May 2016 Accelerating Triple Aim Results @DerekFeeleyIHI Derek Feeley President and CEO Institute for Healthcare Improvement
What is the Triple Aim? System designs that simultaneously improve three dimensions: – Improving the health of the populations; – Improving the patient experience of care (including quality and satisfaction); and – Reducing the per capita cost of health care.
Building Blocks and Set Up Aim: Apply the Triple Aim to a population served by your organization or a population of interest in your region. Choose a relevant Population for improved health, care and lowered cost Articulate a Purpose that will hold your stakeholders together Develop a Systems approach Create a Learning System and choose Measures that will show improvement for the population Develop a Portfolio (group) of projects that will yield Triple Aim results No individual project can accomplish the Triple Aim but a portfolio of projects that are executed well can move closer to the aims. Build a Team of individuals who can manage this work: Executive Sponsor, Portfolio Lead, Project Lead, Content Expert, Improvement Advisor and Measurement Lead Develop a brisk and realistic plan for Execution on projects and accountabilities for results
7 Years of Experience
3 Essential Elements Leadership Learning System Getting to Full Scale
Interdependent Dimensions of High-Impact Leadership Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs . Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
High-Impact Leadership Behaviors What leaders do to make a difference Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs . Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.
Triple Aim places new demands on leaders
Some keys for the new mental models Asking not telling Partnerships (staff, patients, communities) Shaping culture
Humble Inquiry “If a goal of conversation is to improve communication and build a relationship, then telling is more risky than asking. Asking temporarily empowers the other person and temporarily makes me vulnerable.”
Listen to understand – not to respond “Wide lugs an a short tongue is best” Scottish Proverb
Partnerships; Getting to the Third Curve CO-PRODUCTION Outcomes QUALITY IMPROVEMENT Ceding power NEW PUBLIC MANAGEMENT Targets, Sharing power sanctions, inspections Keeping power Inquiry
Explicit Culture – Heroes, Symbols, Structures Implicit Culture – Values, Beliefs, Assumptions, Purpose
Culture eats strategy for breakfast “ The only thing of real importance that leaders do is to create and manage culture.” - Edgar Schein
Schein on Culture Culture is a result of what an organization has learned from dealing with problems and organizing itself internally Your culture always helps and hinders problem solving Culture is a group phenomenon Don’t focus on culture because it can be a bottomless pit. Instead, get groups involved in solving problems
Some Leadership Fundamentals (n=1) Comfortable with complexity and generous with power Heroism is out – humility is in Leaders need to figure out how to partner – co- design and co-produce Leaders need to get the whole team connected to the purpose and to the mission
Learning System for Triple Aim Implementation Whittington et al. Pursuing the Triple Aim: The First 7 Years . The Milbank Quarterly, Vol. 93, No. 2, 2015 (pp. 263-300)
Set-up and Design by Sub-population IHI Triple Aim Collaborative 2009 Sub Primary care Role of Cost Prevention and Integration population patients & control health promotion Micro &Macro families Focus on -Connection with Employer & Health Employed disability and company wellness System integrated people <65 workers comp programs approach (e.g. Onsite trends -Safety and ergonomic clinical staff) advice “Home is the hub” End of life Support for staying Multiple specialists People>65 care in the home if desired Socially Strong mental Strengthen Self help programs Integration w/ public health component family support health& social complex mechanisms services Transition to adult Support for Immunizations and Cooperation with Children and care parenting skills well child care schools families
Model for Improvement ‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’ Dr Donald M. Berwick Former President IHI, Professor of Paediatrics and Health Care Policy at the Harvard Medical School
Multiple PDSA Cycle Ramps Triage Diagnostic Fast Track Capacity/ Testing Patients Demand Change Concepts
A Learning System for Getting to Full Scale Best Practice Phases of exists Build Scalable Test Scale- Set-up Go to Full-Scale Scale-up Up Unit New Scale- up Idea Adoption Leadership, communication, social networks, culture of Mechanisms urgency and persistence Learning systems, data systems, infrastructure for scale-up, Support human capacity for scale-up, capability for scale-up, Systems sustainability
Methods for Spread Executive mandate Emergency mobilization Extension agency Breakthrough Series Collaborative model Campaign model Fishbowl Commercialization Grassroots organizing (one-to-ones) “Wedge and spread” (wave sequence) “Broad and deep” And many more…
Typical v. Exceptional Typical Exceptional They invest in comprehensive strategy development. They have a bias toward starting. They have general goals for adoption. They have explicit national and local aims. (Aim Primacy) Leadership creates standards. Leadership removes barriers. They have “theory lock.” Improvisation is a virtue. Data is for assessment. Data is for rapid adjustment.
“Strong evidence for an innovation is necessary but not sufficient to result in its adoption.” Mark Freeman The International Journal of Management Education, 2012
Making policy as a metaphor for spread policy 1 n pl -cies1. (Government, Politics & Diplomacy) a plan of action adopted or pursued by an individual, government, party, business, etc Experience & Expertise Pragmatics & Judgment Contingencies Evidence Lobbyists & Pressure Resources Groups Habits & Values Traditions UK National School for Government 2006
26 Interesting, Derek but does any of it work for people and patients? Continuity Co-ordination Care closer to home Quality of life Costs
• 5 million people • £12 billion • 14 Health Boards • 8 Support Boards • Integrated delivery • Moving towards social care integration
Multimorbidity is common in Scotland More people have 2 or more conditions than only have 1
Reshaping Care for Older People
Improvement Network Cross sector collaborative to support innovation and test and spread actions which collectively improve outcomes WebEx virtual meetings and e-bulletins Communities of Practice and themed learning events Online portal to share good practice, evidence and resources Training in improvement , spread and sustainability Use of measurement for improvement and benchmarking Support to adopt assets and outcomes based approaches Learning from the experience of people who use services Coaching / mentoring to build local capacity and capability 30 JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors
Anticipatory Care
SPARRA Risk Prediction Tool How many How many previous prescriptions? emergency admissions How many outpatient What age is the patient? has the patient had? appointments? Hospitalisation (3 years) What type of outpatient Psychiatric Admission appointments did (3 years) the patient have? Outpatient (1 year) Any prescriptions for e.g. dementia drugs? Or Emergency Department substance dependence? Any A&E Any recent admissions to (1 year) attendances in a psychiatric unit ? Prescribing the past year? (1 year) Any previous admissions for a long term condition Outcome Year (such as epilepsy? (1 year) PRE-PREDICTION PERIOD OUTCOME PERIOD
North Lanarkshire Patients accepted by ASSET in 29 Months 2,864 Supported at Home 76% are managed in 76% their own home instead of Hospital by the ASSET team Length of Stay Beds 5.7 days Closed 50 5.6 / Day Value £2Million+
Continuity: Strong Primary Care; Medical Home Has a medical home (continuity of care) 100 90 83 80 73 70 65 70 56 53 60 52 51 49 48 48 50 40 33 30 20 10 0 US NETH rUK SWIZ NZ NOR AUS SWE SCO FR CAN GER Charts from 2011 Commonwealth Fund Survey of Sicker Adults
Coordination: Experienced coordination gaps in the past two years Experienced coordination gaps in past two years 100 90 80 70 56 60 53 43 50 42 40 39 37 36 40 30 23 30 20 17 20 10 0 SWIZ NZ NETH CAN NOR FR SCO rUK AUS US GER SWE Charts from 2011 Commonwealth Fund Survey of Sicker Adults
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