Q&A: Triple Aim drives IHI quality guru
Quality care is top of mind for Maureen Bisognano, RN. It has been, ever since she was a young nurse, and developed into a true mission not long later when she worked side by side with Donald Berwick, MD, at the Institute for Healthcare Improvement in Cambridge, Mass.
Today, she is president and CEO of the organization and Berwick serves as president emeritus and senior fellow. Both delivered keynotes at IHI's 26th Annual National forum last week in Orlando, Fla. The centerpiece of the organization's work on improving care has been its focus on the Triple Aim, the IHI initiative that focuses on improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of healthcare.
Bisognano spoke with Healthcare IT News a few days before the forum, offering her take on the progress of the Triple Aim and the work still left to do.
What is your take in general on the Triple Aim so far?
I am very encouraged. I don't think I've been to a health system or even a country in the last couple of year where the Triple Aim isn't in the mission or in the strategic plan. So I do think that the adoption of the AIM, the strategy, the idea that we need to work on all three together is really picking up traction.
And why do you think?
I see it everywhere. I think that in the early days when we first started talking about The Triple Aim, people sort of segmented themselves into either healthcare provider – I run a hospital- a system, or I'm a physician, or I'm a nurse or a pharmacist, or I'm a population health specialist – public health person or I'm a finance person. But rarely would people say I will take on all three. What we're seeing now is that leadership teams are coming together, and they're realizing thatthe way to better quality, and the way to better health and also lower costs will require new models of care. That means the teams need to work together in every way. What they're coming to see is that doing more of the same – either faster or with longer hours – is not producing anything but burnout.
On the quality front, what would you say are the top achievements?
I think the biggest one is about safety. I think what we're seeing now is almost universal application of new safety standards like ventilator bundles and central line bundles. Medication management is safer, and CMS just published a new report this week that talks about the many, many lives and dollars saved as a result of the focus on safety. I would say patient safety is No. 1. Now, I'm going to come back and say we have a long way to go on that, but we have made a lot of progress in the quality area on that.
The second area is really engaging patients. In the past years I've seen really a big shift from providing care to patients to providing care with patients. And that is one of the critical element of The Triple Aim – is really engaging the patient and their family. It's moving truly from 'What's the matter medicine' and then responding to that person's complaint to 'what matters to you?' where you can get somebody whole and vital and supported in those 5,000 hours when at home, where we're seeing the Triple Aim can actually be accomplished.
What's been the hardest to accomplish? What have been the stumbling blocks?
Here's where I think we haven't made as much progress, but I see it right on the horizon. That is making information across the continuum and across the system. As an example, what I see now is physician practices and hospitals understand their patient population by segments. This is critical element to being able to manage at a population level. In the beginning we began by segmenting people by age group or by diagnostic groups so you could tell in your practice or at your hospital you could tell how many patients were diabetic over 65.
What we're looking at now is adding new data so that we understand the whole of the patient. How many are frail, and how many are vital. How many are living alone. The merging now of social data and clinical data is giving us new ways to segment the population and I think will be a great boost in really deeply understanding not only how to take care of these people better when they're sick, but also reach out and prevent illness, harm and falls, for example.
Tell me about the high points of your keynote, what you're hoping to drive home.
What I am going o provoke in the next couple of years is that we start to see safety across the system and we start to understand safety across the continuum. One of the places I see as a safety risk is our failure to coordinate. We have multiple physicians or care givers from different parts of the system taking care of the patient and they're not coordinating and they're not communicating. I see that either duplication or failure to transmit clinical information as a safety problem. So, we're starting to look at how can we create maps of safety risks and harm – and that includes employee risks and harm – across the entire system of care. And that's going to give us a very different view of the challenge that we face going forward.
How did you come to the healthcare quality realm, and what drives you in this quest?
I started my career as a nurse and was a very young nurse when I had a couple of situations that drove me into quality. I'm the oldest of nine children in a big Irish family – all very close. We have the most wonderful family. My sister who is next to me in order had the first baby in the family. He was two months old he went to his doctor for his regular checkup, and the doctor said he was perfect. Everything was fine. Then at the end of the visit, he said I'm going to give him is EPT vaccination, which he did. Within the hours, my sister, who is not in medicine, noticed that the leg where he was injected was swelling and Robbie was having trouble breathing. She brought him back to the office and he was transferred into an intensive care unit for a week, and he was very, very ill. He did recover fully and then came home and again was being deeply spoiled. At 4-months he went back for his regular 4-month checkup. He said he was perfect and normal. At the end of the visit, he said I'm going to give him his DPT vaccination. My sister said, "don't you remember what happened the last time?" He kind of looked up. She said, "you gave him the shot, he had this reaction…" He paused for a minute, he said, "it really had nothing to do with that." Then he said, you know what, I'll give him half a dose. So, he gave him half a dose and Robbie died within 24 hours.
I started to see the system very clearly. When you look at the system, that's when you have to get into quality improvement."
Organizations that have started their work along the Triple Aim, do they keep up their interest?
It's not universal, but I'm seeing great momentum in some places. We're seeing, as example, information systems that are prompting physicians to ask questions that they would never ask before – this patient had this procedure several years ago, therefore they should get a vaccination or they should not get this med. And, creating alert systems that are much broader than any one-on-one interaction. In the old days of a physician kind of trying to cull from the record to prepare for a visit, that depended on his or her ability to cull the record. It's about time, it's about access, information. Now, we're starting to see people build systems that are really helping people to look to Triple Aim.
How does IT drive some of this?
It's both at a population health level and individual level. At Kaiser Permanente, as an example, they build triggers into their dataset that lead to better and better and better clinical outcomes every year. Even in a smaller system, we're starting to see people put data together in a different way so that you can track, as an example, what family issues arise. Because so oftentimes if you just look at the patient in front of you, you might be able to manage the 'what's the matter question', but you really can't finish the 'what matters to you question,' unless you understand this elderly woman's husband died in the last year, and she's been deeply depressed and she has no caregiving. What are the other social supports? We're moving to think about care as much more broad than prescribing a medication. It's about how to keep someone well and vital.
Is there a topic I didn't ask about that you'd like to emphasize?
This idea of the Triple Aim is creating a new sense of team at the top. I guess what used to be that the IT people worked with one language and the finance people worked with another, and the clinical people worked with their different area, and the administrative was different. What I'm seeing now is that everybody is beginning to recognize the assets of the others, and they're coming together speaking a new language, which is the language of patient. I'm very happy about that. I think it represents a shift in the way people work and that's been driving cultural change throughout the organization.
The second is there's not enough recognition that we to build improvement capability, improvement skills in every level. When you see a gap, when you see a problem, how do you see the system and then close the gap. That requires improvement capability.