Now Reading: Pursuing the Triple Aim Book (Launch Event in a separate post)

“We have manufacturing processes with 8,000 data points attached to them. We never had that in health care” – Pat McDonald, Intel Corporation

When I give tours of the Kaiser Permanente Center for Total Health (@kptotalhealth), I say two things relevant to our history:

  1. Sidney Garfield, MD, one person, was able to change the course of health care – the power of the individual should not be discounted
  2. Health care in 1938 was just as “complex” as it is in 2012 if you read Sidney’s writings. There’s nothing keeping an innovator in 2012 from creating as powerful innovations

This book proves both points.

Kenney and Bisognano at the Center for Total Health – Click to Enlarge – View on

This review is written from the perspective of a physician trained and working in an integrated, pre-paid care system, where Innovation is in its DNA. Authors Maureen Bisognano and Charlie Kenney chose to anchor the book with the Kaiser Permanente experience. I read the chapters carefully and I am still impressed.

The Triple Aim

I’ve of course heard of the Institute for Healthcare Improvement (IHI – @TheIHI ) Triple Aim, I honestly hadn’t stopped to carefully consider it previously (I say, authentically, spirit of social media). Here it is:

  • Improving the experience of care—providing care that is effective, safe, and reliable—to every patient, every time
  • Improving the health of a population, reaching out to communities and organizations, focusing on prevention and wellness, managing chronic conditions, and so forth
  • Decreasing per capita costs

Organizations targeting the Triple Aim have gone from looking inward to looking outward, getting outside their walls and reaching out to their communities to improve care overall for populations, whether the population is a panel of diabetic patients or an entire town. And they have gone from paying little if any attention to how money is spent—on tests, procedures, inpatient care, emergency department use, and much more—to recognizing that those dollars are a precious asset for communities, companies, individuals, and our nation.

What’s different about these innovations

From HealthPartners to Bellin Health and the East and West Coast in between :), there are a few things that differentiate these innovations in my mind. And remember, innovation is not “great idea,” as Chris McCarthy says in the book, “We call that innovation only if we know it provides value. Up until then, it is just a concept or an idea.”

  • These are not ideas just launched last year. The experiences detailed here cover decades.
  • They present their successes with data (and in fact the innovations themselves included innovations in analytics)
  • They all show dedication to culture change where necessary
  • They borrow and improve on each others’ work
  • They exist in the world where the majority of “health” is practiced, from hospitals serving a fee-for-service clientele to workplaces big and small, and interestingly to me, are venturing into the social determinants of health space
  • Technology is an enabler, but it is not the focus, this is a glimpse at what the post-EHR era looks like

My own parallel experiences are confirmatory

I was Medical Director of Health Informatics and Web Services at Washington State’s Group Health Cooperative (@grouphealth ) (and an affiliate of The Permanente Federation, where I work now) and knew much about Virginia Mason’s LEAN journey. I was starting a LEAN journey myself and regularly met with my counterparts there.

I have actually visited Kim Pittinger’s practice in Kirkland, Washington, where I saw the primary care “flow station” that was later adopted by HealthPartners in Minnesota. It’s as cool as it sounds.

I was fortunate to shadow Kate Koplan, MD in 2007 when she began her career at Harvard Vanguard Medical Associates, and the record of that experience is on this very blog (see: “When I walk in the room, it’s like going to medical school.” : PCHIT in Boston | Ted Eytan, MD).

Speaking of shadowing, I didn’t know Tony DiGioia, MD before reading the book, but I’ve been an avid shadower since about 2005 – it’s the most respectful thing a leader can do to understand the facts where they matter, where the patient is.

Actually, you can do that even if you aren’t Kaiser Permanente (it’s what Sidney Garfield wanted)

The quote at the beginning of this post describes the awakening that Pat McDonald and the team at Intel Corporation had about their purchasing of health care – it was devoid of metrics, in complete opposition to the way the rest of Intel’s business is run. She brought all levels of her company together with an interested and transforming health system, Washington State’s Virginia Mason ( @virginiamason ) to create a marketplace collaborative for health.

Work like this, or renewing Primary Care in the safety net that CareOregon finances, or an orthopedic surgeon, Tony DiGioia, MD, creating a patient and family operating system to improve all aspects of the triple aim at UPMC ( @PFCC_ ) are all improbable in a discussion of how the provision of health care is currently financed and incentivized.

And yet, they all happened, just like Sidney Garfield’s innovation did, and his vision was that this should happen by the way:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success. It only requires a dedicated group of physicians with reasonably well-organized facilities, a membership desiring their services on a prepaid basis and strict adherence to all these principles. All of this is not to say that US medicine should change over to the Kaiser Permanente pattern. On the contrary, freedom of choice is im- portant; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians. Any change to prepaid group practice should be evolutionary, not revolutionary. Physicians in general have too much time and effort vested in their prac- tice to discard them overnight. It will probably be the younger men, start- ing out in practice, who will innovate. Medical school faculties should point out the advantages and disadvantages of all methods of prac- tice to these young men so that they can choose wisely. – from The Delivery of Medical Care, Sidney Garfield, MD, 1970.

All of these experiences made me grateful that this work is honored in this book, because the success of Kaiser Permanente and all of these innovations can easily be duplicated, and they should be.

When someone says, “We can’t do that because we aren’t Kaiser Permanente” I drift to thinking about what that means – it means “we can’t eliminate disparities in HIV care, so Black Americans will continue to die 15 percent more often than their white counterparts,” or ” we can’t reduce heart disease using a simple medication regimen, so more people will have strokes and heart attacks,” or even more importantly, “we can’t bring the creativity and cognitive capacity of the people we work with to create a better home, work, community, society.”

As Kate Koplan, MD, and I discussed at the book launch event (which I’m covering in the next blog post…), a physician’s cognitive capacity was formerly harnessed for the single patient encounter only. These organizations discovered that this is wasteful, as much as it was found to be wasteful at UPMC that a parking attendant could not participate in creating an excellent surgical experience. I learned from the book and the launch event that health care is now changed. All of the exceptional qualities of people who are in health care (and by definition they are all exceptional, they have to be for a job this challenging) will be brought to solve every problem, big and small. 

The people and organizations profiled here didn’t say, “we can’t do it,” they are saying what Jack Cochran,MD ( @JackHCochran ) says, and you will, too πŸ™‚

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