Triple Aim: Accelerating and Sustaining Collective Regional Action

By David A. Kindig, MD, PhD and John Whittington, MD

I’ve been following the Institute for Healthcare Improvement’s (IHI) Triple Aim for some time. The IHI was founded in 1991 by Don Berwick and a small group of colleagues who were committed to redesigning health care into a system no longer plagued by errors, waste, delay, and unsustainable social and economic costs. In 2005, IHI created a vision to work on three simultaneous aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. A year ago they embarked on a broader regional health improvement effort at the community level.

While openly enthusiastic about their work, I’ve also offered constrictive criticism -- especially regarding their concept of the Third Aim Population Health, and how robustly the non-health care determinants fit into their model and priorities.

But whenever someone asks me (as someone did last week)where to look for the best examples of health care systems working to embrace a population health perspective, I always say those involved in the IHI Triple Aim. 

I talk to John regularly, and last month he shared with me some of his current thinking about how Triple Aim goals can be achieved in geographic regions broader than traditional enrolled members of health care systems. Here are his thoughts:

Over time, the Triple Aim focus has expanded from working with small population groups and adopted a broader, more regional focus. As we move forward with strengthening our regional approach, we're asking ourselves, "What would it take to accelerate and sustain collective action on a population health project in a region that must coordinate with multiple agencies?"

We're now testing a new approach to regional population health projects that's based on what we've learned from existing Triple Aim sites, along with helpful guidance from Kania and Kramer's 2011 article, Collective Impact. We have been working with a number of developing Triple Aim regional communities in Cincinnati, Ohio; Jackson, Michigan; 14 counties in east central Michigan; and 16 counties in North Carolina. We consider the following elements to be essential, based on our research and experience to date.

* Adaptive Leadership -- Having the ability to see the big picture and galvanize that group around a set of clear aims.

* Community assessment -- Gaining an understanding of resources and needs. Who is already working in this project space? What should we know about the needs of those who will be served by the effort, including which existing agencies and services are most utilized?

 * Infrastructure to support the project work -- Meeting demands for core infrastructure elements, including project management, data management, quality improvement advising and logistical support.

* Unified language and approach -- Finding ways to harness, create shared meaning, and ultimately synergy among partners' diverse training and real world experiences.

* Measures -- Selecting and monitoring a set of high-level measures that can be used to gauge progress toward aims.

* Funders -- Working deliberately and strategically to build relationships with funders to support overall project goals.

* Health equity -- Ensuring that the approach addresses needs of high risk populations. In our work to so far, key challenges have included patient management and care coordination, economic or social factors, and patient and family involvement (such as for chronic disease self-management).

* Communication -- Maintaining open lines of communication among partners and with key external entities such as the media.

The elements listed above are being employed in a wide range of initiatives addressing issues such as infant mortality, childhood obesity, adult obesity, care coordination and other population health issues. We see promise in this approach and are interested in connecting with people in communities across the country that have an interest in engaging in this type of work.

While these elements may not seem remarkable to those in public health or community organizing, they are not what we usually see from health care strategy. While regional Triple Aim projects have not matured enough to see long lasting results, they are certainly ones to keep our eyes on.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.

John Whittington, MD is the Institute for Healthcare Improvement's (IHI) Lead Faculty for the Triple Aim.

 

Comments

[Pamela Russo]

Thank you for the brief history and evolution of the Triple Aim with regards to population health - clarifies and offers great promise. It offers a good model for broader and more collaborative interpretation of how hospital community benefits activities could evolve under the new regulations.

[Robert Stone Newsom, PhD]

Interesting approach and glad to see they have the critical element of “funders” in the list. The question as always remains: who are these funders? Whose pocketbook (profits, wages, income) must ultimately be reduced for such population health improvement to occur? All available evidence strongly supports the supposition that neither providers nor private sector insurers have any incentive to reducing their own income and profits for such ‘public good’ funding. Consequently increased taxation is likely the only sustainable approach. However, recent history has demonstrated both the 1% and 99%’s inability and / or unwillingness to meaningfully address the moral hazard inherent in our current healthcare ‘market’ models. In healthcare markets rational self-interest may guarantee that population health continues to be the victim of the tragedy of the commons.

[Mary Lou Andersaen]

At the end of the Clinton administration wuch a program was funded to provide $1M /year for 5 years to support the development of a small group of communities to develop such systems linking all important sectors. Lessons were learned and a continuing organization called Communites Joined in Acgtion continue that mission struggliing without the necessary support to achieve the spreading of the best results. That passion existsa right now in this country. Tap into it!