Why It Matters
The COVID-19 pandemic has disrupted every aspect of our lives, and every feature of the health care we provide. Everyone I know who works in health care has worked harder in the past year than ever before. Many of us have lost people important to us.
Let’s honor our individual, collective, national, and global losses by using the one-year mark of the pandemic to look beyond the acute response to this global calamity. Let’s do more than repair and rebuild the systems we once had. Instead, let’s re-design and re-imagine something better.
We need more than a health care system. We need a health-creating system.
What should we — as a community committed to change, learning, and improvement — do to develop the health-creating system of the future? I have five proposals.
Shift Digital Health from Invention to Implementation
Driven by the demands of COVID-19 response, technology is now integral to both health and health care. Yet, we fall short of realizing its value beyond telehealth and important strategies like “hospital at home.” Walk onto any clinical unit in a modern hospital and you will see that clinical practice today is reliant on both a clinician’s knowledge and compassion and technology’s abilities to supply information and services just in time. But the promise of digital therapeutics, diagnostics, and monitoring systems are held hostage by the limitations of the human systems required to implement them.
Just as we have created workflows to, for example, more reliably deliver antibiotics to prevent sepsis deaths, we must also use quality and reliability sciences to improve the delivery of proven digital therapies and diagnostics. Such technologies that contribute to better individual and population outcomes requires a new agenda for quality improvement that embraces technology not as a mediator of data, but as a mediator of health improvement. Let’s create workflows to leverage these health-improving technologies to connect patients to providers, understand population-level trends and risks, and anticipate errors before they happen.
Create Environments That Empower Patients to Co-Produce Their Care
Health-creating systems are co-produced by patients in relationship with their providers. While our technical expertise as clinicians is vital, the most essential contributor to the outcome is the person whose health is at stake. When we understand this, and design systems appropriately, the results can be groundbreaking.
For example, ImproveCareNow is a fascinating experiment initiated by Cincinnati Children’s Hospital Medical Center for and, crucially, with kids diagnosed with Crohn’s disease and ulcerative colitis. ImproveCareNow is a learning health care system that helps patients, families, clinicians, and researchers work together to speed innovation and scale up lessons learned. ImproveCareNow now reaches more than 30,400 patients and their families across more than 100 hospitals and treatment centers.
As part of this network, patients actively trade knowledge with each other about how to live with their chronic disease. Clinicians learn about best practices, and researchers use clinical encounter data to study and solve the practical problems facing these young patients and their families. These parts have functioned separately before. The innovation here is in how they are working together.
I’m confident that we’ll use learning networks like ImproveCareNow — driven by patients, co-produced with clinicians, and supported by researchers — to provide clinical care in the future because this kind of mutually beneficial cooperation gets results. For example, since 2007, the proportion of patients in remission (with inactive disease) has increased from 55 percent to 82 percent. In addition, 95 percent have satisfactory growth and 97 percent are not taking steroids. The learning health care system concept is already expanding to adult conditions including pancreatic cancer, breast cancer, end-stage renal disease, epilepsy, and many others.
Extend Our Duty to Care to the Safety of Our Workforce
Rates of physical and psychological harm were already on the rise before COVID-19, exceeding risks seen in manufacturing, mining, and construction. A story I heard early last year helps to illustrate why preventing workforce harm and injury is so important.
Before COVID-19 was fully upon us, I had visited a health system in the Southwest. When I told the chair of medicine that safety of the health care workforce was one of IHI’s priorities, he stopped me with tears in his eyes. A few months earlier, his wife of 30 years had been assaulted by a patient just a few miles from where we sat. As the lead nurse of an ambulatory clinic, she had been trying to work something out with a patient who had become agitated when asked for a co-pay he could not afford. The patient broke her arm in three places, and rendered her unconscious from head trauma. She had been on leave ever since.
