Flipping Healthcare Through the Triple Aim

This article is featured in the debut issue of Integrated Healthcare Delivery. To subscribe, visit IHDelivery.com.

In December 2013, Institute for Healthcare Improvement Chief Executive Officer Maureen Bisognano took the stage for her opening keynote and began telling stories of people who were flipping the model of how we treat the health needs of our community. She challenged us to think differently, to focus on the patient’s perspective and trying to accomplish what they were striving to achieve. The audience was humming with excitement and left the great hall asking, “How do we do that?”

Medicine has been going through an interesting transformation. It hasn’t been beautiful like a butterfly, but more awkward and uncertain like puberty.  We’ve watched an industry built without a system’s view of the patient that said, “When you get sick, come on in and we’ll try our best,” turn into one that said, “Yes, we want to be patient-centered.”

Now it’s time to deliver highly reliable, evidence-based care, that begins with the patient’s health and experience at the forefront—all provided at the most reasonable cost.

The IHI Triple Aim and System-Level Measures

The Triple Aim was developed at the Institute for Healthcare Improvement with the intent of improving care through the focus on three dimensions: Population health, experience of care, and per capita cost.¹ The following describes each of the three dimensions.

• Population Health: Achieving results requires improving healthcare outcomes (i.e., mortality and health/functional status), reducing disease burden and limiting risk status for a defined population.
• Experience of care: Defined as a portfolio of goals that include the Institute of Medicine (IOM) Quality Chasm aims: safe, effective, timely, efficient, equitable and patient-centered care bundled with the aim of creating patient satisfaction.²
• Per capita cost: In parallel to the other two aims, this is a consciousness of the significant cost inequality of our healthcare system. The reduction of cost per member of the population per month is key. Understanding hospital and emergency services use rates can be informative.

The three dimensions provide a framework for improvement and support when developing system-level measures with clear aims.

Population Segmentation

While our intent is to develop systems that serve our entire population, we need to segment out a sample of that population in order to test ideas and learn with the intent of building systems and processes that eventually serve all. The following is how population segmentation might work in a community.

• Defining a sub-population: Look within the population you serve and identify a segment with higher-than-average usage and/or higher costs. These may be people who have fallen through a gap in the current  healthcare delivery system—for example, homeless citizens with psychiatric needs.
• Stratify by similar needs: Instead of stratifying based on condition, consider shared needs like access to medication, shelter or nutrition.
• Interventions: Develop ideas to test rapidly on a small scale. Some interventions may be successful and some may not, but all should support the aim of developing knowledge and ideas. The intent is to act on one in order to learn for the population.³

Developing a Portfolio of Projects

Improvements rarely occur through one intervention. Breakthrough improvement is the result of a portfolio of interventions that achieves clearly-charted aims executed using the scientific method. The process of segmenting the population, understanding needs and implementing potential interventions can enable development of a visual display of your theory for system change. It can be helpful to use a tool like a driver diagram (see Figure 1) to present your theory for change.⁴

Chartering Projects

Project success requires thoughtful planning and execution. Before initiating any project in your portfolio, answer these questions:⁵

• What are we trying to accomplish? What is the aim of this project? What will you improve? For whom? By how much? By when? For example, the aim for a project might be to assess 95% of homeless encounters at the shelter clinic for signs and symptoms of psychiatric symptoms by June 30, 2014.
• How will you know a change is improvement? What are the measures for the project? This requires a family of measures including outcome, process and balancing measures, such as setting a specific percentage of homeless encounters to assess.
• What change can we make that will result in improvement? What changes to the process or system can we test and implement that will support improving process reliability and outcomes? For example, using a checklist for signs and symptoms of psychiatric illness.

The project charter should contain information about how the project will be staffed and what resources will be required, including who will be the project sponsor and the project lead. It’s also helpful to sketch out a project plan of key activities and timelines so all involved can have a sense of the predicted execution framework and can prepare for successful completion.

Small-Scale, Rapid-Cycle PDSA Testing

Too frequently effort is wasted on planning and implementing a large-scale project without first gaining adequate knowledge about what works. Dr. W. Edwards Deming promoted the use of the scientific method as a validated approach to test and learn. He encouraged using a modified method known as the “Plan, Do, Study, Act (PDSA) Cycle” as a way to test ideas, on the smallest scale possible (i.e., one patient).

The PDSA approach involves making a plan to test a change to a process and predicting what will happen. Then you do the test and observe what happens. After the test, time is set aside to compare your prediction with what you observed and study anything else you learned. The cycle is complete by deciding how to act on this information; for example, to abandon or adopt the idea or, in the majority of cases, adapt the idea based on what you learned. The last step is to test again.

Due to the small and rapid aim of PDSA tests, testing happens sequentially, continually building on the knowledge from the previous tests. The more you test, the more you learn.⁶

Implementation and Spread

Testing on a small scale acts as our learning lab until we find out if an intervention is effective and worthy of implementation and spread. Determining reliability requires measuring over time and displaying data in run charts (see Figure 2) with evidence that the process has changed and the aim has been achieved. There is no use spreading something that you can’t measurably show works.

Conclusion

The opportunity in your community to improve the care you deliver, the health of the population you serve and at a lower cost is immense. It starts with a focus on the patient and an eye on the aim. Taking a systems approach to testing that learns what works is the method to achieving the goal.

It’s not easy work and we don’t know all of the answers, but collaboratively, those of us who work in this field can aspire to flip the model for integrated healthcare delivery. Bisognano knew we could. It can all start with just one small test of change. What can you test this week?

References

1. Institute for Healthcare Improvement Triple Aim. Retrieved online March 6, 2014 at www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.
2. Institute of Medicine (IOM). 2001. Crossing the Quality Chasm. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
3. Based on ideas developed from Tom Nolan, PhD, Associates in Process Improvement and senior fellow at the Institute for Healthcare Improvement.
4. Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)
5. Langley GJ, et al. The Improvement: A Practical Approach to Enhancing Organizational Performance (2nd Ed.). San Francisco, CA: Jossey-Bass, 2009.
6. Moen R, Norman C. Evolution of the PDCA cycle. 2006.

David M. Williams, PhD, is an improvement advisor with the Institute for Healthcare Improvement and scholar-practitioner studying and enhancing prehospital mobile healthcare systems. His consulting practice, TrueSimple Improvement works in the North America, Europe and the Middle East. Contact him at TrueSimple.com.