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The Triple Aim Unites Us in Pursuit of Health and Health Care

By Kimberly Mitchell | Friday, April 10, 2015

In February 2015 in Doha, Qatar, IHI President Emeritus and Senior Fellow Don Berwick was a keynote presenter at the World Innovation Summit for Health (WISH), a global community dedicated to capturing and disseminating the best evidence-based ideas in health care. His adapted remarks at WISH follow in this blog post. Dr. Berwick is also a keynote speaker at the upcoming May 29-31 Middle East Forum on Quality and Safety in Healthcare in Doha.


My background is as a student, teacher, and practitioner of what I will call modern quality improvement methods, and I believe that these modern methods can help us make progress faster. But we need to understand these methods, support them, and, frankly, avoid other approaches that slow improvement. 

Nation by nation, people by people, we are converging on many quests in common, especially in the pursuit of health and health care. We are together concerned about the aging of populations, in part from the taming of infectious disease and child mortality, and about the burden of chronic illnesses that comes with that. 

We are together concerned about the costs of health care. Even those nations whose health care costs hover around the OECD average of 9% or 10% realize, more and more, that health care is, with all good intent, confiscating resources and opportunities from all other public and private sectors.

We are together concerned about how to create health. By far the biggest cause of ill health is not the absence of health care; it is the presence of poverty and inactivity and poor nutrition and injustice. So, nation after nation is trying to shift attention to those causes, not just their effects.

LEARN MORE: Leading Population Health Transformation, Feb. 22-24, 2017, in San Diego, California

We are together concerned about improving safety in health care, recognizing that millions suffer and die not from the diseases that brought them into care, but from errors and avoidable injuries from the very care that was supposed to help them. And nation after nation, in an age of increasing consumer voice, is exploring what true person-centered care should look like. 

We are together concerned about how to make health care and its activities and outcomes more transparent. What should we measure? How? For whose use?

Here are just a few examples of national projects trying to adjust to these trends:
  • England’s Five Year Forward View is a vision for a National Health Service (NHS) radically redesigning its work on prevention and much better at managing chronic illness.
  • The mission of the Scottish NHS Early Years Collaborative is to make Scotland the best place in the world to grow up.
  • Singapore has a new agency whose focus is to reconfigure their whole care system for an aging population.
  • China’s new Five-Year Plan for its health system is focused on redesign of chronic care, primary care, and person-centered care.

At the Institute for Healthcare Improvement, two colleagues — Dr. John Whittington and Dr. Tom Nolan — in 2006 created the “Triple Aim” framework that summarizes the social need that health systems seek to meet and what health care policy is trying to achieve: better care for individuals, better health for populations, and lower per capita cost. The Triple Aim unites us — or could.

Every nation needs a new bridge to the Triple Aim — one much more capable than today’s health care designs are of meeting the demands of aging and chronic illness, lower cost, authentic prevention, safe and patient-centered care, transparency, and profound technological innovation. But, how?

Many policy-makers in many nations are trying to build the new bridge using classical tools, ones that they are used to: payment changes, new incentives, enforcing standards, and trying to supply measurements that can help markets work. 

But we do not yet have on a global scale the pace and completeness of Triple Aim progress that our nations need. Why not?

Slow, impoverished, scientifically unfounded methods such as “reliance on inspection for improvement” — define what you want (“quality”), measure it, and act on the outliers (the deficient few) — do not help us achieve continual, pervasive, and never-ending improvement. Reliance on inspection does not foster creativity, learning, and pride — it poisons them, because its main harvest is not learning, it is fear.

There is a better way — scientific, grounded in theory, proven in practice, and ready for our use: continual improvement, learning in the face of complexity.

Over the past three or four years, Hamad Medical Corporation, Qatar’s leading medical services organization, and its leaders have deeply and actively embraced modern quality improvement methods. Thousands of employees are learning how to improve their own work processes. Dozens of teams are at work on clear and important goals for improvement, supported by transparency and metrics that are there to teach them, not blame them. Patients and families are being invited to help design and improve the care they seek. And the messages to all staff and clinicians from the executives is clear: our mission is vital, your wisdom is our greatest resource, change is the only route to improvement, and we are here to help you learn, grow, take risks, reach across boundaries, and experience joy and meaning in your work.

And Hamad is not alone. Scores of health care systems around the world are learning and applying these modern quality improvement methods, including most importantly developing countries.

These organizations foster a new culture, value information, and value especially information on defects. Cease blame; trust the workforce; invite them to use their imaginations and creativity and teamwork to reinvent their work. Will they get it right every single time? Of course not. So say to them, “Try, even if you fail. Because in every single failure lies the seeds of the next success — the lessons you can learn and share and celebrate.” And give voice and power to patients, caregivers, families, and communities. The people we serve know far more than we do about what the real needs are, what goes wrong, and what can go right. Our best teachers are those we serve.

Technique matters. And so Hamad and others have adopted as policy systematic approaches to studying and improving processes. IHI teaches the simple yet powerful Model for Improvement. Set an aim. Develop measures to tell you if a change is an improvement. Find something worth testing and test it — quickly, now, with optimism. Plan-Do-Study-Act. I’ll tell you what this really is. It is the democratization of science, the spread of inquiry and learning through an entire workforce.

If we want a better, healthier world — if we want to recover the lost time, energy, and pace that are wasted in silos of fear and withholding — then we need to come to terms with something basic and noble in human nature: we were born to learn, and that learning is the greatest resource humankind has for rescuing itself.

An event is quickly approaching — the Middle East Forum on Quality and Safety in Healthcare, organized by Hamad and IHI, on May 29-31 in Doha, Qatar — at which likeminded people from around the region and world will gather in the spirit of learning and continuous improvement. Events like this — that bring passionate people together to share their successes as well as challenges — enable us all to reach our aims quicker. As a keynote presenter at the Middle East Forum, I hope that you will consider joining with others who are also committed to improving the health of their communities, the care they deliver, and the joy they find in their daily work.

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