1. Reducing mandatory measurement. Much of the current era's mandatory measurement is "useless," Berwick argues, wasting valuable time and money for providers. Berwick says that payers should work with the National Quality Forum to reduce the volume and total cost of mandatory measurement by 50 percent within three years and by 75 percent within six years. "The aim should be to measure only what matters, and mainly for learning," Berwick says.

2. Stopping complex individual incentives. For most, "if not all," clinicians, Berwick argues that the best form of compensation to promote value-based care is "salaried practice in patient-focused organizations." He says payers and health care organizations should halt complicated incentive programs for individual clinicians and that CMS "should confine value-based payment models for clinicians to large groups."

3. Shifting the business strategy from revenue to quality. Improving quality is "a better, more sustainable route to financial success" than focusing on maximizing revenue, Berwick says. To that end, Berwick argues that health care leaders need to view "mastering the theory and methods of improvement as a core competence," while payers need to delink reimbursement rates from input metrics that "are not associated with quality and drive volume constantly upward."

4. Giving up 'professional prerogative' when it harms the team. "The most important question a modern professional can ask," Berwick says, "is not 'What do I do?' but 'What am I part of?'" He adds that young doctors should be trained to value citizenship over professional prerogative, and "physician guilds should reconsider their self-protective rhetoric and policies."

Video: Benefits of a culture of continuous improvement

5. Using improvement science. "Four decades into the quality movement," Berwick observes, "few in health care have studied the work of Deming, can recognize a process control chart, or have mastered the power of tests ('plan-do-study-act' cycles) as tools for substantial improvement." Improvement science, he says, must become a core part of preparing clinicians and managers.

6. Ensuring complete transparency. The rule for transparency, Berwick argues, should be, "Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens." He says Congress, insurers, and regulators should take steps to ease data sharing, and that states should adapt all-payer claims databases.

7. Protecting civility. "The rhetoric of era 1 can slide into self-importance; that of era 2, into the tone of a sports arena," Berwick says. "Neither supports authentic dialogue. Medicine should not ... substitute accusation for conversation."

8. Hearing the voices of patients and families. Further empowering patients and families to shape their care will improve care and lower costs, Berwick says. "Clinicians, and those who train them, should learn how to ask less, 'What is the matter with you?' and more, 'What matters to you?'

9. Rejecting greed. Berwick lists several ways he says the industry has "slipped into tolerance of greed," from high drug costs to "profiteering physicians." Berwick says that stakeholders need to "define and promulgate a new set of forceful principles for 'fair profit and fair pricing,' with severe consequences for violators." He also calls on professional organizations and academic medical centers to "articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care" (Berwick, JAMA, 4/5).