Improving Healthcare Outcomes: Keep the Triple Aim in Mind
“Improve outcomes!” Those are the marching orders for healthcare organizations throughout the United States. We know what improving outcomes means at a high level: It means improving the health of patients and the patient experience, and reducing costs. But once organizations get into the weeds of actual outcomes improvement—once they get into the work of measuring outcomes—the question of what constitutes an improvement becomes much more complex. The truth is that not all outcomes are created equal.
The Triple Aim: Improving Healthcare Outcomes
Everyone in healthcare is probably familiar with the Institute for Healthcare Improvement’s Triple Aim:
- Improving the patient experience of care
- Improving the health of populations
- Reducing the per capita cost of healthcare
The Triple Aim at its most basic represents a framework for improving healthcare delivery outcomes. Ideally, when healthcare organizations go about improving outcomes, they will want to consider all three dimensions of the Triple Aim. It’s an ambitious framework that requires a high degree of system change to attain.
Consider the following example. An organization might initially cut costs by decreasing length of stay (LOS), but this “improvement” isn’t as meaningful without considering how decreasing LOS affects clinical outcomes and patient experience. Did the quick discharge increase the incidence of readmission, risking patient safety and increasing costs? Did it increase or decrease patient satisfaction?
Achieving the appropriate balance among the three dimensions is the fundamental idea driving the Triple Aim and critical to achieving real, long-term change in healthcare delivery outcomes.
The Triple-Aim Litmus Test
The Triple Aim provides a valuable litmus test for assessing whether an organization’s efforts to improve outcomes have the right focus. It helps answer the questions: Does this outcome pass muster as something that is relevant for the patient populations we serve? Is it the most impactful initiative in terms of improved healthcare delivery and health outcomes? Does it encompass multiple dimensions of the Triple Aim?
It’s also a good way to test the maturity of the organization. Is the organization ready to take on rapid improvement cycles to deliver meaningful outcomes? Are the outcomes helping to improve healthcare delivery? Does the organization have the ability to automate measurement of all three dimensions of the Triple Aim?
Using the Triple Aim framework helps put outcomes in a more meaningful context, demonstrating improvement that is visible, meaningful, and relevant. Senior leaders share this detail with their board of directors. It is critical this information be widely disseminated to ensure organizational alignment regarding priorities and incentives.
Communicating successful outcomes improvements to the entire organization is crucial. Visibility to the results of an improvement initiative gives leaders a level of understanding as to the engagement and support of the strategy by all team members. It also allows leaders to identify the capabilities of the organization. What can they learn from departments that are experiencing success? Are there departments that are struggling and need additional support, guidance, or resources?
It’s true—and reasonable—that not every outcome an organization achieves will fulfill all dimensions of the Triple Aim. However, developing the organizational capability to relate every outcome to the Triple Aim is important and worthy. When we engage with a new client or prospect, we often ask the following readiness question: Is your organization capable on a regular basis of approaching outcome improvement from a Triple Aim perspective? The organization’s ability to address that question and to show how their improvement teams are approaching the Triple Aim is a key indicator of readiness to create a data-driven engine for sustainable outcomes improvement.
Start SMART: Approaching Improvement Measures Effectively
Tackling the Triple Aim successfully requires organizations to define clear measures of improvement before implementing improvement initiatives. Improvement measures can be described in three main categories — outcome, process, and balance. Regardless of the type of measure, using the SMART acronym — Specific, Measurable, Actionable, Relevant, and Time-based — is helpful to ensure that goals and aims explicitly state how you will measure success.
A note of caution: While regulatory measures like those from the CMS or The Joint Commission are necessary, and often based on best practices, focusing solely on these measures won’t drive necessary care improvement across the organization. They are often not timely (lagging behind 30-60 days) and often don’t focus on problems or care gaps specific to the organization.
Outcome measures are the ultimate arbiter of whether an organization is achieving high-level goals supporting the Triple Aim. An outcome measure defines what an organization is trying to achieve. For example, an outcome goal might state that the organization will decrease the mortality rate of sepsis patients by 20 percent by a certain date. Reaching this goal will require many iterative process improvements, each of which will have their own measures of success. But the outcome measure – reduced mortality – is the ultimate goal of those improvements.
