pursuing triple aim & sustaining adoptable improvement · 1.5 2 2.5 3 3.5 4 5. are improvement...

Pursuing Triple Aim & Sustaining Adoptable Improvement

Eileen de Villa, Acting Medical Officer of Health, Region of Peel

Chris Hayes, Medical Director, Quality & Performance, St. Michaels Hospital

Jennifer Verma, Senior Director, Canadian Foundation for Healthcare Improvement

September 18, 2015

Meet Frank

• 79-year-old widower• COPD, CHF, Diabetes• Anxious, breathless, can’t manage• Often dials 911 & visits the ED• Hospitalized 7 times over last year • Keeps a packed suitcase by his chair

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@CFHI_FCASScfhi-fcass.ca |

Action plan

Case management

Smoking cessation

Advance care planning

Pulmonary rehab

Self-management support

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Improving the health of the populations

Improving the patient experience of care

Reducing the per capita cost of health care

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DESIGN OF A TRIPLE AIM HEALTH SYSTEM

Define “Quality” from the perspective of an individual in

the population

http://www.ihi.org/Engage/Initiatives/TripleAim/Documents/ConceptDesign.pdf 5

“Triple Aim by Triple Method”

Content developed by IHI6


In an effort to Improve healthcare are

we making it Harder to provide care?

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HYPOTHESIS

Change initiatives that do not add additional workload and have high perceived value are more likely to be adopted, cause less workplace burden and, achieve the intended outcomes

More adoptable

Less adoptable

Perceived value

Workload

SameReduced Increased

DesignFor

Here!

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HIGHLY ADOPTABLE IMPROVEMENT

InterventionDesign

Burnout, change fatigue, cynicism, error, workarounds

ImplementationStrategy

Sustainably adopt improvement intervention

-

+

VALUE

Intended outcomesNOT achieved

Intended outcomesachieved

* The person icon represents the collective recipients of the change; those individuals required to carry out the tasks associated with the intervention

How we are askingpeople to do it

What we are askingpeople to do

WORKLOAD CAPACITY

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HIGHLY ADOPTABLE IMPROVEMENT

Selected Factors Associated Questions

End-user participation Are end-user staff/ physicians involved in the change?

Alignment and planning Does the change initiative align with the organization’s and/or team’s goals and has the rollout been planned effectively?

Resource availability Are the required resources (training, equipment, time, personnel) for the implementation of the change initiative known and will they be made available?

Workload How much workload (cognitive, physical, time) is associated with the intervention?

Complexity How complex is the change intervention?

Efficacy What degree of evidence and belief is there that this intervention will lead to the intended outcome?

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In an effort to Improve healthcare are

we making it Harder to provide care?

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Q1. Triple Aim FocusIs your system designed to improve care experiences, population health and per capita cost of care?

Q2. Quality Improvement FocusIs your system designed to create the conditions that make QI achievable and sustainable?

AVERAGE PRE-SURVEY RESPONSES: TRIPLE AIM & QUALITY IMPROVEMENT

Quality Improvement Readiness

Trip

le A

im R

ead

ine

ss

No Slightly Somewhat Yes

No

Slightly

Somewhat

Yes

1

1.5

2

2.5

3

3.5

4

1 1.5 2 2.5 3 3.5 4

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AVERAGE PRE-SURVEY RESPONSES: TRIPLE AIM

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1.5

2

2.5

3

3.5

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5. Are improvement projects at your organization aligned withthe Triple Aim? (n = 28)

2. Is the Triple Aim an explicit part of your organization’s strategy? (n = 29)

1. Do you currently focus your organization’s activities on the needs of populations and improving population results in health, care and cost? (n = 29)

4. Is your organization currently achieving results in line with the Triple Aim? (n = 27)

3. Does your organization measure its results around all three dimensions of the Triple Aim: population health; care experience and per capita cost? (n = 28)

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AVERAGE PRE-SURVEY RESPONSES: QUALITY IMPROVEMENT

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1.5

2

2.5

3

3.5

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6. When it comes to end-userparticipation in QI, are end-user staff

and physicians involved in thechanges? (n=29)

