Pursuing the Triple Aim

Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs

Maureen Bisognano, Charles Kenney

• Publisher: Jossey-Bass
• Year: 2012
• Print ISBN: 9781118205723
• eBook ISBN: 9781118240847
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Written by the President and CEO of the Institute for Healthcare Improvement (IHI) and a leading health care journalist, this groundbreaking book examines how leading organizations in the United States are pursuing the Triple Aim—improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care.

Even with major steps forward – including the Affordable Care Act and the creation of the Center for Medicare and Medicaid Innovation -- the national health care debate is too often poisoned by negativity. A quieter, more thoughtful, and vastly more constructive conversation continues among health care leaders and professionals throughout the country.  Innovative solutions are being designed and implemented at the local level, and countless health care organizations are demonstrating breakthrough remedies to some of the toughest and most expensive challenges in health care.

Pursuing the Triple Aim shares compelling stories that are emerging in locations ranging from Pittsburgh to Seattle, from Boston to Oakland, focused on topics including improving quality and lowering costs in primary care; setting challenging goals to control chronic disease with notable outcomes; leveraging employer buying power to improve quality, reduce waste, and drive down cost; paying for care under an innovative contract that compensates for quality rather than quantity; and much more. The authors describe these innovations in detail, and show the way toward a health care system for the nation that improves the experience and quality of care while at the same time controlling costs.

As the Triple Aim moves from being largely an aspirational framework to something that communities all across the US can implement and learn from, its potential to become a touchstone for the work ahead has never been greater. Pursuing the Triple Aim lays out the vision, the interventions, and promising examples of success.

Chapter 1

HealthPartners

Care Model Process and Continuous Healing Relationships

HealthPartners, based in Bloomington, Minnesota, is the largest consumer-governed, nonprofit health care organization in the United States, employing twelve thousand workers serving 1.3 million people in Minnesota and surrounding states. It is an integrated system, combining a health plan with a medical and dental group that includes eight hundred physicians, four hospitals, and fifty clinics. HealthPartners operates in a state that is home to some of the most innovative health care reform laboratories in the nation, including the Mayo Clinic and Park Nicollet. The overall quality of care in the state is excellent, and costs run about 30 percent below the national average for Medicare patients. HealthPartners costs run even lower—up to 10 percent below the state’s average.

In this chapter we focus on HealthPartners’ transformative work in primary care, targeted at reliability and the Triple Aim, and we place particular emphasis on the breakthrough work HealthPartners has done on chronic conditions, particularly diabetes.

At IHI, we have worked side-by-side with HealthPartners on a variety of initiatives for more than a decade. We believe it is one of the great health care organizations anywhere in the world. In its pursuit of the Triple Aim, HealthPartners has built a care delivery system based on a rock-solid foundation of reliability, customization, access, and coordination of care. A conservative estimate suggests that spreading HealthPartners’ best practices throughout the nation has the potential to save $2 trillion over the next decade.

Hearing a Call to Change the System

In the life of a major, integrated health care system, it is often difficult to identify the critical moment, the event, that will serve as a kind of true north for at least a decade going forward. But Dr. Brian Rank can pinpoint that moment for HealthPartners. It came in 2001 with the publication of Crossing the Quality Chasm: A New Health System for the 21st Century, a report by the Institute of Medicine (IOM). This report captivated Rank like few other books, reports, or papers he had ever read.

“The Chasm report was the turning point for us,” says Rank, a medical oncologist who serves as medical director for HealthPartners Medical Group & Clinics. “It really does set out a road map for moving from visit-based care to continuous healing relationships. It speaks directly to chronic disease management. It’s both a theoretical and practical appeal to the issues that continue to plague American health care and health care in the world in general.”

When Crossing the Quality Chasm was published, Rank was in his third year as director of the HealthPartners medical group. He had completed his training at the University of Minnesota in 1985, “when quality in health care was, ‘Go do a good job and don’t harm anybody.’” But in the ensuing years he and his colleagues on the HealthPartners leadership team had seen disconnections throughout health care—an obvious lack of coherence; an absence of intelligent processes to make things fit together for patients. Like many physicians searching for a better way forward, he had been struck by the earlier IOM report To Err Is Human (Kohn, Corrigan, & Donaldson, 2000).

