In one community, a health care leader (who asked to remain anonymous) described a health system CEO who encouraged his employees to participate in a coalition working on a regional Triple Aim initiative with the goal of slowing down the improvement process. Some community partners, for example, made less money when the population's health improved. For regional coalitions, finding opportunities to improve health and care was typically straightforward, but it often proved more challenging to build a community-wide financing model for this same population. Some organizations chose their own employees as their relevant population, which improved the employees’ health and created a better care experience for them while also reducing health care costs for both employer and employees. In some cases, the payment model actually penalized them when they improved health because it led to less need for health care and, consequently, less revenue. Even though these organizations saw the value of improving health and care for the population, their payment model did not reward them for lower per capita cost. In the early days of our work, organizations often chose a population for which only 2 dimensions of the Triple Aim made sense, with the most likely weakness being per capita cost. In order to achieve sustainable improvement, organizations were encouraged at the outset to choose a population or populations for which all 3 dimensions of the Triple Aim were important. The 141 sites in the collaborative are summarized in Table Table1 1. We noted the contrasts in the contexts and structures of those sites that made progress and those that did not. 6 Progress here was defined as showing at least some improvement in process measures related to a site's design or in outcome measures related to the Triple Aim. The case control study approach that we used was based on the different sites’ progress.
#IHI TRIPLE AIM SERIES#
Accordingly, IHI supported organizations in a series of collaboratives to adapt and refine the Triple Aim small theory. 3– 5 Such collaborative efforts provide a structure for observational research. This process should lead to improvement, and transparently measuring the progress of high-performing teams provides further motivation. The IHI Breakthrough Series Collaborative model, first developed by IHI in the 1990s, provides a forum for multiple sites with the common aim of working collaboratively and exchanging successful and unsuccessful approaches in real time. In 2007 IHI established a collaborative to begin testing and refining our Triple Aim small theory. Øvretveit and colleagues refer to such principles as “small theory” and propose that a small theory be tested and refined across numerous sites and in different contexts so that it can be adapted and refined. The researchers also set out the principles forming the foundation of the work to achieve the Triple Aim: the simultaneous pursuit of the Triple Aim, identification of a population of concern, and designation of an “integrator” with specific roles and functions. I n an article published in 2008, researchers from the Institute for Healthcare Improvement (IHI) posited that, in order to improve US health care, it was necessary to pursue a system of linked goals called the Triple Aim: “improving the individual experience of care improving the health of populations and reducing the per capita costs of care for populations.” 1 Drawing on our 7 years of experience, we describe 3 major principles that guided the organizations and communities working on this endeavor: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. Since that time, IHI and others have worked together to determine how the implementation of the Triple Aim has progressed.
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