I recently came across an interesting news story. Boston Medical Center (BMC), a safety net hospital, is making a big investment in pursuing the Triple Aim.
What does BMC think will be the key to improving individual and population health while reducing costs? Housing.
BMC is investing $6.5 million over the next five years to support a range of initiatives to make housing more affordable, safer, and more stable. Other Massachusetts hospitals, including Boston Children’s Hospital and Baystate Medical Center, are also dedicating funds to housing.
Why are a growing number of health care systems making these kinds of investments? Because research indicates that health care only contributes between 10 to 20 percent to overall health. In other words, improving patient care is necessary but not sufficient. If we’re serious about creating better health at lower costs, we need to put some of our energies into partnering with communities to address the social determinants of health, including housing, education, and employment.
Quality improvement (QI) can play a big role. Through our 100 Million Healthier Lives Scaling Community Accelerators through Learning & Evaluation (SCALE) initiative (funded by the Robert Wood Johnson Foundation), IHI has learned that combining improvement science with a community’s energy and assets is a powerful formula for change.
We can become better health care citizens by applying what we know as health care improvers to working on the social determinants of health with our communities.
QI in Unexpected Places
We have a tendency in health care to narrowly define how to use QI. Perhaps we forget that we didn’t invent it. QI methods — like aim setting, testing changes, and measuring the impact of those changes — were applied in a range of other domains long before health care ever adopted it.
IHI is seeing all over the world that we can work with partners to successfully apply QI in communities. Like any QI initiative, it takes some contextualization. You can’t just assume that the same methods we use to reduce surgical site infections will apply directly to reducing homelessness. Our experience indicates, however, that basic improvement approaches are applicable when we learn from — and co-design adaptations with — others in the community. And, when you work in communities, you can find quality improvers in unexpected places.
We often identify potential improvers in schools, for example. Teachers and young people often embrace — and quickly grasp — improvement science. They appreciate its practicality and how it can help them achieve their goals. One case of this is in a community of a little over 3,000 people in northeast Wisconsin called Algoma. Algoma was one of the original SCALE communities.
Six high school students took the IHI/HarvardX improvement science online course and learned the basics of quality improvement. Then, with guidance and support from Algoma’s wellness coordinator and staff at Bellin Health, they applied what they’d learned to tackling some of the issues in their community.
The first thing they did was use QI to teach CPR. Very quickly, the students used QI methods to train two-thirds of their community.
Excited by their success, the students then taught other children about QI and they turned their attention to cleaning up the beaches in Algoma. Then they helped provide healthy snacks for their school and local food bank by finding “ugly fruit” that supermarkets didn’t want to sell. It’s hard not to be inspired when you see young people between the ages of 11 and 16 using their knowledge of improvement science to help transform their community.
The community-wide Live Algoma movement now includes a wide range of initiatives and partners, including the school system, industries and other employers, the parks and recreation department, social service agencies, and health care providers. Together, they’re making changes to influence health outcomes now and for future generations.
Health from the Community Perspective
What would it take to apply QI in communities to improve health? First, it’s necessary for health care to avoid assuming we have all the answers.
We need to approach communities with an attitude of humble inquiry and ask some important questions. What do you think are your community’s most important health issues? What coalitions could we join (or help create) to address those issues?
It could be homelessness and the health of people experiencing homelessness. It could be food insecurity.
In Scotland, it’s helping children reach their full educational potential. A few years ago, Scotland created the Early Years Collaborative (EYC) because they recognized that investing in the health and well-being of children was the ideal way to improve the long-term overall health of the country. Recognizing educational attainment as a major driver of health outcomes, the EYC applies what Scotland learned about using QI methods in the Scottish Patient Safety Program to help schools.
With some of IHI’s Strategic Partners, I recently visited some schools participating in the program in Fife, the county where I was born and brought up. In a small primary school, the assistant head teacher and two of the class teachers showed us their QI work. If you can imagine going to the IHI National Forum and seeing the poster boards full of improvement stories, that’s what it was like there.
The educators were relatively new to QI, but they clearly understood how to use improvement science and methods. They showed me a set of driver diagrams that were impeccably crafted, with clear aims and a set of primary and secondary drivers that lined up.
Their results blew me away. They went from no children in the class able to achieve their basic numeracy milestones for that age group to every student in the class achieving them. Just as we recognize in hospitals that no amount of quality assurance alone is going to achieve breakthrough results, they recognized that testing alone wouldn’t achieve these kinds of results for their school.
Using QI helped them move from only tracking progress with annual testing to tracking progress every day. They started saying things like, “I’m going to make a small test of change. If it works for one child, I’m going to try it with three. If it works with three, I’m going to try it with 10. If it works with 10, then I’m going to do it with the whole class.”
Our hosts then took us to another school where 34 teachers from about 12 primary schools had gathered together in a learning collective. They all told similar stories. They had embraced QI as their methodology and were seeing unheard-of breakthroughs in performance. One school had improved attainment by 20 percent in a single year. Literacy was better, numeracy was better, and classroom and school ground behavior was better.
Being Good Citizens
Clearly, the QI skills we’re building in health care systems are transferable to education and to other endeavors. But some may question why they should deploy their organization’s QI expertise outside their walls when there are more than enough challenges inside a hospital. If you’re a leader wondering how your board members would respond to this idea, I suspect many would welcome it. After all, most people on the boards of health care systems join because they care about the community in which they live. In fact, some board members may be the very people who can help you make the case to others and connect you with the right partners.
Applying QI to the social determinants of health is an investment in the long-term health of your health care organization and your community. We have a duty as citizens to be generous with our knowledge. There are tremendous health benefits for all of us if we can find the will to make this commitment.
Editor’s note: Look for more from IHI President and CEO Derek Feeley (@derekfeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.
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