Lessons for the future of health care



Donald M. Berwick, md, mpp president and ceo

institute for healthcare improvement

the commonwealth fund

lessons for the future of health carelesso n

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Escape Fire



lessons for the future of health care

Donald M. Berwick, md, mpp president and ceo

institute for healthcare improvement

the commonwealth fund

new york, new york

Escape Fire




On December 9, 1999, the nearly 3,000 individuals who attended the 11th Annual National

Forum on Quality Improvement in Health Care heard

an extraordinary address by Dr. Donald M. Berwick, the

founder, president, and CEO of the Institute for Healthcare

Improvement, the forum’s sponsor. Entitled Escape Fire,

Dr. Berwick’s speech took its audience back to the year

1949, when a wildfire broke out on a Montana hillside,

taking the lives of 13 young men and changing the way

firefighting was managed in the United States. After

retelling this harrowing tale, Dr. Berwick applied the

lessons learned from this catastrophe to the health care

system—a system that, he believes, is on the verge of its

own conflagration.

One of the three men who survived the Montana fire

did so through an ingenious solution and a leap of faith

—by making an escape fire. Dr. Berwick suggests that

the current state of health care demands as extreme and

dramatic an approach. To make his case, he describes the

failings of the health care delivery system as they were

revealed in his wife’s treatment for a serious illness. Only


Escape Fire is an edited version of the Plenary Address delivered

at the Institute for Healthcare Improvement’s 11th Annual National Forum

on Quality Improvement in Health Care,

in New Orleans, Louisiana, on December 9, 1999.

Copyright © 2002 Donald M. Berwick. All rights reserved.

Published in 2002 by The Commonwealth Fund,

One East 75th Street, New York, New York 10021-2692.

Book Design: Landesberg Design Associates, Pittsburgh

Photography : Imagebank /Photodisk (cover), Paul B. Batalden (page 7),

USDA Forest Service (page 8), Eric Carlson (pages 14–15),

Donald M. Berwick (page 36), Steve Starr for Corbis/SABA (pages 48–49)

Printing: Broudy Printing Inc., Pittsburgh

ISBN 1-884533-00-0

The site of the Mann Gulch fire, which is described in this book, is listed in the National Register of Historic Places. Because many regard it as sacred ground, it is actively protected and managed by the Forest Service as a cultural landscape.



Ultimately, Dr. Berwick’s brighter future for health

care requires the courage to acknowledge the shortcomings

of our current system and the will to transform it. We

hope that his speech will serve as a beacon, guiding the

health care system toward a brighter future.

Stephen C. Schoenbaum, md

Senior Vice President, The Commonwealth Fund

1 Davis K., Schoen C., and Schoenbaum S. “A 2020 Vision for American

Health Care,” Archives of Internal Medicine, (160)22: 3357–62, 2000.

2The World Health Report 2000—Health Systems: Improving Performance,

World Health Organization, 2000.


by abandoning many of the traditional tools of health care

delivery, only by opening up the system to the patients it

serves and instituting a standard of excellence, he says,

will the health care system be transformed.

The Commonwealth Fund is pleased to publish

Escape Fire in its entirety. We share its vision of a health

care system that is accessible to all at all times, designed

from the patient’s perspective, and grounded in science.

This vision is consonant with the aims of The Common-

wealth Fund, as set forth in “A 2020 Vision for American

Health Care,” and it illuminates the path for our

Program on Health Care Quality Improvement.1

Despite enormous expenditures and sophisticated

technologies, America’s health care system has been rated

37th in the world.2 We hope that Escape Fire will stimulate

all who read it to work to change this. For the general

public, this means addressing the need to provide access

to care for everyone at all times, demanding safer and

better care, and being willing to support the process of

improvement. For those in health care delivery, it means

abandoning the rhetoric that we provide the best care in

the world and using our vast power and resources to

redesign the system. For those who license or accredit or

regulate the system, it means informing the public about

health care standards and raising the bar on performance.




These are the flowers of Mann Gulch. And these are the markers of death.



Twenty miles north of Helena, Montana, the Missouri River flowing north cuts into the eastern

slope of the Rocky Mountains on the first leg of its great,

semicircular, 2,500-mile journey to meet the Mississippi.

Lewis and Clark passed through this spectacular formation

on July 19, 1805, and named it “Gates of the Mountains.”

Two miles downriver from the Gates, a small, two-mile-

long canyon runs down to the Missouri from the north-

east. This is Mann Gulch.

It is the site of a tragedy: the Mann Gulch fire. More

than 50 years ago, on August 5, 1949, 13 young men—

12 smokejumpers and one fireguard with the U.S. Forest

Service—lost their lives here in a fire that did not behave

as they expected it to. Although the disaster, the first one

in which smokejumpers died, was headline news at the

time, the story fell into relative obscurity until a book

appeared. Called Young Men and Fire, it was written by

Norman MacLean, a Shakespeare scholar and the author

of A River Runs Through It. MacLean, who had fought

forest fires as a young man, became obsessed with the

Mann Gulch story, and spent two decades researching it.

site of tragedy The smokejumpers’

last desperate moments

are shown in this

map, which uses letters

to mark the points

at which each was

overcome by the fire.





The first reconnaissance team headed down the south

side of the gulch. The foreman, Wag Dodge, became wor-

ried that the group could get trapped on that side. He

ordered them to come back and cross with the rest of the

men to the north side of the gulch, opposite the fire, and

head down the hill, so that the river, an escape route,

would be at their backs as they fought the fire.

The north side of the gulch was grassland, covered

in bunchgrass 30 inches tall, with almost no trees. It was

unfamiliar terrain to these firefighters, who had been

trained in the forests around Missoula.

Dodge was the first to spot the impending disaster—

the fire had jumped the gulch from the south side to the

north. It had ignited the grass only 200 yards ahead of

the lead smokejumpers, blocking their route to the river.

No one had seen the potential for this flanking action,

since the downhill view was obstructed by a series of low

ridges, and they had no detailed maps.

Now a race began. Dodge knew that the grassfire

would cut off the route to the river, and would head

swiftly up the north slope toward the firefighters. He

ordered the group to reverse course immediately, and

head back up the slope toward the ridge crest, hoping to

get over it before the fire did.

The north slope of Mann Gulch is steep—a 76 percent

slope on the average. Photos don’t capture the reality. You

His book was published in 1992, two years after his death

at age 87.

Many of you have probably read Young Men and Fire.

For those who haven’t, let me briefly tell the story.

On the afternoon of August 4, 1949, a lightning storm

started a small fire near the top of the southeast ridge of

Mann Gulch—Meriwether Ridge, a slope forested with

Douglas fir and ponderosa pine. The fire was spotted the

next day; by 2:30 p.m., a C-47 transport plane had flown

out of Missoula, Montana, carrying 16 smokejumpers.

One got sick and didn’t jump. The rest—15 men between

17 and 33 years old—parachuted to the head of the gulch

at 4:10 p.m. Their radio didn’t make it. Its chute failed to

open, and it crashed. They were joined on the ground

by a fireguard, who had spotted the fire. Otherwise, the

smokejumpers were isolated from the outside world.

The smokejumpers were a new organization, barely

nine years old in 1949. Building in part on military

experience from World War II, they were reinventing the

approach to forest fire containment—aggressive, highly

tactical, and coordinated. To them, the Mann Gulch fire,

covering 60 acres at the time of the jump, appeared rou-

tine. It was what they called a “ten o’clock fire,” meaning

that they would have it beaten by ten o’clock in the

morning of the day after they jumped.

They were wrong.





right past the answer. The fire raged past Wag Dodge and

overtook the crew. Only three made it to the top of the

ridge, and one of the three was so badly burned that he

died a few hours later. Of the 16 men who had fought the

fire, three lived: Robert Sallee and Walter Rumsey, who

made it over the crest, and Wag Dodge, who survived

nearly unharmed in his escape fire.

have to go there to understand. It is hard even to walk up

such a slope, but these young men were trying to run up

it. Add air 100 degrees at the start and superheated by the

rushing fire, add the poor visibility from smoke and air-

borne debris, add the weight of the packs and tools that

these men were taught never to drop, and add their

inexperience with the pace and heat of grassfires—

far hotter and moving a lot faster than fires in forests.

At 5:45 p.m., when the crew turned around, the fire was

traveling toward them at 120 feet per minute, or 1.4 miles

an hour. Ten minutes later, at 5:55 p.m., it was traveling

at 610 feet per minute—seven miles an hour.

Wag Dodge knew they would lose the race to the top.

With the fire barely 200 yards behind him, he did a strange

and marvelous thing. He invented a solution. On the spot.

His crew must have thought he had gone crazy as he took

some matches out of his pocket, bent down, lit a match,

and set fire to the grass directly in front of him. The new

fire spread quickly uphill ahead of him, and he stepped

into the middle of the newly burnt area. He called to his

crew to join him as he lay down in the middle of the burnt

ground. Dodge had invented what is now called an “escape

fire,” and soon after Mann Gulch it became a standard

part of the training of all Forest Service firefighters.

But, on August 5, 1949, no one followed Wag Dodge.

They ignored him, or they didn’t hear him, and they ran




learning from disaster A group of students

from The Wharton School

at the University of

Pennsylvania learn vital

lessons in teamwork,

communication, and

improvisation from the

Mann Gulch tragedy.



When I first read Young Men and Fire, the story gripped me. I didn’t understand why until I

read a paper by Professor Karl E. Weick, of the University

of Michigan. Weick is a student of organizations, espe-

cially organizations under stress, and even more especially

organizations that are able to function well under trying

conditions, the so-called high-reliability organizations, like

aircraft carriers and the smokejumpers at their best. His

paper is called,“The Collapse of Sensemaking in Organi-

zations: The Mann Gulch Disaster.” I want to review some

of Weick’s main points here, and then I will find my way—

though you probably think I can’t—back to health care.

Weick asks two questions about the Mann Gulch

tragedy: Why did the smokejumpers’ organization unravel?

And, how can such organizations be made more resilient?

Weick regards the group of Mann Gulch smoke-

jumpers as an organization, and he thinks that one of the

key roles of organizations is what he calls “sensemaking.”

He has written a fine book called Sensemaking in Organi-

zations. Sensemaking is the process through which the

fluid, multilayered world is given order, within which





For the Mann Gulch smokejumpers, what appeared

to be a small, manageable fire quickly turned into some-

thing unknown, and much more dangerous. Weick calls

this sudden loss of meaning a “cosmology episode.” The

experience is fundamental and terrifying—the group,

the roles, the interrelationships, the tools, the orderliness

that the sensemaking organization had provided collapse,

and people are left alone, unable to communicate with

each other. They panic.

Weick supplies a “recipe” for the collapse of sense-


Thrust people into unfamiliar roles; leave some

key roles unfilled; make the task more ambiguous;

discredit the role system; and make all of these

changes in a context in which small things can

combine into something monstrous.

Now, maybe my route back to health care is becoming

a little bit clearer.

Is health care unraveling? Are we in a cosmology


In a recent survey of 42 medical group practices

about morale among physicians and office staff, only 15

percent of the respondents rated their work environ-

ment as “good” or “excellent.” Medicare and Medicaid

managed care rolls are dropping monthly. We have tens

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.

Weick tells the story of a reconnaissance group of

soldiers lost in the Alps on a training mission. It was

winter, they had no maps, and they seemed hopelessly

lost. They were preparing to die, when one soldier found

a map crushed down at the bottom of his pack. With the

map in hand, they regained their courage, bivouacked

for the night, and proceeded out of the mountains the

next day to rescue. Only when they were recuperating in

the main camp did someone notice that the map they

had been using wasn’t a map of the Alps at all; it was a

map of the Pyrenees. Weick uses this story to point out

that sensemaking is an act of its own, valuable in itself,

and independent of any notion of reality. “This story

raises the remarkable idea,” he says, “that, when you are

lost, any map will do.”