“To Err Is Human hit on the American psyche,” says Rank. “It was all over the media—100,000 preventable deaths in hospitals every year. Safety experts were on TV saying ‘don’t go into the hospital without a friend so no one does anything bad to you.’” But to Rank and his associates at HealthPartners, the Chasm report—which received a fraction of the public attention heaped upon To Err Is Human—was a vastly more important document, for it spoke to the absence of a system to provide better, safer, more efficient and affordable care. In other words, it went directly toward what Rank and his colleagues wanted to accomplish at HealthPartners. The Chasm report noted that although To Err Is Human “was a call for action to make care safer, this report is a call for action to improve the American health care delivery system as a whole, in all its quality dimensions, for all Americans” (p. 2).

The very idea embodied in the opening of the report—that health care “routinely fails to deliver its potential benefits” (p. 1)—was a damning indictment of the world’s most scientifically advanced society.

“The current care systems cannot do the job,” stated the report. “Trying harder will not work. Changing systems of care will” (p. 4). The report stated that

health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes [p. 4].

Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case [p. 1].

Although the Chasm report was all but ignored at many if not most organizations throughout the nation, it was immediately embraced at HealthPartners, where CEO Mary Brainerd and her leadership team were united in their belief that this report carried seminal importance. “It was such a powerful description of the things that were standing in the way of delivering the care that everyone who goes into health care intends to deliver,” says Brainerd. “It was a really clear articulation of the things we need to overcome in order to get there.”

Recognizing a Broken System—A Nonsystem

The report was also an affirmation of what Brainerd, Rank, and their colleagues had believed for some time—that the health care system was badly broken; in fact, that it was not a system at all. Rank and his administrative counterpart Nancy McClure, senior vice president of HealthPartners Medical Group & Clinics, read the report as soon as it was published, and McClure recalls it as a “seismic shift” in health care. The report defined the quality goal for American health care as embodied within six aims—it is care that is “safe, effective, patient centered, timely, efficient, and equitable” (p. xi).

“We knew the minute we read it—the nanosecond we read it—that the six aims would give us a framework going forward,” says McClure. “We knew the chassis was broken. Health care had not developed reliable processes and systems like other industries.”

The old system—or more precisely nonsystem—was built on a platform of presumed physician omniscience, the idea that a doctor, well-trained in medical school, working essentially alone in a solo practice or independently in a group practice, would know what was best for every patient. Although that approach served many patients very well, indeed, it also meant that best practices were not updated and applied consistently. It meant enormous unneeded variation in care, not only from one area of the country to another but also among clinics and doctors in the same organization. “You are assuming, without a system, that every doctor is going to remember what to do and just do the right thing,” says McClure. “It creates chaos.”

That lack of a system, says Brian Rank, essentially told doctors that “if you just try harder you can get better. Every clinician that I know is already working as hard as they can.” Prior to Crossing the Quality Chasm, Rank says, doctors would conduct a variety of improvement projects that would seem, at the moment, quite successful. But “when we turned our attention away, whatever it [was] we improved went back to whatever it was before, because the system didn’t change.”

“Because,” McClure interjects, “there was no system.”

Brainerd, Rank, McClure, and others saw the report both as an indictment of what was wrong with health care and as the beginning of a road map for what needed to change. They were drawn to the six aims as a way to define quality and measure improvement. “It was the first time that anyone had articulated a set of dimensions where efficiency, effectiveness, safety, and patient centeredness were all considered elements of quality,” says McClure. “Before that, technical quality was typically seen as in opposition to utilization management—as if you couldn’t be efficient and have high quality at the same time.” Table 1.1 displays a comparison that Rank believes tells much of the Chasm story.

