his speech with a gripping story about a 1949 Montana forest fire that engulfed a parachute brigade of firefighters. Panicking, they ran, trying to make it up a 76 percent grade and over a crest to safety. But their commander, a man named Wag Dodge, saw that their plan wasn’t going to work. So he stopped, took out some matches, and set the tall dry grass ahead of him on fire. The new blaze caught and rapidly spread up the slope. He stepped into the middle of the burned-out area it left behind, lay down, and called out to his crew to join him. He had invented, on the spot, what came to be called an "escape fire," and it later became a standard part of Forest Service fire training. His men, however, either thought he was crazy or never heard his calls, and they ran past him. All but two were caught by the inferno and perished. Inside his escape fire, Dodge survived virtually unharmed.

As Berwick explained, the firefighter's organization had unraveled. The men had lost their ability to think coherently, to act together, to recognize that a lifesaving idea might be possible. This is what happens to all flawed organizations in a disaster, and, he argued, this is what is happening in modern health care. As medicine tries to cope with the advancing complexity of knowledge and treatment, it is falling short in performing even the simplest of its tasks.

To fix medicine, Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing. We should be routinely comparing the performance of doctors and hospitals, looking at everything from surgical complication rates to how often a drug ordered for a patient is delivered correctly and on time. And, he insisted, hospitals should give patients total access to the information. "'No secrets' is the new rule in my escape fire", he said. He argued that openness would drive improvement, if simply through embarrassment. It would make it clear that the well-being and convenience of patients, not of doctors, were paramount. It would also serve a fundamental moral good, because people should be able to learn about anything that affects their lives.

In 2005, Don Berwick said in a Newsweek article that "When I climb Mount Rainier I face less risk of death than I face on the operating table." Like all of us, he uses this same system, and is thus not immune to it's failings. He has described his wife's treatment, while she was in the hospital, this way: "One medication was discontinued by a physician's order on the first day of admission and yet was brought by a nurse every single evening fo 14 days straight." His experience is consistent with a Harvard Public Health, 2002 study: "More than 1 in 3 doctors reported errors in their own or a family member's medical care."

Don is perhaps unique in believing that it's possible to increase quality and reduce costs simultaneously. There is no substitute for a passionate change leader who has such a vision, is effective in pathfinding, and is committed to making their ideas stick. His ideas and insight have been focused on the effective delivery of value in the health care system, rather than just implementing change for change's sake, or to make political headlines, and are thus very refreshing. But for any change efforts to be effective, they must confront the constraint of the underlying culture's readiness and willingness to embrace and enable those changes.