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.





hospitalizations for a total of more than 60 inpatient days in

three institutions, while she gradually experienced increas-

ing pain, lost the ability to walk, and became essentially

bedridden. For most of that time, nobody could tell us

what exactly was happening or what her prognosis was.

I can report some better news now, because Ann has clearly

begun to improve. She can now walk long distances with

a cane, and she is beginning to get back to her work, and

she and I think she is going to be all right, though it will

take a long time.

My dilemma is this: Our ordeal has been enormously

painful and intensely private, and it is by no means over

yet. To use it for any public purpose, even to speak about

it, risks crossing a boundary of propriety and confiden-

tiality that ought not to be crossed. And yet, this has

been the formative experience for me overall in the past

year—the experience of the decade—and it resonates

so thoroughly with the mission of improving health care

that not to learn from it also seems wrong.

I asked Ann for permission to speak about her illness,

and she agreed. She and I both hope that some good can

come of it.

Let me first say that this painful summer and fall have

left me more impressed than I have ever been with the good

will, kindness, generosity, commitment, and dignity of

the people who work in health care—almost all of them.

of millions of uninsured Americans, significant medica-

tion errors in seven out of every 100 inpatients, tenfold

or more variation in population-based rates of impor-

tant surgical procedures, 30 percent overuse of advanced

antibiotics, excessive waits throughout our system of care,

50 percent or more underuse of effective and inexpensive

medications for heart attacks and immunization for the

elderly, and declining service ratings from patients and

their families. In 1998, the American Customer Satis-

faction Index rated Americans’ satisfaction with hospitals

at 70 percent, just below the U.S. Postal Service (71%) and

just above the Internal Revenue Service (69%). Racial gaps

in health status remain enormous; a black male born in

Baltimore today will, on the average, live eight years less

than an average white male. All this happens with per

capita health care costs 30 to 40 percent higher in the

United States than in the next most expensive nation.

But, is the health care system unraveling? Isn’t that

going a bit too far?

I face a personal dilemma here. This has been a tough

year for my family, and especially for my wife, Ann, who

last spring began developing symptoms of a rare and

serious autoimmune spinal cord problem. In early March,

Ann competed in a 28-kilometer cross-country ski race

in Alaska. Two months later, she couldn’t walk across our

bedroom. From April through September, Ann had six





concerned; now, I am radicalized. If what happened to

Ann could happen in our best institutions, I wonder

more than ever before what the average must be like.

Above all, we needed safety, and yet Ann was unsafe.

I have read the work of the physician Lucian Leape docu-

menting medication errors, but now I have seen them

firsthand, at the sharp end, sitting by Ann’s bedside for

week after week of acute care. The errors were not rare;

they were the norm. During one admission, the neu-

rologist told us in the morning, “By no means should

you be getting anticholinergic agents,” and a medication

with profound anticholinergic side effects was given that

afternoon. The attending neurologist in another admis-

sion told us by phone that a crucial and potentially toxic

drug should be started immediately. He said, “Time is of

the essence.” That was on Thursday morning at 10:00 a.m.

The first dose was given 60 hours later—Saturday night

at 10:00 p.m. Nothing I could do, nothing I did, nothing

I could think of made any difference. It nearly drove me

mad. Colace was discontinued by a physician’s order on

Day 1, and was nonetheless brought by the nurse every

single evening throughout a 14-day admission. Ann was

supposed to receive five intravenous doses of a very toxic

chemotherapy agent, but dose #3 was labeled as “dose

#2.” For half a day, no record could be found that dose #2

had ever been given, even though I had watched it drip

Day after day and night after night, Ann, our children,

and I have been deeply touched by acts of consideration,

empathy, and technical expertise that these good people—

nurses, doctors, technicians, housekeepers, dieticians,

volunteers, and aides of all sorts—have brought to her

bedside. The kindness crosses all boundaries. I asked Ann

what she regards as the most impressive moments of

help in her inpatient experience, and she mentions, first,

a housekeeper who every evening would come into her

room and, while cleaning, talk about her children and

ours—a common humanity. Ann also remembers the

young infectious disease fellow who, in the darkest of

our hours, sat by Ann’s bed and said what we were feel-

ing: “Not knowing is the worst thing of all.” Until then,

no one had quite labeled this deep source of suffering.

For these incessant kindnesses, we are deeply grate-

ful. We were fortunate, indeed, to have access to care in

several of the finest hospitals in our nation.

Which makes it hard to tell the other side of the story,

too. Put very, very simply: The people work well, by and

large, but the system often does not. Every hour of our

care reminded me, and alerted Ann, about the enor-

mous, costly, and painful gaps between what we got in

our days of need, and what we needed. The experience

did not actually surprise me, but it did shock me. Put in

other terms, as a friend of mine said: Before this, I was





so many settings that, short of a graph, no rational inter-

pretation was possible. As a result, physicians often reached

erroneous conclusions, such as assuming that Ann had

improved after a specific treatment when, in fact, she had

improved before it, or not at all. The experience of patient-

hood, or patient-spousehood, as the case may be, was often

one of trying to get the attention of decision-makers to

correct their impressions or their assumptions. Sociolog-

ically, this proved very tough, as we felt time and again

our migration to the edge of the label “difficult patient.”