7. When it comes to alignment andplanning, do QI change initiatives

align with your organization's and/orteam's values and goals and is

implementation rollout plannedeffectively? (n=29)

8. When it comes to resourceavailability, are the required

resources (training, equipment, time,personnel) for the implementation ofchange initiatives known and made

available? (n=29)

9. When it comes to workload, howmuch workload (cognitive, physical,

time) is associated with changeinitiatives? (n=28)

10. When it comes to complexity,how complex are change initiatives in

your organization? (n=27)

11. When it comes to efficacy, whatdegree of evidence and belief is there

that interventions will lead tointended outcomes in your

organization? (n=28)

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GROUP DISCUSSION I

Q1. What do the readiness survey findings mean?

Q2. Are there any findings that are particularly surprising?

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Pursuing Triple Aim at Peel

CFHI’s EXTRA Symposium

Dr. Eileen de VillaMedical Officer of Health (Acting), Peel Public Health

September 18th 2015

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The Region of Peel

• Peel is one of the largest municipalities in Canada, and the second largest in Ontario, serving 1.3 million residents in the City of Mississauga, the City of Brampton, and the Town of Caledon combined

• Peel has experienced rapid population growth, increasing 12% from 2006 to 2011

• Approximately half of Peel’s residents are immigrants to Canada, with 10% arriving within the past five years

• 12.6% of people in Peel are living below the Low-Income Cut-Off (LICO)

• Peel’s BHLC Team is a joint collaboration between the Health Services and Human Services Departments

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Purpose Statement

• Individuals who are homeless or under-housed are potential high-cost health care users, often having both acute and complex chronic health-related issues. These individuals may face a number of barriers to accessing and receiving appropriate health care, including lack of identification (e.g., health insurance card), mental health issues and addictions. The lack of a coordinated system for care for this transient, high-needs population results in negative health outcomes for individuals and an inefficient use of health-care resources

• In August 2011, the Peel Homelessness Health Strategy was released. The strategy acknowledges that the “development of a comprehensive and integrated approach to planning and delivery of health services that enhance individual, family and community capacity is an important component of an overall strategy to reduce or eliminate homelessness”

• Our project team will utilize the Triple Aim approach to move towards the mission of this strategy which is to improve the equity of access to health and human services for Peel’s homeless and at-risk population while reducing health care costs.

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Population Segmentation

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Portfolio of Triple Aim Projects

Project Type Triple Aim Dimensions

Transitional Supports Program

Existing Project Population Health Experience of Care Per Capita Cost

Bramalea Community Health Centre and Wilkinson Road Shelter Partnership


Peel Alternatives to Choosing Hospitalization (PATCH)


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Population Measures

Dimension Proposed Measure Data Source Data plotted on run chart

(Y/N)Population Health

Current housing status Client questionnaire Y

Self-rated health status Client questionnaire Y

Self-rated mental health status Client questionnaire Y

Current daily alcohol or drug use Client questionnaire Y

Experience of Care

% who report an appropriate location for healthcare

Client questionnaire Y

Has a current family doctor (visited within the past two years)


% with unmet healthcare needs Client questionnaire Y

Per Capita Cost Average number of ED visits in the past three months (self-report)


Average number of in-patient hospitalizations in the past year (self-report)


Average number of stays in emergency shelters

HIFIS database Y

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Proposed Next Steps

• Development and implementation of data and measurement strategy

• System integration and expansion of health care provision in Regionally operated shelters in Peel

• Advocate for system integration for care management programs in Peel for population

• Expansion of Triple Aim work to other program areas (for example, transitional housing, street outreach program)

• Knowledge transfer to build internal quality improvement capacity 23

Key Conditions for Success –Building Triple Aim Explicitly into Organizational Strategies:

1. Bridging Internal Divisions

Bringing together divisions with different mandates, purposes and types of service

Recognizing “common” client population despite different service delivery reasons/outcomes

Overcoming organizational mindset related to health/Health’s mandate and shifting responsibility to appropriate organization

2. Working with external partners

Defining roles and identifying expertise with external partners

Act as an integrator organization and measurement resource 24

Key Conditions for Success –Aligning Improvements with Triple Aim:

