Trissa Torres, MD, MSPH, FACPM, is IHI's Chief Operations and North America Programs Officer. In the following interview, she describes the path she took to IHI and how to address some of the major issues health care leaders in North America face today.
Q: What was your path leading up to IHI?
I was always interested in exercise and fitness — health, in general — so I started my career in health promotion. I entered a Master’s program focused on behavioral changes to help people become healthier, more physically fit. This brought me to the Pentagon, where I led an exercise program. I taught aerobics at the Pentagon!
Feedback I got from participants in this program was revealing. They would say things like, “My doctor told me I probably shouldn’t exercise because of my high blood pressure.” I started to see that doctors were not very well trained in nutrition and promoting healthy behaviors.
But at the same time, I was hearing how much people look to their physicians as their first source of health advice and information. This made me see that we need to change the way we practice medicine so doctors are more focused on promoting health rather than taking care of people when they’re sick — treating disease.
I knew the only way I could help drive the changes I saw were needed was to become a doctor myself — to become a spy, infiltrate the ranks and change the way medicine is practiced from the inside.
Q: How did medical school influence your approach to health care?
Medical school taught me to practice medicine, but was also frustrating because it reinforced the “sick care” approach to medicine — that what we have is not a health care system, it’s a sick care financing system. We pay to take care of people when they’re sick, and the sicker they are the more we pay.
But then, for my residency, I found the perfect specialty area: preventive medicine. A lot of my colleagues had never heard of this field. But when I explained it to non-physicians, people would say, “Of course, that’s exactly what we need.” So, what’s the disconnect? That’s what I was trying to influence.
My residency also exposed me to public health, which broadened my view, to populations and how to impact population health. I wondered, How do we bring the public health and medical worlds, which are a chasm apart, closer together?
Q: What did you find on entering the health care workforce?
After my residency I went to Genesys Health System in Flint, Michigan. It was in the early 1990s, when health care reform and universal coverage were in the spotlight. There was a lot of uncertainty about policy changes, on top of financial pressures throughout our industry. So leadership at Genysys realized that focusing on prevention was strategic: keeping patients healthy means you don’t have to care for them when they’re sick. So they hired me, a preventive medicine physician.
I started developing new models of care that could integrate traditional sick care with prevention. We knew the primary care doctor-patient relationship is crucial, but we also knew doctors often don’t have time to engage patients in the depth of conversation needed to support behavior change.
We developed an approach using Health Navigators — individuals who serve as extensions of the primary care practice team and support patients in healthy behaviors and self-management. So, instead of saying: “You need to lose weight,” maybe a navigator or physician says: “What worries you? What’s important to you?” A patient with high blood pressure and a family history of diabetes might say, “I want to make sure I’m around for my kids. I’m really worried I’m going to end up like my mom — she lost her eyesight at in her 40s.”
The physician or navigator might then bring up healthy eating and exercise, leading the patient to consider: “I can start walking a little bit every day. That’s something I can do.” She’s motivated to reach her goal because it matters to her, and she does: her blood pressure comes down, she feels better, and she’s then inspired to find other ways to improve her life.
We had many successes at Genesys, demonstrating that people really can change their behaviors and improve their health outcomes. In turn, we documented reduced use of high-cost services including ER visits and hospitalizations.
Around this time Genesys got involved in the first IHI Triple Aim prototyping phase. We were already working on those three components: improving care for individuals, focusing on population health, and reducing health care costs. Bringing them together in a systematic approach made perfect sense.
In 2012, as my role on the team helping Genysys transition to a Pioneer Accountable Care Organization [ACO] was coming to a close, I learned about the opportunity at IHI. I could tell it was a natural fit for me.
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Q: What do you think are the major issues facing health systems in North America [the region whose programs you oversee at IHI?
US providers and health systems are under tremendous pressure to improve value, which we define as: How are we best utilizing our resources within health care to improve the outcomes for those we serve?
One example is new payment mechanisms. Different financing models have been tested and adopted across the US for almost a decade. Even with political uncertainties in health care right now, IHI continues to support health care organizations figuring out how to use the payment changes to support better care delivery.
So we work with Accountable Care Organizations that are taking financial risks; they’re saying, “When our money flows to us differently, what does that allow us to do to provide better care?” Some of IHI’s customers are testing bundled payments, another new payment model. And this is all going to continue. We’ll keep supporting health systems in learning how to leverage the reimbursement changes to help them drive toward better outcomes.