We needed respect for our privacy, personal attention,

and timely care. Often we got it. But often we didn’t. On

at least three occasions, Ann waited alone for over an hour,

cold and frightened on a gurney in the waiting area out-

side an MRI unit in a sub-basement in the middle of the

night. A nurse insisted that Ann swallow her pills while

she watched, “because elderly patients sometime drop

their medicines.” Ann’s bedtime was 10:00 p.m., but her

sleeping medication was often brought at 8:00 p.m., to

accommodate changes in nursing shifts. By Day 30 of

hospitalization, Ann knew exactly which sleeping pills

would work and which would not, and yet it was a daily

struggle to get the right ones to her, as new clinicians

insisted on trying their own approaches, ignoring Ann’s

expertise. One place gave a sleeping pill at 3:00 a.m., and

then routinely woke Ann at 4:00 a.m. to take her blood

in myself. I tell you from my personal observation: No

day passed—not one—without a medication error. Most

weren’t serious, but they scared us.

We needed consistent, reliable information, based,

we would have hoped, on the best science available.

Instead, we often heard a cacophony of meaningless and

sometimes contradictory conclusions. Ann received

Cytoxan, which causes hair loss and low white blood cell

count. When would these occur? we asked. The answers

varied by a factor of five. Drugs tried and proven futile

in one admission would be recommended in the next as

if they were fresh ideas. A spinal tap was done for a test

for Lyme disease, but the doctor collected too little fluid

for the test, and the tap had to be repeated. During a cru-

cial phase of diagnosis, one doctor told us to hope that

the diagnosis would be of a certain disease, because that

disease has a benign course. That same evening, another

doctor told us to hope for the opposite, because that same

disease is relentless—sometimes fatal. Complex, serial

information on blood counts, temperature, functional

status, and weight—the information on the basis of which

risky and expensive decisions were relying—was collected

in disorganized, narrative formats, embedded in nursing

notes and daily forms. As far as I know, the only person

who ever drew a graph of Ann’s fevers or white blood cell

counts was me, and the data were so complex and crossed





involved. And yet, to my knowledge, only three of these

individuals made any effort to follow Ann’s course after

any particular discharge, and these three are actively

managing Ann’s outpatient care at this time. The rest

have, I suspect, no way at all to know how she is faring,

or whether their diagnoses and prognoses were, after all,

correct. Continuity, when it occurred, was based on acts

of near heroism. Ann’s primary neurologist travels fre-

quently for speaking engagements. When he was away

during crucial times, he phoned Ann every day, whether

from Amsterdam, London, Geneva, or San Francisco.

One after another, caregivers told us of their own

distress. The occupational therapist apologized for cut-

ting back Ann’s treatment, explaining that 17 OTs had

been laid off the week before. The doctors told us about

insurance forms and fights for needed hospital days. The

nurses complained that the transport service never came.

And the bills were astounding. They have been

covered by our insurance, for which we are immensely

grateful. But I cannot reconcile what happened with the

fees. Pharmacy charges of $30 for a single pill. Remember

the Colace that was discontinued but brought anyway?

Well, there it is: Pill by pill charges for all the days on

which the nurse opened the unneeded packet and threw

it in the garbage. Radiology charges of $155 per film for

second readings of 14 films transferred from one hospital

pressure, which never varied from normal. An emergency

room visit for a diagnostic spinal tap that should have

taken two hours evolved into an 11-hour ordeal of con-

stant delay.

In all of our hospitalizations, there have been only

two instances when someone actively sought our feed-

back on the care system itself. Only two people ever asked

us to make suggestions about how their system could be


We needed continuity. Ann’s story was extremely

complex, and evolved over many weeks. And yet we often

felt that the only real memories in the system were ours.

Times of transition of responsibility, such as the first of

the month, were especially trying. On one “first of the

month,” the new senior attending physician walked into

Ann’s room, cheerfully introduced himself, and asked,

“So how long have you had MS?” Ann doesn’t have MS.

Over and over and over again Ann had to tell her story,

longer and more complex as time passed. By the fifth or

tenth or fifteenth iteration, any plausibility to the com-

mon explanation—“fresh minds, two heads are better

than one”—gave way to our doubts that any of these

caring people ever talked to each other at all. “Discharge”

from a hospital really meant it. I would estimate that 50

different doctors and three times as many nurses became

closely involved with Ann’s care in hospitals—intensely





They see it every day, and even if their defensive routines

no longer permit them to say what they see, they do see it:

errors, delays, nonsensical variation, lack of communi-

cation, misinformation, the care environment not at all

a place of healing.

to another. MRI scans over and over again for $1,700,

$2,000, $2,200 per procedure. Ann’s care has been billed

at perhaps $150,000 so far, at a minimum, and the bare

fact is that, of all that enormous investment, a remarkably

small percentage—half at best, probably much less—

stood any chance at all of helping her. The rest has been

pure waste. Even while simpler needs, for a question

answered, information explained, a word of encourage-

ment, or just good and nourishing food, have gone unmet.

Not all of these flaws in care were equally present in

all of the hospitals. Some were much better than others.

In fact, if we could combine the best of care in each, we

would have a system far closer to ideal. But some of these

defects existed everywhere, and this was in some of the

best hospitals in America.

I am deeply, deeply grateful for the people, and I

respect the institutions a great deal. But we have so much

left to do. We are causing harm, and we need to stop it.

I think the fire has jumped the gulch. The blaze is on

our side. As I waited helplessly for Ann to get a medicine

when “time was of the essence,” I even felt the fire licking

at my heels.

The people know this. Not just the people in the

beds, but the people doing the work, too. The doctors

and nurses and technicians and managers and pharma-

cists and all the rest know— they must know—the truth.




“Why do organizations unravel?” asks Karl Weick.“Because they no longer make sense of the world,”

he answers. I love medicine. I love the purpose of our

work. But we are unraveling, I think. Sense is collapsing.

And yet, this does not need to happen. Sensemaking

is within our reach. Karl Weick asks a second question,

with much more embedded optimism: “How can organi-

zations be made more resilient?”

He answers that resilience has four sources in orga-

nizations, equipping them to, in his words, “forestall

deterioration” of their sensemaking function.

First, there is “improvisation,” the ability to invent

when old formulas fail. The young men at Mann Gulch

had been trained to never, under any circumstances,

drop their tools. One of their tools was a Pulaski, a com-

bination axe and pick that is very useful in fighting forest

fires. It’s not useful to carry it up a 76 percent slope when

a grassfire is racing toward you at 610 feet per minute.

