There is only one pie, and it is all we have and all we will ever have...

I unfortunately did not have a chance to go to the IHI national forum this year (or any year before that), but apparently it was Disneyland for quality improvement nerds. Don Berwick gave an amazing opening address comparing health care to the "tragedy of the commons" - in the common grazing area, without ownership, individual sheepherders exert externalities by grazing to the maximum, leaving the commons barren. Eventually, no one gets any grass. In health care, all stakeholders want green grass, but no one wants to stop grazing or pay for fertilizer. Some expect the government to pass laws that will grow grass and also please everyone, which means continued grazing and no fertilizers required - a Deus Ex Machina that is hardly possible in the real world.

Berwick urged us to look at the commons - it is all we have, and it has no one else but us. We, every individual, all need to step up and, instead of constantly taking, learn to give - or there will be nothing left for anyone to take. His inspiring speech says it all:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

More on his address here.