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Transformation is not just another way of saying "change."
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The Five Ps of Triple Aim Transformation

By Derek Feeley | Tuesday, April 30, 2019

Line of Sight

You hear a lot about “transformation” in health care today. It’s become a bit of an overused buzzword. Sometimes people use it as if it’s just another way of saying “change,” but I see transformation and change as two very different things.

As we say at IHI, all improvement is change, but not all change is improvement. Likewise, all transformation is change, but not all change is transformation.

How can you tell the difference? Transformation is not comfortable. If what you’re doing doesn’t result in some uneasiness, then it’s not meaningful enough to be transformational.

The Triple Aim — improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care — represents transformation in the world of health and health care. Pursuing it effectively takes a fundamental shift from the mindset that has dominated health care in the past.

The example of the Triple Aim helps illustrate the five elements needed for true transformation. I think of these as the five Ps:

  1. Paradigm shift — Making a series of small adaptations won’t lead to transformation. You need to change how you do things so profoundly that there’s no going back to the way things we were. Deming’s System of Profound Knowledge shifted the existing paradigm about improving quality. The Triple Aim also represents a paradigm shift.
  2. Plan — Transformation needs a plan to get from the current state to the future state. Your destination — and how you’re going to reach it — must be clear. Pursuing the Triple Aim requires organizing and sequencing new approaches to address old problems. What are the steps you’ll take, for example, to help connect patients with diabetes to resources in their community if they need help with healthy eating, exercise, or access to medication? Who needs to be involved in creating that network of support?
  3. Proactive — Undertaking transformation means taking control and creating a path instead of being only reactive. Meaningful pursuit of the Triple Aim requires going beyond dealing with the consequences of illness. It means focusing on prevention and moving upstream to create health and prevent illness. The very essence of the Triple Aim is a shift away from reactive “fixing” to proactive building. Proactive Triple Aim transformation means creating a portfolio of balanced and integrated projects and a set of measures that work across all three domains. It also requires balancing measures so you don’t prioritize one domain of the Triple Aim at the expense of the others.
  4. People — It only takes one of us to make change, but transformation is driven by the many, not the few. No transformation can happen without a critical mass of people willing to fully commit to new ways of thinking and behaving. No one health care leader can achieve the Triple Aim on their own. Its pursuit requires engaging people in every aspect of the health care system and beyond.
  5. Purpose — What purpose does your organization serve? Unless you and your organization know the true significance of your work, the changes you make won’t add up. Transformation requires people with a shared purpose to give meaning to their efforts. Some organizations talk about transformation, but they’re just comparing themselves to others. That’s not enough motivation to challenge the status quo. The Triple Aim requires us to have a clear and shared purpose at the very center of what we do. The Triple Aim is not an end in itself — it’s a means to an end. IHI President Emeritus and Senior Fellow Don Berwick talks about the Triple Aim as a single aim with three dimensions. It’s the integration of those three that give people pursuing the Triple Aim a sense of purpose.

Whenever I’ve spoken with people committed to their Triple Aim journey, they’ve talked about how it requires them to tackle transformation and not just change. In times of so much uncertainty in health care around the globe, it can be tempting to wait to see where the wind blows before we take bold action. But patients can’t wait for that. Too much harm is happening while we wait for certainty that may never come.

(Having difficulty watching this video? Watch on YouTube.)

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on the IHI blog.

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