And yet, the reconstructed journeys of the victims of the

fire show that several carried their Pulaskis a good way

up the hill as they raced for their lives. Wag Dodge, in the





underdeveloped,” Weick maintains, “then they are on

their own. And fear often swamps their resourcefulness.

If, however, a role system collapses among people where

trust, honesty, and self-respect are more fully developed,

then new options…are created.”

I think that this idea—the loss of sensemaking—is

a powerful vocabulary for interpreting the health care

crisis of our time. At least it captures the most disturbing

aspects of what Ann and I experienced this year. If I’m

right, then it might lead us to new ideas that are every bit

as tough to embrace as Wag Dodge’s escape fire, and every

bit as promising. I want to imagine health care’s escape

fire, and I want to be bold.

I have decided to divide the question into two parts.

It seems to me that the health care system’s capacity to

preserve sensemaking in a time of crisis requires change

at two levels. I call them preconditions and designs.

Preconditions are a set of shared assumptions that

don’t tell us what future we need to build, but that give

us a chance of staying in order long enough to tackle that

issue. They make sense possible.

Designs are the basic ideas behind the escape fire itself.

These are the new ways of thinking about what we do. The

new sense. The scheme we create together to organize a world

that threatens otherwise to become chaotic and overtake us.

midst of ultimate crisis, improvised the escape fire, though

no one followed him.

Second, there are what Weick calls “virtual role

systems.” These systems refer to the ability of individuals

to carry, as it were, a social system inside their heads—

to assume structures even when they are not externally

apparent. If the smokejumper crew had still seen Wag

Dodge as their leader when he invented his escape fire,

maybe they would have followed him. They didn’t: The

smoke and fear and noise and shock had not only dis-

rupted the smokejumper system as a formal entity, it had

also disrupted its representation in the mind of each

individual. The organization could have been preserved

if individual minds had held on to it, but they did not.

The system fragmented, and the roles disappeared.

Third, says Weick, resilience within an organization

is maintained by “the attitude of wisdom.” He quotes

John Meacham, who writes, “Ignorance and knowledge

grow together.…To be wise is not to know particular

facts but to know without excessive confidence or exces-

sive cautiousness.…[In changing times] organizations

most need…curiosity, openness, and complex sensing.”

Fourth and finally, Weick says, resilience requires

“respectful interaction.”“If a role system collapses among

people for whom trust, honesty, and self-respect are





need to go by stressing the current system. You can’t

possibly run fast enough up a 76 percent slope.

Let me show you the difference. At the Institute for

Healthcare Improvement, we have two bathrooms. Each

has a sign on the door that can be set in two positions:

“vacant” or “occupied.” You flip the sign as you enter and

leave. Or, you don’t. In 71 observations, I obtained the

following data. The sign was correct 43 out of 71 times,

or 61 percent of the time. It was wrong 39 percent of the

time. The most common error, 30 percent of the time,

was that the sign said “occupied” when the room was

actually vacant. This error causes moderate to severe dis-

comfort in timid staff members who do not check the

door handle. The other error, 10 percent of the time, was

that the sign said “vacant” when the room was actually

occupied. This error can cause injury if a staff member

tries to pull the door and it is locked, or embarrassment

if they trust the sign and the occupant has forgotten to

lock the door.

The sign system functions poorly. In fact, if you

simply guessed that the room was vacant, you would

have been right 44 times out of 71, or 62 percent of the

time—more often than the sign.

I decided to fix the system by emphasizing it. Here

is my reminder sign. It never lasted more than an hour

I can see five preconditions that give us a chance at


The first is the toughest: We need to face reality.

This is very, very hard. 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. Our challenge is not

to develop more sensitive ways to detect our risks, our

errors, our flaws, our variation, our indignities, our frag-

mentation, our delays, our waste, our insults to the people

we say we exist to serve. Our challenge is to have the cour-

age to name clearly and boldly the problems we have—

many—at the size they occupy—immense. We must find

ways to do this without either marginalizing the truth-

teller or demoralizing the good people working in these

bad systems.

David Lawrence, former CEO of Kaiser Permanente

Foundation Health Plan, has said it best. He said, “The

chassis is broken.” Our challenges are not marginal and

their solutions are not incremental. The sooner we get hon-

est about those facts, the sooner we can get on with the job.

The second precondition is that we drop the Pulaskis.

Our current tools can’t do the job. We can’t get where we




before someone tore it down. I tried to highlight its

importance by making a sign for the sign for the sign,

but that, too, was torn down. The experiment ended with

a surge of graffiti, which I thought lacked taste.

Such an approach will never work. On the other hand,

you and I have both been in airplanes with a lavatory sign

system that is right nearly 100 percent of the time. The

reason is that the locking system in airplane lavatories

uses a design principle called a “forcing function.” It

doesn’t allow for choice—you can’t lock the door or turn

on the light without changing the sign. And you can’t

open the door without changing the sign again.

Our health care escape fire will have the same prin-

ciples. It will not just invoke different tools, it will force

us to drop the old ones. Health care’s backpack is full of

useless assumptions so old and often repeated that they

have become wisdom from the mouth of Hippocrates

himself, and one questions them at grave risk to one’s

professional relationships.

Precondition number three is that we “stay in

formation.” Weick refers to this as having virtual role

models. In the Mann Gulch fire, the organization dis-

appeared at the moment of crisis. It became every man

for himself. Nobody remembered that Wag Dodge was

the most experienced and the leader, or that together the

crew might learn something that separately they could





The fourth precondition is procedural: To achieve

sense, we have to talk to each other, and listen. Sensemaking

is fundamentally an enterprise of interdependency, and

the currency of interdependency is conversation. In the

noise and smoke of the fire, just at the time when our inter-

dependency is most crucial, it becomes most difficult to

communicate. This will not do. Civil, open dialogue is a

precondition for success.