Outcome measures hold the improvement team accountable to itself and with leadership, setting the standard for whether the team is meeting its goals. They deliver important visibility to the organization about the value of the improvement team work. The transparency that results from sharing the team’s progress against these measures builds momentum and support throughout the organization.
An outcome measure also maintains the focus of the improvement team and prevents scope-creep. An outcome measure serves as the North Star for the improvement project. When an organization gets a lot of creative people in a room trying to solve a problem, it’s common to hear things like, “Wouldn’t it be cool if we tried this?” The team can step back and evaluate ideas against their North Star to determine whether the idea furthers the achievement of the goal. Without purposeful, focused measures, the desired outcome will not be achieved, regardless of the level of dedication or innovation of the team members.
Process Aims and Measures
Although outcome measures show improvement toward the high-level goals of the organization, they don’t define how to achieve those goals. That’s where process aims and measures come in. Aim statements specify targets for measureable process improvements that ultimately contribute to achievement of outcome goals.
For example, an organization may write an aim statement to decrease the time it takes to recognize sepsis in the emergency department (ED) and to initiate evidence-based interventions like the 3-hour bundle. Associated measures may be “time from ED arrival to sepsis recognition” or “time from sepsis recognition to initiation of the 3-hour bundle.” Other aim statements may specify a target for improving overall compliance to the sepsis 3-hour bundle, or to improvement in individual elements of the bundle, like timely antibiotic administration. Associated process measures would be “x percent compliance to all the sepsis 3-hour bundle” or “time from sepsis recognition to antibiotic administration.”
Process aims and measures empower clinicians to take action on the data and improve care. An outcome goal to improve sepsis mortality by 20 percent fails to provide detail for how clinicians contribute to achieving the goal. Engaging frontline employees in the development of process aims and measures allows them to understand how care processes contribute to improvement outcomes, and how these processes will be evaluated. It also ensures the process improvement aims are clear, measurable, and meaningful. Clinicians can see how improving the timeliness of antibiotic administration contributes to achieving the successful outcome of improved mortality. The measure provides direction and instruction for the clinician. It is an early indicator of whether the organization is progressing toward meeting the objectives of the improvement initiative. Over time, the outcome will begin to reflect these improvements in the process.
As clinicians engage with specific interventions and process measures, they learn what works and what doesn’t and can give feedback to continue to refine processes. In turn, improvement teams can use process measures to provide encouragement and feedback to clinicians and help them evaluate further opportunities for improvement. This feedback loop is a critical aspect of creating a culture that drives improvement.
The Triple Aim serves as the ultimate framework for thinking of balance measures. An improvement in one of the dimensions of the Triple Aim should not result in a negative outcome for the other two. Achieving balance is key as organizations pursue these ambitious and very important improvement objectives.
A Sepsis Example from Thibodaux Regional Medical Center
Thibodaux Regional Medical Center has historically used lean principles to identify opportunities for cost savings and to achieve clinical outcomes improvement. As Thibodaux Regional entered the shared-risk market, it was critical that senior leaders and physicians identify and prioritize improvement opportunities—together.
Employing an enterprise data warehouse and analyzing key process analytics, the cross-functional team identified sepsis as an area for improvement. Keeping the Triple Aim at the forefront, Thibodaux Regional set goals to reduce overall sepsis mortality by 25 percent, reduce costs by 20 percent, and maintain a 99 percent patient satisfaction rate.
To improve patient outcomes, the team established early recognition protocols in the ED, developed an algorithm for early identification of at-risk patients, and initiated three- and six-hour sepsis bundle protocols. They created aim statements and process measures around these changes, and physicians were held accountable for complying with the new protocols.
At the start of the improvement initiative, Thibodaux Regional’s sepsis mortality rate was already outperforming the national sepsis mortality rate of 14 to 18 percent.
Several months after implementation, Thibodaux Regional had achieved and is maintaining a sepsis mortality rate. The Thibodaux Regional team has decreased their sepsis mortality rate to half of the U.S. national average. In addition to the reduction in sepsis mortality rate, Thibodaux was able to reduce variable cost per sepsis case by 7.3 percent and increased patient satisfaction for sepsis patients to the 93rd percentile.
Thibodaux Regional represents the positive returns hospitals can achieve as they strive to improve outcomes for quality, patient satisfaction, and cost. Keeping the Triple Aim in mind when creating a strategy for optimizing outcomes empowered the organization to confidently and successfully pursue care improvement objectives.
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