3. Creating Triple Aim Infrastructure:

Creating a burning platform and unifying purpose

Establishing governance and reporting structures

Align opportunities to improve quality and reporting across Divisions

Build leadership support to move ahead despite daily challenges

Prioritizing measures in all three dimensions

Balance with process measures related to projects

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Key Conditions for Success –Achieving Triple Aim Results at Scale:

4. Achieving Triple Aim results at scale:

Triple Aim focuses on starting with small number of patients and scaling up to population

Need to focus on development of sustainable programs at scale

Need to provide evidence that interventions will lead to intended outcomes at scale

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Key Challenges –Focusing on Needs of the Population:

1. Lack of data systems and measurement

Difficult to segment population using current data systems

Lack of common datasets and common performance measures

Misalignment between Triple Aim measures and funding requirements/contractual obligations

Need to develop coherent data and measurement strategy

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Key Challenges –Aligning Improvements to Organization’s Values and Goals:

2. Applying Triple Aim to Canadian Context

IHI developed Triple Aim in US context with focus on per capita costs

Payer defined differently in Canadian context

Complex where multiple sectors incurring the costs

3. Focus on Primary Health Care

Region does not provide primary health care to the population

Key considerations related to care are different for public health and social services

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Coalition Governance and Inter-SectoralLeadership

• Need to capitalize on opportunities to share responsibility for population across Divisions

• Role-modelling collaboration to the community partners (Health and Human Services together)

• Create leadership structure with clear common goals

• Understand the role of internal and external stakeholders

• Be cognizant of reporting and funding relationships within the sector

• Identify roles and expertise within the sector and use appropriately

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How does this apply to your organization?

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Closing Slide – Pursuing Triple Aim at Peel

• Triple Aim/Better Health at Lower Cost collaboratives provided learning opportunity for members within two internal Divisions

• Focus on common population despite different mandates and types of services provided

• Create strong leadership support and regular reporting structure

• Need to make deliberate decisions about organizations role as integrator within the sector

• Create portfolio of projects within organization’s control to ensure progress continues

• Recognize amount of time and resources required

• Maintain momentum despite challenges

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Entire population served within one region

Interventions intended to address the needs of subgroups using PDSA cycles

Start small, learn, adjust

Sub-population, high cost and or high utilization people from the larger population

People who have “fallen through the cracks” of our “rescue-care” system

Sub-groups, people from the high cost, high use subpopulation who can be stratified based on similar needs

Subgroups based on needs versus conditions

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BUILDING A Triple Aim PORTFOLIO



Execution Methods to Achieve Results at Scale

• Testing - Try and adapt ideas to learn what works in your

system

• Implementation - Make a change a permanent part of the day to day operation of the system

• Moving to scale-Have individuals (and providers) adopt the changes

-Overcoming the structural issues that arise when moving to scale

Content developed by IHI

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Multiple Plan-Do-Study-Act (PDSA) Cycles

Tests Over Wider Conditions - 125

Implementation of Changes

Continued Replication



CONDITIONS FOR IMPLEMENTATION SUCCESS

• Efforts to improve healthcare can increase workload

• The Highly Adoptable Improvement model and guide supports focusing on the impact of change on care providers and staff and seems useful and usable

• Ongoing work in this area will continue to provide guidance on effectively implementing improvement initiatives and programs

• Change is hard….let’s avoid making it harder!!

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GROUP DISCUSSION II

Q1. On performance…

• Do you know how good you are?

• Do you know where your variation exists?

• Do you know your rate of improvement?

Q2. On setting performance goals…

How can you improve the degree to which your organizational/system readiness to change is aligned with the goals/values of your recipients of change?

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“A vision without execution is an hallucination.”

Jeffrey E. Garten, The Mind of the CEO

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CONTACT

Dr. Chris Hayeswww.highlyadoptableQI.com

[email protected]

@DrChrisHayes

@HighAdoptQI

Dr. Eileen de Villa

Jennifer Verma

[email protected]

@CFHI_JVerma

@CFHI_FCASS

[email protected]

@epdevilla

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http://www.highlyadoptableqi.com/