The fifth, and final, precondition for success I can

see is leadership. You don’t achieve sense without having

leaders. Effective leaders in high-reliability organizations

exhibit certain skills: clearly defining tasks; demonstrat-

ing their own competence; disavowing perfection so as

to encourage openness; and engaging and building the

team. Leadership like this makes constructive, informed

interactions more likely and, at a deeper level, leaves the

sensemaking apparatus intact as the context changes.

I believe that these five preconditions—facing reality,

dropping the old tools, staying in formation, communi-

cating, and having capable leadership—set the stage for

making sense as the fire blows up. Now we have a chance.

What does the escape fire look like?

not. The men’s bodies afterward were literally strewn for

300 yards across the slope.

Successful sensemaking can’t leave anyone out. Health

care’s disintegration is not yet every man for himself, but

it is every discipline for itself, every guild for itself. As a

result, we tend to assume today that one guild’s solution

cannot be another’s. We assume that either we will pre-

serve quality or cut costs; that patients will get what they

ask for or that science will prevail; that managers will

run the show or that doctors will be in control; that the

bottom line is financial or moral.

This won’t work. No comprehensive solution is

possible if it fails to make sense to any of the key stake-

holders. At least four parts of our crew need to share in the

solution—a common answer—or the crew will fall apart.

Whatever escape fire we create has to make sense in the

world of science and professionalism, in the world of the

patient and family, in the world of the business and

finance of health care, and in the world of the good, kind

people who do the work of caring. I think the toughest

part of this may be in terms of the business and financ-

ing of care. There is a tendency to assume that financial

success—e.g., thriving organizations—and great care are

mutually exclusive. However, we will not make progress

unless and until these goals become aligned with each other.




I think that health care’s escape fire has three primary design elements. None is totally new, but together,

fully realized, they would create a care system that is as

different from today’s as a 76 percent slope is from an

escape fire. I will call these elements access, science, and


“Access” refers to the property of a system that

promises, “We are there for you.” The current system of

care embeds processes and assumptions that ration, limit,

and control access. To get help requires appointments,

permission, authorization, waiting, forms, and procedures

to which the person in need must bend their need. In the

current system, first we allocate the supply, and then we

experience the demand. We accept as inevitable that acces-

sibility at some times—weekends, nights, holidays—is of

course different from 9 to 5. Demand often feels unpre-

dictable, threatening, and even hostile, and we reply with

equal unpredictability, threat, and counter-accusations

about insatiable patients and unrealistic expectations.





that we have trouble seeing it. The health care encounter

as a face-to-face visit is a dinosaur. More exactly, it is a

form of relationship of immense and irreplaceable value

to a few of the people we seek to help, and these few have

their access severely curtailed by the use of visits to meet

the needs of many, whose needs could be better met

through other kinds of encounters.

The alternatives to visits in the escape fire are many:

self-care strongly supported and unequivocally encour-

aged; group visits of patients with like needs, with or

without professionals involved; Internet use for access to

scientific and popular information; e-mail care between

patients and clinicians; and well-managed chat rooms,

electronic and real, for patients and significant others

who face common challenges.

Payers should take careful note: Most of you still pay

only for Pulaskis. The greatest potential for reducing costs

while maintaining and improving the lot of patients is to

replace visits with better, more flexible and fine-tuned

forms of care. But almost all current payment mechanisms,

whether enforced by the market or mapped into organi-

zations by internal compensation systems, use impover-

ished definitions of productivity that actively discourage

the search for and incorporation of non-visit care.

Another form of access is access to one’s own med-

ical information; it, too, is a form of non-visit care. An

All of this changes in the escape fire. The new system

of access can be summarized in one phrase: “24/7/365.”

The access to help that we will envision is uncompromis-

ing, meeting whatever need exists, whenever and wherever

it exists, in whatever form requested.

Before the howling starts, let me remind you of one

precondition: Drop your Pulaskis. 24/7/365 is not at all

achievable with the current tools. Meeting demand this

well within current frameworks is harder than running a

marathon up a 76 percent grade. It cannot be done.

Our Pulaski in the search for access is the encounter

—the visit. Total access 24/7/365 begins to be achievable

only when we agree—scientists, professionals, patients,

payers, and the health care workforce—that the product

we choose to make is not visits. Our product is healing

relationships, and these can be fashioned in many new and

wonderful forms if we suspend the old ways of making

sense of care.

The access we need to create is access to help and

healing, and that does not always mean—in fact, I think it

rarely means—reliance on face-to-face meetings between

patients, doctors, and nurses. Tackled well, I believe that

this new framework will gradually reveal that half or more

of our encounters—maybe as many as 80 percent of

them—are neither wanted by patients nor deeply believed

in by professionals. This is an example of a problem so big





Whenever we put a block or bottleneck in the way of

knowledge transfer—whether we call it an appointment,

or permission, or even a decision by anyone other than

the person who wants to know—we add cost without

value and fail to meet need. We also put 24/7/365 even

further from our reach.

I recently visited a magnificent new hospital, which

has developed a state-of-the-art health information library

for patients. There were computer terminals everywhere,

user-friendly books, three-dimensional models, and a

full collection of instructional videotapes. I spoke to the

nurse who ran the library, and she complained that it

was vastly underutilized because they were having a hard

time getting doctors to send their patients there.

I asked, “Why not go directly to the patients and get

the doctors out of the loop?”

She said, “The doctors would never go for that.”

I wanted to say, “Come into my escape fire. In here,

we know that information is a form of care, and that

doctors’ visits and decisions are, too. And we want to make

sure that anyone who needs either gets it. Doctors are

useful for some forms of caring; information resources

like yours are useful for others.”

