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“What is our purpose? Where are the needs being unmet by the system? Where are the inequities?”
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Pursuing the Triple Aim Takes More Than High-Quality Care

By Chesley Rappleye | Tuesday, October 22, 2019
Pursuing the Triple Aim Takes More Than High-Quality Care

In 2017, East London NHS Foundation Trust (ELFT) was the only mental health and community health trust in England rated “outstanding” by England’s Care Quality Commission (CQC). Having set a mission in 2013 to provide the highest quality mental health and community care in England by 2020, ELFT had attained an impressive range of results, including significantly reduced incidents of inpatient violence, medication errors, waiting times for treatment in the community, and improved staff satisfaction and engagement. They had also won numerous honors, including Trust of the Year and a staff engagement award. ELFT had, by any measure, become an NHS leader and standard setter in quality and safety.

Still, ELFT was not satisfied. They paused to have what was referred to as “The Big Conversation.” As Amar Shah, ELFT’s Chief Quality Officer, puts it, “We had a strong sense that we needed to go beyond just providing high-quality care.” Providing a wide range of mostly out-of-hospital services to a population of around 1.7 million people in the East of London, Bedfordshire, and Luton, the Trust was acutely aware of the variation in outcomes and life chances for those living in the areas they serve.

ELFT held a series of discussions with over one and a half thousand people, including staff, patients, and other stakeholders to define the future of the organization. According to Amar, they asked a series of probing questions: “What is our purpose? Where are the needs being unmet by the system? Where are the inequities?” As Amar recalls, “We needed to think much more around the outcomes that matter to the people in our communities and start to tackle some of the determinants of health outcomes that aren’t in our direct control.”

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ELFT decided that the Triple Aim framework was a useful anchor because it helped integrate their work on population health, improving patient experience and care quality, and increasing value and reducing costs. Now the Triple Aim drives improvement activity at the local level, encouraging teams to go beyond service-level improvement to address the system level (in service of the overall wellbeing of patients and staff), and the strategic level (helping frame delivery of the organizational strategy).

Amar would be the first to say that ELFT is still learning their way through Triple Aim implementation, but he shared some of his reflections to date on population health and equity:

  • “Start by considering who’s not thriving in the current system,” Amar advises. ELFT serves one of the most densely populated and diverse regions of England. This compelled them to consider how to redesign to serve those most disadvantaged by the current system. “This helped us prioritize who most needs our concerted efforts to achieve Triple Aim outcomes,” Amar explains.
  • Take the time to understand your population — Amar notes that ELFT uses improvement methods to do this. “We go through a very simple three-part data review at the start of any of our population health improvement work,” Amar says. “This enables us to listen directly to people with lived experience within the population in question, and people who are providing formal or informal support for them. We also learn from the quantitative data we have available to us [about the population].”

Even this simple exercise, that Amar estimates takes no more than two or three weeks, is enlightening. “We can learn a lot about the variation and inequity in access, experience, cost, and outcomes,” he says, even in what can sometimes look at first glance to be a uniform population.

  • Explicitly address equity — Identifying and tackling inequities in outcomes is an integral part of improving population health. According to Amar, “One of the most important steps we’ve taken is to be more aware of equity and to be more transparent and open about talking about inequity, particularly, so that we can identify it. Whenever we’re working on a complex quality or safety issue, we ask, ‘What is the difference we see in outcomes by particular characteristics? Does that tell us something that we’re missing in our current approach?’ We also use quantitative data to be transparent about disparities in outcomes and reporting on that throughout the organization.”
  • Partner to design solutions — Says Amar, “All of our improvement activity is in partnership with service users or patients and family members. The next stage of our journey is taking what we have learned about partnering at the service level and then translating that to partnering with citizens and the local community in our improvement and Triple Aim work.”

Since the start of The Big Conversation, ELFT has been deemed “outstanding” by the CQC again. Despite this recognition — or maybe because of it — they know they still have hard questions to ask and work to do. As ELFT Chief Executive Navina Evans has stated, “Together we are striving to build a culture of continuous improvement with ELFT. Recognition from the CQC is pleasing for us all but remains part of that improvement process and not an end.”

Chesley Rappleye is an IHI New Business Manager.

Editor’s note: East London NHS Foundation Trust is a member of IHI’s Health Improvement Alliance Europe and will present at the IHI National Forum on SH01: Practical Guide to Achieving the IHI Triple Aim on December 8, 2019 from 1:00 - 4:30.

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