The Non-Scalability of Charisma

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.

Don, of course, has extraordinary strengths as a leader, particularly in visioning and communicating. His annual IHI speech is legendary, for good reason. Consider this, from a 2004 Boston Globe profile:

Just from appearance and demeanor, you’d expect the 5-foot-10 Berwick to deliver an earnest but dull PowerPoint speech. He doesn’t wave his arms and never raises his voice, which has a low, occasionally rasping quality to it…. But there is a quiet charisma about him. He knows how to simultaneously play on the emotional and logical sides of his listeners’ brains. He is also the king of metaphors. Over the years, his listeners have heard him explain health care in relation to his younger daughter’s soccer team; the sinking of a Swedish warship; the Boston Red Sox; Harry Potter; NASA; the contrasting behaviors of eagles and weasels; his wimpy Ford Windstar (a dated reference since he now drives a used BMW convertible); and his left knee.

I’ve heard Maureen speak on several occasions, and she is quite good. But she’s no Don Berwick.

So what will happen to IHI in a post-Berwick era? The Institute remains an essential resource for thousands of hospitals around the country, and will undoubtedly continue its vital role. But my guess is that IHI will ultimately need to find a charismatic physician-leader to fill Don’s humongous shoes (unless they can hold off until Don returns from CMS, which could be as soon as late-2011, if a pissed off Senate stonewalls him when his recess appointment expires). Part of IHI’s magic has been getting, and keeping, docs at the table, and I doubt Maureen will be able to do this over the long haul, notwithstanding her impressive skills. I hope I’m wrong, but I don’t think I am.

A few days after hearing of Maureen’s appointment, I read a JAMA piece by Peter Pronovost of Johns Hopkins. Peter, of course, is the Genius Award-winningarchitect of the Keystone Project, which nearly eliminated central-line associated bloodstream infections (CLABSI) in Michigan ICUs, saving hundreds of lives and millions of dollars. Based on this breathtaking success, Peter received megabucks from AHRQ and some philanthropists to roll out his checklist initiative to the other 49 states.

Peter tells me that there have been some real success stories in the first year – a couple of states have seen results comparable to Michigan’s. But the glass is more empty than full – the implementation rate in most states has been sluggish; in some, downright pitiful.

Why? In the JAMA paper, Peter writes, plaintively,

In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates…. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is?

Pronovost sees the root cause of this poor response as an accountability gap on the part of hospital executives and physicians. That’s clearly part of the problem, but a bigger one may be that there is only one Peter Pronovost, and he can’t be in 50 states. Peter, like Don, has one-of-a-kind charisma; recall Atul Gawande’s 2007 observations of him in the New Yorker:

Forty-two years old, with cropped light-brown hair, tenth-grader looks, and a fluttering, finchlike energy, he is an odd mixture of the nerdy and the messianic… People say he is the kind of guy who, even as a trainee, could make you feel you’d saved the world every time you washed your hands properly. “I’ve never seen anybody inspire as he does,” Marty Makary, a Johns Hopkins surgeon, told me. “Partly, he has this contagious, excitable nature. He has a smile that’s tough to match. But he also has a way of making people feel heard.”

The fact that it seems impossible to export Michigan’s success to the rest of the country is particularly disheartening, since there are few other safety and quality interventions with such strong evidence of benefit; whose successes were reported in the New England Journal of Medicine, the lay media, and now two books (by Gawande and Pronovost); and whose implementation is sostraightforward – no technology or expensive equipment needed, just a 5-item checklist coupled with some leadership commitment, measurement, and a dab of culture change. If we can’t disseminate this intervention, what will happen when we try the hard stuff?

If you’ve ever spent any time with a professional investor, you’re familiar with this concept of scalability – a “desirable property of a system, a network, or a process, which indicates its ability to either handle growing amounts of work in a graceful manner or to be readily enlarged.” United Airlines isn’t very scalable – additional passengers require more planes, crews, peanuts, and fuel. Nor is General Motors. But Google and Facebook are endlessly scalable. Once they had their basic design and infrastructure down, the thousandth user added relatively little incremental cost over the 999th. Ditto the millionth. Venture Capitalist-types begin foaming at the mouth when they hear about a scalable idea, since profitability soars when you add new revenues without additional expenses.

Our problem is that Pronovost doesn’t scale, and neither does Berwick. Trying to roll out the checklist initiative without Pronovost’s cheerleading and handholding doesn’t work very well. Nor can IHI replicate the mass enthusiasm that accompanied its 100,000 Lives Campaign without Berwick at the head of the parade.

What does this mean? I fear that it means that the business case to improve quality and safety has not yet reached the point where full engagement by healthcare organizations and caregivers isn’t dependent on the personal engagement of individuals with unique leadership and communication skills. We’ll know it has when states and CEOs are asking – even begging – Peter to help them prevent ICU infections, and when IHI and similar organizations are being tapped constantly for help, even if the answer to the predictable question, “Can Don come to our hospital to kick off our initiative?,” is always “no.”

We’re blessed to have the likes of Pronovost and Berwick in the quality and safety arena – we’d never have gotten to where we are today without them. But we’ll know that we have truly arrived when we no longer depend on them to get the work done.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.