So, the first element of my escape fire is total access,

without compromise: 24/7/365.

employee of the Institute for Healthcare Improvement

recently had a test for a potentially serious disease. She

called the clinical office for the result, and heard the

following: “Yes, Ms. Smith…your result is right here. It

is…uh-oh…ah…Ms. Smith, I am not authorized to

give you this information. You will need to talk with the

doctor. He will be back tomorrow.” When my wife was

on Cytoxan, she and I were the only people who were

actually tracking her white blood cell count graphically,

and yet several of her nurses refused to tell us the white

count results when they became available.

The medical record properly belongs to the patient,

not to the care system. It must become an open book to

the patient, available without restriction, hesitation, or

suspicion. Diane Plamping, a public health researcher

from the U.K., offered me the following rule about access

to information: “Nothing about me without me.”

In my escape fire, we will have a new view of the

nature of information in health care. In the current model,

information is treated generally as a tool for retrospec-

tion, a record of what has happened, a stable asset that

we may or may not use to recall the past, or to defend or

prosecute a lawsuit.

Here in my escape fire, the view of information is

different. Information, we now see, is care. People want

knowledge, and the transfer of knowledge is caring, itself.





Physicians stand only to gain from this change of

perspective. They know, as I do, that the volume of sci-

entific medical literature today far outpaces the capacity

of any one doctor—any 100 doctors —to stay up-to-date.

Dr. Larry Weed—a physician and a specialist in medical

informatics—says that asking an individual doctor to

rely on his memory to store and retrieve all the facts

relevant to patient care is like asking travel agents to

memorize airline schedules. The art of the physician is to

synthesize many different sources of information; this

art should be used exactly and only when less expensive,

less creative resources will not suffice.

This issue does not begin with a commitment to

artificial intelligence or knowledge management. It begins

with a commitment to standardize excellence.

This includes a commitment to safety for patients

and for staff. By some calculations, the aviation indus-

try’s safety record is better than health care’s by a factor

of 1,000 or more. And aviation safety has improved ten-

fold in the past three decades, during a period of massive

growth in volume and technology. This has been accom-

plished through science, not through exhortation. There

are safe designs and there are unsafe designs. The issue

has very little to do with the will or capability of human

beings, who almost never intend errors to happen. It has

a lot to do with whether leaders, board members, and

The second element is science. At its best, the help

we offer is based in knowledge. When care matches

knowledge, it is most reliable. When care does not match

knowledge, we fail to help, either by omission (failing to

do what would help) or by waste (doing what cannot

help). The current world is far too tolerant of mismatches

between knowledge and action, far too permissive of

omission and waste. As a result, our care is unreliable,

our answers are inconsistent, and our practices vary with-

out sense.

The escape fire looks different. I urge here that we

adopt Dr. James Reinertsen’s formulation: “All and only.”

“We will promise to deliver, reliably and without error, all

the care that will help, and only the care that will help.”

The Pulaski here may be an illogical commitment to

the autonomy of clinical decisions. Just as the hospital

with the patients’ library illogically places the doctor

between the patient and the information the patient

wants, so the system fundamentally committed to auton-

omy places the individual doctor’s mind between the

patient and the best knowledge anywhere. Doctor visits

are irreplaceable, sometimes; so is a doctor’s autonomy

to assure that the patient is well served. But, in my escape

fire, I would place a commitment to excellence—stan-

dardization to the best-known method—above clinician

autonomy as a rule for care.




information access A cardiology patient at

the University of Colorado

Health Sciences Center

reviews his electronic

medical record with Chen-

Tan Lin, md, as part

of a study of information

access and its value.




the burden it must bear so that it can deliver the care. As

a result, behaviors and systems emerge to control or limit

interactions—as if they were a form of waste—and to

regard commitment to interaction as a secondary issue in

training, resource allocation, hiring, firing, and incentive.

In the escape fire, we see it differently. Here, we

know that interaction is not the price of care; it is care,

itself. A patient with a question presents an opportunity,

not a burden. Time spent in building patients’ skills in

self-care is not a way to shift care, it is care. Access to

information is desirable not because it improves care or

supports compliance, but because it is a form of care.

University of Michigan education professor David

Cohen says that no education occurs until what he calls

“inert” assets (books, teachers, rooms, curricula, rules,

budgets, and so on) interact with each other and with

students. Education is interaction. People in educational

organizations, he says, often behave as if the inert assets

were essential and the interactions expendable. They fight

political wars over budgets, space, and personnel, and

spend little time defending and perfecting the inter-

actions among these assets through cooperation, commu-

nication, teamwork, and knowledge about students.

It is the same in health care. Care is not doctors,

nurses, hospitals, computers, books, rules, or medicines.

These are inert. Care is interaction among our assets and

managers employ the best available knowledge about safe

designs for tasks, equipment, rules, and environments

instead of relying on outmoded traditions and impover-

ished theories about motivation and “trying harder.”

A scientific system of care would guarantee that the

best-known approach is the standard approach.

The third element of the escape fire I will call

“relationships” or, perhaps, “interactions.” While the first

element, access, encourages us to consider how people

get to the help they need, and the second, science, asks us

to consider how we can assure that the best knowledge

informs action, the interactions element challenges our

current notions of the very nature of help, itself. It raises

the question of what, in the end, we are spending $1 trillion

to produce. It is about our purposes.

In Mann Gulch, the transition of purpose was stark

and total—from defeating a ten o’clock fire to saving

lives. Until that event, the smokejumpers’ training and

intent were focused almost entirely on the first task, and

very little on the second. They felt invincible. After Mann

Gulch, it became clear to all that smokejumper safety

and survival was a task on its own, and the most impor-

tant one.

In the current framework, health care tends to regard

human interactions more as a toll or price than as a goal

or product. The system tends to act as if interactions were





according to his or her needs, not ours. Our measure of

successful interaction is not just an average of how we

have done in the past for “them,” but also the answer to

the inquiry, “How did I just do for you?”

Third, interactions in the escape fire begin with this

assumption: The patient is the source of all control. We

act only when the patient grants that privilege, each time.