Decreasing overuse is also critical to boosting value. We know overuse is rampant in our health care delivery system, not through the fault of individuals or institutions but because of outdated payment methods. Old reimbursement incentives created a default that more care is better. So we have to change that culture, and there are lots of opportunities to do that.
One example that’s relevant today is opioids. We know a big part of addressing the opiod epidemic is making sure treatment is available and accessible to people who are addicted. But just as important, if not more, is decreasing the flow of opioids into the community — which starts with us, providers, addressing our prescribing patterns. Where are the opportunities for us to skinny down our opioid prescribing to the few who truly need it? This has to go hand-in-hand with working to keep illegal drugs out of our communities in the first place.
Q: What is an example of an area for improvement of value?
Improving care transitions is a huge area of opportunity. We know that handoffs from facility to facility are where our patients are most vulnerable. IHI is helping organizations broaden their perspective beyond their walls to address these gaps. So, rather than looking at quality and safety only within a hospital and within an ambulatory care setting, health system teams IHI is working with are using improvement science and methods to coordinate care across the entire continuum of care for each of their patients.
As part of this work, IHI is making connections with care settings new to us, including long-term care facilities. We’re bringing classic, traditional safety work to organizations that haven’t had the attention of health care improvers in the past.
Q: How is IHI addressing equity?
We know there are unjust disparities in health outcomes for those we serve. Some of the biggest disparities are by race. IHI has acknowledged that we’ll never make a dent in health inequities until we address racism — the institutional racism embedded in our organizations. This isn’t bigotry; it’s the advantages and disadvantages built into our systems that we now have to dismantle.
The process of figuring out how we eliminate institutionalized racism starts personally, addressing our own individual biases that often we’re not aware of. So I am definitely a white person of privilege, and there are many aspects of my privilege that I am blind to. And until I can become aware of those, I won’t be able to see the consequences, the negative impact on communities around me and throughout our society. So I have work to do, individually; we have work to do as organizations and together, in teams. And only then can we really start dismantling those barriers that have been reinforced over a long history.
This work is humbling and often uncomfortable, but it’s also what I’m most excited about at IHI. From the start, we’ve acknowledged that IHI is not expert in this area: tackling equity in general and racism in particular. So we’re not doing this alone. We have sought out other individuals and organizations that have been on this journey for a long time.
In April 2017 IHI launched a two-year initiative called Pursuing Equity that aims to reduce inequities in health and health care access, treatment, and outcomes. Eight health care organizations of different size, geography, and patient populations are working with IHI to apply practical improvement methods and tools, spread ideas, and disseminate results and lessons learned about improving health equity.
The ultimate goal of Pursuing Equity is to lay the groundwork for a national initiative that identifies ways health care organizations can impact equity in areas like employee wellness and social determinants of health, in addition to reducing clinical disparities at the point of care.
IHI is incorporating learnings from Pursuing Equity into all of our initiatives across all settings in which we work. We raise the question of equity and how it impacts quality, safety, and outcomes of patients from the start.
A key part of these efforts involves helping teams step outside their boundaries, for example, bridging barriers between health care delivery and community services. Through the 100 Million Healthier Lives initiative, community organizations and health care delivery systems that are already driving toward change but doing it independently learn to work together to achieve better outcomes more quickly in their local communities.
In a project in Michigan, we are helping patient-centered medical homes build clinical community linkages to identify what services in their local community would help meet the needs of their patients. So, for example, if a provider has a patient whose family is hungry too often, she can connect them immediately with a local food bank. Because food impacts patients’ health as much as their medicine does.
Q: How are leaders to lead, given such uncertainty in the US health care system?
There are general leadership behaviors and strategies we recommend. One is around creating community, a community of leaders; an environment where we realize we’re in this together. We’re not alone; we can learn from each other.
Another key is for leaders to recognize the assets they have, within their staff and within their communities, and intentionally leverage those assets. For example, moving to true co-design of care – co-designing with our patients, with our frontline staff, with our community partners – can actually help organizations thrive despite the climate around us and address what really matters.
The bottom line is that political uncertainty doesn’t change our overall trajectory. It may create setbacks and side-steps, but it’s not going to change our direction. We know that we have to use our money better to ensure financial sustainability. We have to improve quality and safety and drive down the overall cost of health care. We have to achieve better outcomes for our patients, populations, and communities that we serve. How we get there is where politics can come into play, but the direction is still the same.