Tripling down on care improvement

Seven years and counting, the Triple Aim continues its work on quality
By Bernie Monegain
10:06 AM

Editor's note: In the three-part cover story of our January issue, Healthcare IT News takes a look at the three big challenges health information technology is trying to help solve: quality improvement, improved access to care and cost reduction.

The famous "Triple Aim" framework developed by the Institute for Healthcare Improvement seeks to improve the patient experience of care, improve population health and reduce the per capita cost of healthcare. As the industry tries to tackle all three of these huge goals at once, IT – whether it's electronic health records, patient portals, health information exchanges, telemedicine technologies or business intelligence and revenue cycle tools – is instrumental.

In the first part of this series (parts two and three will run Jan. 13 and 14), we put the spotlight on quality.

So much has been done to treat ailing healthcare systems since the Institute for Healthcare Improvement introduced the Triple Aim back in 2007. Still, there is much work yet to do, says Maureen Bisognano, president and chief executive officer of IHI.

The Triple Aim is a framework with goals to: Improve the patient care experience, improve the health of populations and reduce per capita healthcare costs.

It seems simple enough on its face. But the complexity rests in the "triple" part of it. The improvements have to be pursued simultaneously. No fair leaving out any side of the triangle.

As she prepared for the IHI's 26th Annual National Forum in Orlando, Fla., this past month, Bisognano, who has served at the institute for 20 years – 14 of them as executive vice president and the past four years as CEO – seemed optimistic.

"I am very encouraged," she told Healthcare IT News. "I don't think I've been to a health system or even a country in the last couple of years where the Triple Aim isn't in the mission or in the strategic plan," she said. "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."

[See also: Quality care, rather than federal funds, drives IT adoption, healthcare execs say]

Why does the Triple Aim framework seem to be gaining steam? In Bisognano's view, it's because the people who make health systems run seem to be working together. They are less fragmented, less isolated, more inclined to work as a team. Slowly, new models are forming.

"I see it everywhere," she said.

“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," Bisognano explained.

Today, she has observed that leadership teams are coming together, and they're realizing that the way to better quality, and the way to better health and also lower costs is going to require new approaches – new models of care.

"That means the teams need to work together in every way," she said. "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."

In the not so long-ago past, physicians would see patients in the office. They aimed to optimize the visit. They spent time preparing to make the most of the 15-minute encounter with the patient. And, usually, they followed up afterward.

Today, Bisognano is seeing new models taking hold.

"I think what they're realizing now is that the average patient who has a chronic disease (in the U.S. the majority of people over 65 have more than one chronic disease), they can either optimize two 15-minute visits or they can optimize the 5,000 hours – 5,000 waking hours when these people aren't taking care of themselves." she said. "They're seeing assets – like the patient and the family that they didn't see before. And, they're expanding their vision and their work beyond the walls of the office and the hospital."


"(The Triple Aim) is proving to be a hard nut to crack, and I think I have seen on the campaign trail a fundamental reason why. It's because we have not yet made the problem big enough."​​                _____________________________________________________________________________________________________            ​

Donald Berwick, MD, is founder of the IHI in Cambridge, Mass. He has recently returned to the institute as president emeritus and senior fellow, after running the Centers for Medicare & Medicare for a couple of years and ending a campaign for governor of Massachusetts.

"It's good to be back," Berwick said at the start of his keynote at the IHI Annual National Forum last month.

Turns out, Berwick’s bid for office was an eye-opening campaign. He saw some towns and cities in Massachusetts with serious problems, elementary schools with rats in classrooms, heroin addiction on the streets, he looked in the barred glass windows into prison cells, with every face looking back at him a face of color.

"I've seen a wealthy state in a wealthy nation descend steadily toward injustice," he told the IHI audience.

Later he quoted Dwight D. Eisenhower who once said, "When I meet a problem that I can't solve, I try to make the problem bigger."

"Healthcare, the Triple Aim, it is proving to be a hard nut to crack, and I think I have seen on the campaign trail a fundamental reason why. It's because we have not yet made the problem big enough."

"The opposite of disease is not wellness," he told the audience. The opposite of disease is justice. Report from Massachusetts, too many are left out; too many are suffering – not just from the absence of health, but from the absence of justice."

They are also suffering from medical errors – though improved from past years, healthcare leaders agree that they occur too frequently.

Bisognano would agree; she did not come to quality improvement work on a whim.

As she tells it, she is among a family of nine children – a big Irish family, a wonderful family, all close. When Bisognano was a young nurse, her sister, the one closest in age to her, was the first in the family to give birth.

Robbie was beloved from the moment each member of his family laid eyes on him. He was two months old when he went to his doctor for his regular checkup, and the doctor said he was perfect. At the end of the visit, he said, the doctor gave a DPT vaccination. A reaction took him to the intensive care unit for a week. He recovered fully and went home. A couple of months later he was again at the doctor's office for his four-month checkup.

They said he was perfect and normal. Again, at the end of the visit, the doctor said, "I'm going to give him his DPT vaccination."

"My sister said, 'Don't you remember what happened the last time?' Bisognano recalled. "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."

"My sister asked me three questions that day," she said:

  • Why did the doctor not have the hospital record, and why did the hospital not have the doctor record. Because, she said, I think we could have figured this out if it wasn't fragmented. And who really holds the record and how do we put the patient together electronically.
  • Why did he not know – because she had done some research after Robbie died – that that's not we do anymore. It used to be that way. But the standard and the evidence had changed. Yet the physician was trying to keep up with so much information, he was not up-to-date on that.
  • The third question was: "Why didn't he listen to me?"

"Those three questions just really changed the way I looked at my job,” said Bisognano. “I couldn't look at nursing as care for one patient at a time. I started to see the system very clearly. When you look at the system, that's when you have to get into quality improvement.”

And, that's how Bisognano ended up sitting next to Berwick for 20 years, someone she regards as a mentor. So is Paul Batalden with whom she worked at Hospital Corporation of America and at Dartmouth before he retired and today serves as IHI fellow. The late Joseph M. Juran, MD, taught her about quality improvement, she said.

Technology is vital to achieving the Triple Aim, in her view.


"We're starting to see people put data together in a different way."


At Kaiser Permanente, she noted, they build triggers into their dataset. It leads 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," she said. "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."

What areas of improvement are most lacking?

"Here's where I think we haven't made as much progress, but I see it right on the horizon," Bisognano said. It's making information available 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.

"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 age population 85 and older is the fastest growing segment in the U.S. and the majority of women over 75 are living alone at home, she points out.

"So there's a set of risks there that we didn't use to see," she said. "That data was not available. 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."

At the annual forum, Bisognano introduced Derek Feeley, who joined IHI as executive vice president in 2013.

He shared the podium with Bisognano for the national forum keynote.

And, he began his remarks on a high note: "Six years on from the launch of the Triple Aim, we have not had this much feedback from people, so much reinforcement of Triple Aim thinking as we have in the last 12 months. It's become an organizing framework for reform."

"We need to be humble, but we need to be brave," he told the audience. "There's a path to be set, and we need to set it."

He introduced a coalition that IHI formed of a more than 60 organizations committed to improving the health of 100 million people by 2020.

"Just pause for a second to think of the audacity of this," he said. "We are very serious about this. The coalition members are committed to implementation."