The current system—the one ablaze—often behaves as

if control over decisions, resources, access, and informa-

tion begins in the hands of the caregivers, and is only

ceded to patients when the caregivers choose to do so.

My wife had a surgical procedure and awoke in the

recovery room asking for me. I was not permitted to join

her for almost 90 minutes, even though she repeatedly

asked that I be allowed to comfort her. Why did that staff

and that institution willfully separate a man and his wife

at a time when they could have offered support to one

another? By what right does a nurse, doctor, or manager

make a decision that violates basic principles of human

decency and caring? As a husband and as a physician, I

know that the rationale for asserting that right stands on

infirm ground. In any other setting, such an act would be

obviously wrong. In this one, it is less obvious, but it is

still wrong.

Control begins in the hands of the people we serve.

If we caregivers wish to take it, we must ask. If a patient

between assets and patients. To perfect care, we must

perfect interactions.

Four properties of interaction ought to be objects of

investment and continual improvement in the escape

fire. The first we have already covered: to regard infor-

mation transfer as a key form of care, and to increase the

accessibility, openness, reliability, and completeness of

information for patients and families. Generic, scientific,

and patient information should be available to them

without restriction or delay. “Nothing about me without

me” is a formula for idealized interaction just as it is for

idealized access.

Second, interactions should be tailored to patients’

needs. The call to arms here comes to me from a friend

named Art Berarducci, who, when he was CEO of a small

hospital, placed over the entrance a sign that read: “Every

patient is the only patient.” Each person in need brings to

us a unique set of qualities that require unique responses.

The overall list of such qualities may be familiar: comfort,

dignity, communication, privacy, involvement of loved

ones, respect for cultural and ethnic differences, need for

control and sharing in decisions, and so on. But, for each

individual, “quality of care” means balancing these various

needs at levels that only the individual patient can deter-

mine. In the escape fire, we are not finished—we have not

achieved excellence—until each individual is well served





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 relation-

ship; 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.

It is a new system, and a lot of the old tools won’t

work anymore. Those who cling to their old tools and

allow our organization to disintegrate will find little sense

either in the burning present or in the challenging future.

For them, sensemaking will have failed, and the panic of

isolation will drive them up a slope that is too far and

too steep for them to make it. For the rest, the possibility

of invention and the opportunity to make sense—new

sense—will open not just routes of escape, but vistas of

achievement, that the old order could never have imagined.

denies control, then we must accept their will as a matter

of right. We are not hosts in our organizations so much as

we are guests in our patients’ lives.

Finally, the interactions we nurture should be trans-

parent. People often say that health care needs more

“accountability.” I have never quite known what that

means. But I do understand the notion of transparency,

and why it may help in the sensemaking process, and per-

haps better achieve what those who urge accountability

mean to have. In the old world, burning now, there is a

premium on secrecy. The highly desirable goal of confi-

dentiality has mutated into a monstrous system of closed

doors and locked cabinets. “Nothing about me without

me” has a necessary correlate: “I can discover what affects

me.” Health care should be confidential, but the health

care industry is not entitled to secrecy.

The burden of reporting that has arisen in a world

burning with conflict and mistrust has cast transparency

in its most negative light. And yet I cannot imagine a

future health care system in which we do not work in

daylight, study openly what we do, and offer patients any

windows they want onto the work that affects them. “No

secrets” is the new rule in my escape fire.

These are the elements of my escape fire, first draft.

I envision a system in which we promise those who depend

on us total access to the help they need, in the form they





About the Author Donald M. Berwick, md, mpp, is president, CEO, and cofounder of the

Institute for Healthcare Improvement (IHI) in Boston. IHI is a not-

for-profit organization dedicated to improving the quality of health

care systems through education, research, and demonstration projects,

and through fostering collaboration among health care organizations

and their leaders. Dr. Berwick is a clinical professor of pediatrics and

health care policy at Harvard Medical School. He is also a pediatri-

cian, an associate in pediatrics at Boston’s Children’s Hospital, and

a consultant in pediatrics at Massachusetts General Hospital.

An internationally recognized expert on health care quality

improvement, Dr. Berwick has published extensively in profes-

sional journals in the areas of health care policy, decision analysis,

technology assessment, and health care quality management.

About the Institute for Healthcare Improvement The Institute for Healthcare Improvement (IHI) is a not-for-profit

organization dedicated to improving the quality of health care in

the United States and around the world. Founded in 1991 and based

in Boston, Massachusetts, IHI develops, demonstrates, and draws

attention to the most effective strategies for improving health care

and fosters collaborations among health care organizations and

their leaders to put those strategies into place.

Employing a staff of more than 50 people and maintaining

partnerships with over 200 faculty members, IHI offers compre-

hensive products and services that facilitate demonstrable improve-

ment in health care organizations. The goal is to close the gap

between what is known to be the best care and the care that is

actually delivered.



About The Commonwealth Fund The Commonwealth Fund is a private foundation established in

1918 by Anna M. Harkness with the broad charge to enhance the

common good. The Fund carries out this mandate by supporting

efforts that help people live healthy and productive lives, and by

assisting specific groups with serious and neglected problems. The

Fund supports independent research on health and social issues

and makes grants to improve health care practice and policy.

The Fund’s two national program areas are improving health

insurance coverage and access to care and improving the quality

of health care services. The Fund is dedicated to helping people

become more informed about their health care, and improving

care for vulnerable populations such as children, elderly people,

low-income families, minority Americans, and the uninsured. An

international program in health policy is designed to stimulate

innovative policies and practices in the United States and other

industrialized countries. In its own community, New York City, the

Fund makes grants to improve health care and enhance public

spaces and services.

The Commonwealth Fund

One East 75th Street

New York, NY 10021-2692

(212) 606-3800 (t)

(212) 606-3500 (f)

[email protected]




Donald M. Berwick, md, mpp president and ceo

institute for healthcare improvement

the commonwealth fund

lessons for the future of health carelesso n

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