For two years now, IHI has been working with a group of 30 health systems to identify evidence-based interventions to enhance physical and psychological safety, and implement these actions to prevent workforce harm and injury. The group tracks serious harm events, and their data indicates that rates of workforce harm and injury have spiked during the pandemic.
To help mitigate this impact, IHI published “Psychological PPE”: Promote Health Care Workforce Mental Health and Well-Being, guidance to help us all support each other during these challenging times. And, last September, IHI and 27 patient safety partner organizations published Safer Together: A National Action Plan to Advance Patient Safety. The National Action Plan makes clear that workforce safety is a prerequisite for safe and effective patient care. Health-creating systems of the future must create health for those providing care.
Ensure an Authentic Focus on Equity
Two decades after the Institute of Medicine identified equity as one of the six features of a remade health care system, it’s clear that we have not made enough progress on equity. Neglecting this aim is not an option in the health-creating systems of our future. There is no Triple Aim — improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care — without equity. There can be no quality without equity.
Striving for equity must compel us to explore new ways to design the work of improvement. I’ve been studying the work of john a. powell, a UC Berkeley law professor who first articulated the framework known as targeted universalism. Targeted universalism entails pursuing processes aimed at helping specific (targeted) populations to meet (universal) goals to benefit all.
Consider the success of our colleagues at Southcentral Foundation in Anchorage, Alaska. They began their COVID-19 vaccination efforts by focusing on the most marginalized among the Alaska Native and American Indian populations they serve. This strategy has helped Alaska to achieve one of the highest percentages of people fully vaccinated in the US. We can get to universal goals using targeted strategies.
Twenty years ago, IHI and others led the charge to shed light on preventable patient harm in health care. We’ve measured rates of infections and injuries. We’ve worked to eradicate harms using improvement science, policies, and regulations. And that work continues. Similarly, health-creating systems will name, measure, make visible, and then work to eliminate the harms perpetrated by ongoing institutional racism and historic injustice. Inequities are not inevitabilities.
Design for Scale
For decades, we’ve seen health systems, policy-makers, and researchers create amazing models of care. Yet successful demonstrations in one part of the system have been difficult to spread. During this pandemic, however, we’ve seen scale up as we’ve never seen it before, at a tempo that has been breathtaking. Meeting the moment has required focus, ambition, infrastructure, and freedom to get to scale.
IHI has been working for the past three years on Age-Friendly Health Systems (AFHS), an initiative of The John A. Hartford Foundation and IHI that seeks to improve care for all older adults across the US. Participants in the AFHS initiative have built a network of over 2,000 clinical practice sites across the country that implement the 4Ms Framework for Age-Friendly Care: What Matters, Medication, Mentation, and Mobility. The incredible results — including fewer readmissions, less delirium, fewer ED visits, and shorter lengths of stay — have allowed older adults to spend more time at home and with those most important to them. We now share Age-Friendly lessons learned with ambulatory clinics, nursing homes, and long-term care settings.
The AFHS initiative helps illustrate the power of using focus, ambition, infrastructure, and freedom to propel improvement farther, faster by:
- Centering attention on care for older adults (focus)
- Setting (and surpassing) the bold aim of spreading the 4Ms to 1,000 health care locations by the end of 2020 (ambition)
- Providing clear, evidenced-based guidance and support (infrastructure)
- Offering the flexibility to implement the guidance in the way that worked best on the local level (freedom)
Applying the best of what we’ve learned during the pandemic will help us scale up the pursuit of equity, workforce safety, learning health networks, and digital safety. To build a health-creating system, we need goals and ambitions that operate at the scale of the problem.
During this pandemic, we have reconsidered accepted truths. We used to believe coordination across a whole city’s health system was impossible. We used to believe that we couldn’t develop science in real time or a vaccine in under a year. We are now living with all those realities today.
The spirit, mission, and purpose of improvement is at the heart of everything we now do. Let’s make the most of this, and build the health-creating system we so desperately need. We need more than incrementalism; we need transformation.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.