Table 1.1. Simple Rules for the Twenty-First-Century Health Care System

Current Approach	New Rule
Care is based primarily on visits.	Care is based on continuous healing relationships.
Professional autonomy drives variability.	Care is customized according to patient needs and values.
Professionals control care.	The patient is the source of control.
Information is a record.	Knowledge is shared and information flows freely.
Decision making is based on training and experience.	Decision making is evidence based.
Do no harm is an individual responsibility.	Safety is a system property.
Secrecy is necessary.	Transparency is necessary.
The system reacts to needs.	Needs are anticipated.
Cost reduction is sought.	Waste is continuously decreased.
Preference is given to professional roles over the system.	Cooperation among clinicians is a priority.

Source: Kohn, Corrigan, & Donaldson, 2000, Table 3-1.

In 2001, HealthPartners publicly incorporated the six aims of Chasm into its mission, vision, and organizational goals and Brainerd changed the annual planning process so that goals and plans had to relate to the six aims.

Focusing on Reliability and Standardization

Rank, McClure, and others at HealthPartners convened physician and administrative teams from the medical group to focus on creating reliable systems of care that could be implemented across the HealthPartners organization. They were asking the doctors to think beyond a particular visit or individual and more toward how the clinical teams could collaborate for the patient’s benefit; how they could reduce variation and achieve a higher degree of standardization around agreed-upon best practices.

Thinking differently is often a challenge in health care, but it was nothing new at HealthPartners. There was something icon-oclastic in the organization’s DNA and certainly in its history. As a member-owned and member-governed cooperative, its governance structure has helped to make it particularly patient focused. When patients control the board—when patients are the board—it makes a difference.

“We have a history of saying we are not just here to do business as usual,” says Brainerd. The organization was seen as somewhat revolutionary when it was started back in the 1950s, with its intensive consumer focus. Located on Como Avenue, it was nicknamed “Commies on Como” early on and Brainerd says that the intent was never to be a traditional health system. “Consumers hiring doctors to work on a salary in a clinic instead of in a small business was revolutionary,” she says. HealthPartners was posting quality outcomes on the Web for consumers to use as early as 1997, and Brainerd points to this practice as evidence of the organization’s new approach. “People began with an idea that this was a different model, a different set of values, and I think we have done a pretty good job over time in living those out,” she says. “I think the recent work is bigger scale. We are a bigger system. The challenges are greater.”

Zen and the Art of Physician Autonomy

As Brainerd, Rank, and the leadership team worked to create a new system of care, an article by Dr. James Reinertsen (2003) was published that captured their attention. Dr. Reinertsen had formerly practiced at Park Nicollet, a Twin Cities neighbor to HealthPartners. He had since moved on to become CEO of Beth Israel Deaconess Medical Center, a Harvard teaching hospital in Boston. The article, published in 2003 in Annals of Internal Medicine, was titled “Zen and the Art of Physician Autonomy Maintenance,” and Rank regarded it as a superb description of a major flaw in American health care: the failure to standardize knowledge and to apply it broadly and consistently for the benefit of patients. “For me, it was a seminal article,” says Rank. “It takes on the myth that every doctor has to figure out the science for everything all the time. In oncology, we have national cooperative trials where the standard of care is specified. But for a lot of medicine—look at the Dartmouth Atlas—there is wide variation.”

Many physicians, says Rank, apply the knowledge and techniques they acquired as medical students twenty or more years ago even in cases where new techniques have proven superior. Rank knew this from experience of course, but the Reinertsen article powerfully reinforced that notion. “Every doctor, even today, is trained in a medical training system in which we all recreate wheels,” says Rank. “You never trust anyone to synthesize that science, and you are supposed to understand and have read all seventeen thousand randomized clinical trials this year added on to what you knew for last year and then synthesize the science yourself. That is a total impossibility and it is a massive failure pathway.”

The articl...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Dedication
• Preface
• Acknowledgments
• The Authors
• Chapter 1: HealthPartners
• Chapter 2: Intel and Virginia Mason Medical Center
• Chapter 3: CareOregon and Affiliated Clinics
• Chapter 4: The Alternative Quality Contract
• Chapter 5: Bellin Health
• Chapter 6: The Patient and Family Centered Care Methodology and Practice
• Chapter 7: Kaiser Permanente
• Chapter 8: No Excuses
• Epilogue: Innovation Everywhere
• References
• Index