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Why Improving Health Care Isn’t Enough

By Uma Kotagal | Thursday, September 5, 2019

Why Improving Health Care Isn’t Enough

As health systems mobilize in pursuit of the Triple Aim, more are sharing their quality improvement (QI) skills with their community partners. Uma R. Kotagal, MBBS, MSc, is Senior Fellow at Cincinnati Children’s Hospital Medical Center (CCHMC) and Senior Fellow at IHI. In the following interview, she describes why — though CCHMC is consistently ranked one of the top pediatric hospitals in the US — they understand they can’t improve the health of their community on their own.

What made CCHMC decide to use your QI expertise in partnership with your community to pursue making Hamilton County in Ohio the healthiest in the US?

For years, we had been seeing data that showed that — while we were improving health care — the health of the children in our community was getting worse. Asthma hospitalization rates, infant mortality, and issues of mental health and obesity in children were high or had worsened over time.

We were doing great work improving our systems, and we’re ranked very high among children’s hospitals across the US. But we also had to acknowledge that the overall health of children in our community was not great.

At one of [CCHMC’s] strategic planning meetings, a couple of senior members of the leadership team made a strong and compelling case for including population or community outcomes in our strategic plan. This was not universally accepted at first, but as we discussed it with the leadership team and the board, everyone agreed that it was important.

How has your work in the community evolved since those first strategic planning meetings?

I think this is our ninth year focusing on the community. Our first strategic plan focused on things closer to health care, such as partnering with school nurses to improve outcomes for kids with asthma. We also began including Legal Aid Society of Greater Cincinnati members as part of the clinical team to mitigate housing and other legal issues that impacted health. But as we got deeper in the community, we learned that we needed to do more than simply make health care better.

In the early days, we said things like, “Kids with asthma are not getting their inhalers. Let’s make sure we deliver them.” Now, we’re asking things like, “What does better health really mean?” “Are our children thriving?”

What does building QI capability and capacity look like in the community?

It’s built on understanding the complexity of the work and how it’s different from what we do in the hospital. In the community, for example, you work with multiple structures, different philosophies and approaches. We knew that people wanted to do a good job but didn’t always have the skills to do it at the level necessary to move the outcome. We decided there was a need to build improvement capability across various sectors so we could improve effectiveness and, therefore, impact.

We decided to adapt and modify the learning networks we had been using in health care for the community. We launched a cross-sector community improvement network focused on transforming early childhood outcomes in partnership with community organizations. We agreed on specific early childhood outcome measures. Once we did that, we went back to what was successful for us inside the hospital: building deep bench capacity so that everybody understands how to measure, focus on outcomes, and run PDSA tests.

We started by inviting community members into our internal training, but eventually designed an improvement science training program for the community called Impact U in partnership with an organization called Strive Partnership. Over time, we understood that we had to go deeper and build support inside community organizations for their leaders.

Is the improvement training specifically for community leaders?

It’s a nested model. We start with community leaders because we believe that, when they change how they see and do things, organizations also change. We decided our first class would include leaders from organizations like the United Way, the Cincinnati Public Schools, and the Urban League.

We began with leaders who were interested and engaged and had strong relationships and impact in the community. It helped that Cincinnati Children’s had a track record for solving problems inside the hospital. People could see the organization had improved so much, so they were willing to trust that maybe this was a good idea.

We knew that we might not get everybody we wanted at the beginning. Over time, however, demand has increased and now several major community groups want to use improvement in their organization.

How do you adapt teaching QI for the community?

Some components are the same. For example, every [participant] must do a project, including senior leaders. Over time we’ve been using more community-based examples because when the community only sees health care examples, it’s easy to say, “That’s health care. You don’t know anything about education.”

If you find the right leader and start to build their capability, they get it almost immediately and they want to send other people. We help link [the improvement lessons] to their priorities and say, “What do you want to change first? What’s your theory about how to do that? Who needs to learn this?” We help them be strategic about who comes to the training.

One big difference is that we have the students start with personal improvement projects alongside a system-level improvement project. We do this because you have more control over a personal improvement project. It helps to build confidence and improvement skills while changing the system will inevitably take longer.

Like many health systems, CCHMC has a major presence in your community. How has that influenced your engagement with potential partners?

[Our position in the community] is a plus and minus. The plus is that we have credibility. But that just gets you into the conversation. After that, you build trust by being a good partner and [demonstrating] humility. Senior leaders and the board need to be in it for the long haul. When you earn and keep trust, people believe you’re serious and committed.

How do you demonstrate humility?

We don’t say, “Here are eight things you should do.” Instead, we say things like, “We think this method could work. Would you be willing to try it? We’ll work with you to see if it does.”

We acknowledge and respect that others have expertise. We ask questions with humility: “What does this look like for you?” “In health care I would say this. What would you say?”

We work hard on being responsive and providing support. It doesn’t mean we don’t push or aren’t persistent, but our QI consultants and coaches will meet people wherever they are — at their office, in a coffee shop, or by phone.

How would you summarize the progress you’ve seen so far?

The progress is slow and exhilarating at the same time. We’ve partnered with many individuals and organizations.

For example, we’ve worked with our health department on a shared way to measure children thriving at age five. We’ve partnered intensely with the schools. This is important because, as kids come to fewer primary care visits [as they grow older], it’s in school that the work needs to happen.

We’ve partnered with United Way to help build improvement capability in the agencies they support who work with kids. We’re working with the city council on housing issues. We’ve made a lot of progress on our most important partnership — with parents — on design thinking and working together to improve outcomes.

What are some of your targets?

Our focus is early childhood. We’re looking at children from what we call [in pediatrics] “minus nine to nine.” In other words, before pregnancy to age nine. We picked that [age range] because the positive trajectory for children tends to be established in that period.

Our goals include decreasing infant mortality and transforming primary care to improve population-level outcomes. We focus on reducing disparities in avoidable hospitalizations. We have goals linked to 3rd grade literacy — a key predictor of long-term outcomes — in partnership with the Cincinnati Public Schools. We are developing early prototypes to address the social determinants [of health]. We also have some proven prototypes that we can start to scale up. But we have a long way to go.

What advice do you have for health care systems about bringing QI to their communities?

  • Get to know your community — Health care can’t know how best to contribute to better health without knowing who our patients are and understanding their stories. The social determinants of health can’t be addressed from inside the hospital.
  • Be humble — Institutions in most communities will welcome health care’s help with solving difficult problems if we arrive with humility and the attitude that the partnership is what will make a difference.
  • Choose a unifying population problem or measure — I am biased, but I think focusing on kids is a great idea. The evidence is so strong that our communities are healthier when we invest in children. Focusing on kids can be unifying because they represent the future. Many elected officials also look at mental health costs or the long-lasting impact of poor education and they see the benefits of better support for kids and their families. Starting with older people is also a good idea.
  • Ask key questions — How can we reduce disparities? Are we able to close the gap? What would it take to make our community healthy?

Is there a story that helps illustrate the importance of working in the community?

There’s a young man who’s a single parent. He has a powerful commitment to this work. He’s very proud of how well his two children are doing in school, but he worries about their safety in a neighborhood where gun violence is too common. He’s discovered that he can help others in his community. He’s building a prototype teaching other parents about housing safety, and about their rights as tenants.

There are grandmothers who are promoting reading. They collect data on parents reading to their kids by texting each other. They’re energized and building a social model for change.

We have a [community] feast every month because our design work suggested that people needed to work and hang out together. At these neighborhood-based gatherings, people bring ideas to help each other. There is so much strength and resilience in the community. Our goal is to connect with hundreds of people who can help us understand what’s needed so we can co-produce potential solutions. We don’t want to be doing anything to anybody. We want to work with people.

Editor’s note: This interview has been edited for length and clarity. 

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