Why It Matters
Over the years, IHI has learned a great deal from the communities and organizations we’ve worked with in pursuit of population health. Drawing from a decade of experience, we have compiled a list of “watch-outs” we can share to help health systems avoid some common pitfalls when working to support populations.
Watch-Out #1: Don't assume only C-suite leaders are important.
It’s nothing new to talk about the importance of leadership. It’s essential for a leadership team to articulate the strategic importance of the organization's work on the Triple Aim, for example. I’d caution people, however, against assuming that the only leaders who matter when you’re striving for transformational change are in the C-suite. It’s essential to bring leaders from throughout your organization to the table when you’re sharing your theory of change about how to best meet the needs of your population.
For example, assemble leaders from the front line, middle management, and executive levels to determine how best to focus on your highest-risk, most complex patients, and how to coordinate all of the work. It takes multiple levels of leadership to break down silos, focus on getting results, and reallocate work.
Also, to make change, these leaders will need to look across your current work and assess whether it will help to achieve the Triple Aim. Where are the gaps? This inventory will inevitably lead to decisions about new initiatives, as well as sometimes difficult conversations about longstanding work that may or may not have the highest leverage to support your population.
To make room for sustainable change, you’ll need to say no to some work and possibly end some long-term projects because — if you don’t — you’re going to overburden people by continually adding to their workloads. You’ll need the support of leadership at various levels to make those kinds of strategic decisions.
Watch-Out #2: Think populations, not projects.
When thinking about making improvement, our default tends to be to think about projects instead of populations. However, just focusing on improving your diabetic population’s hemoglobin A1c numbers isn’t enough.
The most forward-thinking health and health care organizations are bringing all of their work together to see impact at scale for a population — such as improving the overall health status for a population, or increasing life expectancy. No one project will be able to move these population-level measures.
It can sound daunting to take on such a huge challenge, but we often find that people don’t realize that the results of their individual projects can add up and result in big changes.
For example, one community pursuing the Triple Aim in Shelby County, Tennessee, found that more than 40 organizations in the region were working on various changes that could contribute to a reduction in infant mortality, yet no one was measuring all of it in a coordinated way. Before this realization, the county had gone years without meaningful progress on infant mortality.
When asked at a community meeting whether they considered themselves responsible for infant mortality in their region, many stakeholders said “no.” (They probably thought it was too huge a problem to solve.) Many of the organizations and agencies were working on worthy programs and services for families, yet tracking mostly process measures.
They said things like, “We make sure that young moms come for their appointments and get the best care possible.” “We deliver quality breastfeeding and education and support programs.” “We build awareness about the importance of prenatal vitamins.” While all of it is important for the health of pregnant women in the community, each intervention in isolation will have minimal impact on the population as a whole.
Once all the people at this community meeting identified their respective projects and programs, they had an epiphany about their efforts. They realized that with a common aim of reducing infant mortality and a shared set of measures to track their progress, together they could take on infant mortality. It was as if they realized, “I can contribute to something that’s bigger than my grant says I should be, or bigger than I thought our organization’s mission says we should be, and we can really reduce infant mortality.”
The only way that’s going to happen is if you start to think about populations rather than projects.
Watch-Out #3: Don’t automatically start new work.
You may not need to start a lot of new projects in order to better serve your population. Often, when people take a close look at their work from a population health perspective, they realize they’re already doing much of what’s necessary.
Think through your organization’s inventory of work. What dimensions of the Triple Aim is each project hitting? Not every project will hit all three, and that’s okay. They should, however, work together and add up to addressing every dimension.
Don't assume you know all you need to know unless you've done a thorough needs assessment to understand your population. Identify the population you hold yourself responsible for, explore and understand the needs and assets of that population, and then assemble the projects and services that can best meet those needs. Only together, in concert, can the projects achieve the Triple Aim for the population.
Watch-Out #4: Remember that population management is a team sport.
Right now, we’re seeing a lot of organizations hiring for roles they’re calling “Director of Population Health” or “Vice President of Population Health.” However, many struggle with even the first step of putting together a job description for this new role because they don’t yet know what they need to do the job.
If you don’t understand that population management is a team sport, you run the risk of establishing an executive-level role for population health with no real authority or decision-making power. Some have set up a population health executive position as more of a data analyst who reviews dashboards. While that will add some value (especially in the short term), it’s not sufficient for long-term transformation to better design, coordinate, deliver, and pay for services for a population.
Rather than creating a new role, think about how you might assemble a team that can develop and execute on a comprehensive strategy to support your population.
Assembling that team should include creating a governance structure to manage the Triple Aim that includes the top leaders and key stakeholders. A great multidisciplinary population health team includes clinical and financial leaders. It includes those who understand data systems for improvement. People who can build and tap into relationships with other community organizations and partners who also serve the population should be on the team.
When assembling your team, consider the following questions:
- What is the burning platform for this work? Do you have an articulated purpose statement for why you want to work on the Triple Aim for your population?
- Does this team have the authority to allocate the time and resources needed to achieve your aims for your population?
- Do the members of this team have authority over areas that will change because of this work?
- Can this team create the vision of the new system focused on pursuing the Triple Aim for the community as a whole and build the will among all leaders in the organization?
- Will this team champion the spread of successful changes throughout your organization or community (in collaboration with other stakeholders)?
Watch-Out #5: Don’t assume that good planning is all you need.
You can have a great, thoughtful plan. However, if you are spending most of your time in a conference room creating a plan for serving your population, not only will you run the risk of designing services that won’t match the needs and assets of the population, you will slow the pace of your work.
Organizations that create a plan to “go live” with full implementation before testing changes, learning from those tests, and measuring the results over time run the risk of rolling out large programs with a high chance of failure.
Invest in building the quality improvement expertise of your team. What you learn about how to create a system for learning as you go will save you time, energy, and resources. A comprehensive learning system includes:
- A set of aims based on what you know about your population;
- Measures to track progress towards the aims;
- A definition of what “scale” is for you (e.g., 11,000 Medicaid beneficiaries; 4,500 women; 125,000 patients);
- Small-scale testing including individuals with lived experience in your population;
- Continuous oversight of the learning system; and
- Periodic rebalancing of your portfolio of work over time.
We hope that these tips will help you reconsider your assumptions, save you time, build on your strengths, and take full advantage of your opportunities. Many thanks go to the more than 150 organizations IHI has worked with over the years who have contributed to this learning.
Ninon Lewis is an Executive Director at IHI.
You may also be interested in:
A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost