Sometimes all it takes to improve care is a clipboard and a will to work in a new way. That’s how Dr. Peter Pronovost recently reduced dangerous infections among ICU patients at hospitals in Baltimore and Michigan.

Pronovost is a critical-care specialist who runs the Center for Innovation in Quality Patient Care at the Johns Hopkins School of Medicine. (Yes, echoes of Kerr White).

Troubled by the incidence of infections among his ICU patients, Dr. Pronovost wrote down on plain paper a set of steps to avoid infections when putting an IV line or catheter into a patient. This checklist was simple stuff medical staff knew they should do but few rigorously followed, such as washing hands with soap, placing sterile drapes over the entire patient, wearing a sterile mask, hat, gown and gloves.

At first colleagues and management scoffed at the notion. But over the next two years, that checklist—along with the professional tenacity of nurses—showed a significant decrease in the number of infections and deaths and saved the hospital $2 million. This was huge. Dr. Pronovost became a man on a nationwide mission, showing up at as many as seven hospitals a month to pitch the proven benefits of ICU checklists. Hospitals and doctors at first treated him like an eccentric on an impractical, quixotic quest for the unattainable. Nurses, however, got it right away. When Dr. Pronovost asked them to observe doctors inserting lines, within a month they found missteps about a third of the time. Nurses became instant checklist champions.

As the word spread, Michigan’s hospital association put checklists to work in their own ICUs. Though federal regulators later questioned technical aspects of how the follow-up research was conducted, they did not challenge the use of checklists to improve the quality of care. In fact, participating Michigan hospitals estimated that within 18 months the checklists saved 1,500 lives and an estimated $175 million.¹⁰ As an ancient African adage says, “with a little seed of imagination you can grow a field of hope.”

This is quality improvement at its most dramatic. Pronovost’s elemental use of a checklist and clipboard turned him into a national leader in applying clinical research to improving the quality of care. He’s received the John M. Eisenberg Patient Safety and Quality Award in Research Achievement (named for the late founder of AHRQ and a dear old friend and mentor). Atul Gawande, one of the foremost writers on health care today, highlighted Pronovost’s work in one of his feature stories in The New Yorker.

In many hospitals, however, institutional resistance to such a simple lifesaving exercise remains significant. Dr. Pronovost explains that “the fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science.” Medical science has three core tasks, he says. They fall into “three buckets:” (1) understanding disease biology; (2) finding effective therapies; (3) delivering those therapies effectively.

“The third bucket has been almost totally ignored,” he says. “That’s a mistake, a huge mistake.” At RWJF, we are working with old friends and new partners to fill up that third bucket.

“Collaborate” is the key word. Without collaboration, the financial, clinical, professional and personal forces that frame our health care universe will continue to struggle with many of the same old pieces of the same old health care puzzle. In the absence of cooperation and partnership, it is not surprising that after all these decades of trial and error, failure and neglect, the pieces still don’t fit.

I know from my own personal observations at a community clinic in New Jersey that people worry about getting good care and are put off by too many choices. There’s not enough clear, trustworthy information. Too often process rules over professionalism, with payers and health plans an intrusive presence in the examining room.

People end up feeling that their doctors are so crunched for time they don’t get a chance to ask questions about their symptoms, treatments and medications. More than half of them fear something bad will happen to them if they go into the hospital. Research into medical errors says their fears are justified.

The so-called system sometimes seems so absorbed in taking care of itself that it doesn’t seem willing or able to deliver the high-quality patient care that millions of highly trained and passionately committed health care professionals know how to provide. It doesn’t help that outdated reimbursement schemes continue to pay providers for how much they do, not for how well they perform. And some health care professionals forsake the ethical tenets of their own professions as they contest payment proposals that would measure and publicly report on their performance.

Meanwhile, cost and coverage, not quality, dominate the national debate. Quality lacks drama, slick sound bites and high-profile public champions. More difficult to explain, quality gets short shrift from elected leaders and is short-changed by the media.

In curious discordance with the evidence, the political refrain often is “we have the best health care system in the world.” But the personal and family experiences of two-thirds of all adults—66 percent—leave them “dissatisfied” with the quality of health care, according to a noteworthy CBS News opinion poll last fall.¹¹ And international research consistently indicates that we lag behind other major societies in delivering timely and effective care, in patient care outcomes and in the overall health of our people.

America’s infant mortality rate is the highest among 23 nations. Our teenagers are the most obese adolescents in the world. We are the only industrialized nation without universal health coverage. On key measures like access, quality and efficiency of care, we rank last or next-to-last in a comparison with five other countries (Australia, Canada, Germany, New Zealand, the United Kingdom). Health care providers in the United States are far behind their colleagues in other modern countries in using information technologies like electronic medical records.¹² The U.K. annually spends nearly $193 per person on health information technology; the United States spends 43 cents per person.¹³

As Kerr White’s Green Mountain Boys found in Vermont, to this day the facts and figures of health care vary wildly no matter how we measure, whether by geography, clinical taxonomy, what it costs or what it achieves. What does not vary is the solid evidence that money alone cannot buy quality. We’re spending more than $2 trillion a year on health care—16 percent of our Gross Domestic Product, or $7,026 a year for each one of us¹⁴—yet it makes little measurable difference in the effectiveness of care or in better patient outcomes.

Why not? A big reason is that there is not yet a single well-functioning regional health care market in all the country. Not one. The dots are not getting connected. We know. We’ve spent time and resources searching for even one effective market. It is not to be found.

We intend to change that. We’re going to connect the dots.

In April 2007 the Board of the Robert Wood Johnson Foundation reached this pivotal conclusion:

No one entity or edict can, on its own, affect the quality and nature of patient care across all its dimensions and sites . . .

What the nation needs now is sustained collaboration, at the local level, toward a shared and ambitious goal of high-quality care.

Here’s the context: Yes, national health system reform may sound good as a lofty concept. For years we’ve heard that the answer to reform is through incremental government action by way of legislation, regulation and executive edict.

Tinker around with enough small changes, this school holds, and somehow the whole system will be healed. The evidence, however, suggests that piling project upon project may accumulate great weight from the top down but does not lead to system change.

As all the data makes clear, in reality there still is no national “system” of American health care (aside from Medicare and the Veterans Health Administration).

Sure, the collection and analysis of data mined nationally is vital to identifying best practices and consistent national standards of care. National disease, health care professional and trade organizations also give an important voice to those with specific experience, expertise and insight. Nonprofits like the Commonwealth Fund and the Kaiser Family Foundation provide a valuable national service by organizing and disseminating important information.

However, improving the quality of patient care itself is not an abstract, academic or figurative concept. It is a hard reality that can take place only at the precise point where patient care and real patients converge. That happens locally, where families live, work and play, where they know their physicians and trust their hospitals.

Fortunately, the fraying threads that lace together health care’s fragmented segments are still intact in our communities. Here, the evidence suggests, it is still possible to influence all those different forces that shape exactly what health care is, how it’s delivered, who gets it, what it costs, and how well it works.

Down home—this is where we can fill Dr. Pronovost’s “third bucket.”