Compared to other Western countries, infant mortality in the US is shockingly high.
High infant mortality is a social problem that can only be solved through massive collaboration and out-of-the-box innovation.
To tackle this issue I propose to tap into the “creativity of the swarm,” using collaborative innovation to help parents and caregivers take the best possible care of their children even before they are born and increase the quality of care in the first years of an infant’s life.
A good starting place, I believe, is to connect parents and healthcare providers in what I call Collaborative Innovation Networks (COINs). These are dynamic teams in which diverse stakeholders with a shared vision collaborate to achieve a common goal. COINs form from the interaction of like-minded, self-motivated individuals who enable innovative ideas to be pushed forward. The participants join because they are committed to the common vision and want to be part of the innovation that “will change the world.”
How many people could be motivated by the goal of reducing infant mortality?
Through COINs, we can collectively address key topics such as breastfeeding, screening for developmental delays, and recognizing maternal depression. We can increase the quality of care for infants by creating peer learning and innovation groups of parents, where knowledgeable parents help others learn to take better care of their babies. Weaving a network of social support around parents in need helps them weather the storms of daily life. Just like in the beehive where bees take care of their young as a community, mothers and fathers in a collaborative innovation network can learn from and support each other.
One of the key factors for high-functioning COINs is communication. As we have found in our research, better communication leads to better collaboration, which in turn leads to more innovation. Ultimately, we want to increase the collective intelligence of these teams. In research at the Center for Collective Intelligence, my colleagues found that there are four key predictors that will increase collective intelligence of groups:
The more team participants communicate with one another, the more collectively intelligent the team is.
When participants communicate equally, instead of a few participants doing most of the talking, the collective intelligence of the team is higher.
When everyone contributes equally to team success, a team is more collectively intelligent.
The higher the emotional intelligence (measured through a test called “Reading the Mind in the Eyes”) of each team member is, the higher the collective intelligence of the team is.
It all starts with connecting parents and healthcare providers, encouraging them to better communicate such that they can innovate more. Talking more, talking more evenly, contributing ideas more evenly, and taking care of the emotional needs of each other will help to create better networks that will generate better ideas to reduce infant mortality.
As I take on my new role at NICHQ as leader of a national initiative to reduce infant mortality, I find myself in a struggle very familiar to those of us in public health who focus on promoting the health and wellbeing of entire communities – that is, how to maintain the public’s engagement and interest in the health priorities we are championing. Given the many priorities and important issues that are competing for our collective attention, it is easy to understand how policy makers and the public become numbed to the recurrent “calls to action” and the exhortations to pay more attention to: domestic violence, bullying and teen suicides, opiate addiction, gun violence, breast cancer, diabetes, obesity, prematurity and infant mortality…and the list goes on. All of these issues are incredibly important and for those families and communities who are touched by them, each leaves a lasting legacy of sorrow and lost potential. If all of these causes (and more) are worthwhile, how do we make gains on any when the initial response might be to lament that we can’t do everything?
When faced with seemingly overwhelming challenges, humans can be very effective at partitioning the huge into the feasible. The first step is maintaining our faith that our efforts, when thoughtfully and creatively applied, can actually change outcomes. Once we have that confidence, then we need to gain the attention of our communities and key stakeholders whose insights and collaboration are required for our efforts to be successful. How do we break through the cacophony of dire statistics and grave warnings about so many “epidemics”?
I believe we need to adjust our language, not to substitute our appropriate reliance on data with sensationalized attention grabbing headlines, but rather to make the problem more concrete for those who don’t confront it every day.
Infant mortality is a good case in point. The US rate of 6 deaths per 1,000 live births doesn’t really have much tangible meaning to the general public. In fact, if anything, six seems like a pretty small number. But what about 24,586? That is the number of US infants who died before their first birthday in 2010. This is the equivalent of about 1,000 kindergarten classrooms of children that will never be filled. Recognizing that not all infant mortality is preventable, the question then becomes not what do we do with the number six, but how many of those kindergarten classrooms can we commit to filling with children who are healthy, happy and ready to learn. Suddenly the problem and the motivation to fix it become more real. For a state with an infant mortality rate of 9.7 per 1,000, a 20 percent decline to 7.7 would be incredibly impressive in the world of public health. But realistically, how many people will really be excited by a change from 9.7 to 7.7? For most, that hardly seems like a change at all. Yawn – turn the page, flip the channel and move on. But if we were to say that this equates to saving three entire classrooms of future kindergarteners, it might pique more interest. People can visualize a classroom of giggling kindergarteners, while describing a change from 9.7 to 7.7 has none of the same power to evoke our basic human desire to protect our offspring.
Thinking of our social “epidemics” in this way changes the discussion from statistics to people, from counting to compassion. It will help the public better understand the issue, commit to solutions, and recognize and applaud successes – and, most importantly, support more efforts to save the next classroom of children and the next.
Those who teach the Model for Improvement often ask, “What will you do by next Tuesday?” It’s a quick way of jump starting the rapid testing that is one of the hallmarks of improvement science. At the end of this post, I offer a “next Tuesday” challenge.
Today, Peter Gloor, founder of the concept of Collaborative Innovation Networks, led a session with NICHQ on how to bring more innovation into our work. (His concept is one of the methods at the core of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality, the expansion of which we are honored to be leading.) Peter shared with us his most simple roadmap for innovation, and it went like this:
Collect crazy ideas.
Select the craziest.
Find people willing to work on the craziest ideas.
Peter is an innovative thinker, to say the least. Yet his approaches are also very grounded…
My colleague Karthi Streb* and I recently attended a Champions for Change event to learn more about how to achieve collective impact. Collective impact happens when a group of participants from different sectors commits to a common agenda for solving a complex social problem. The concept was first articulated in a 2011 Stanford Social Innovation Review article by John Kania and Mark Kramer.
During the trip, Karthi and I talked a lot about a lot of things (our work, our kids, the amazing Pacific salmon and Vancouver scenery…) as we grew more and more excited about the possibilities of more explicitly using a collective impact framing in our work at NICHQ. And as we talked about our work and our kids, I remembered the book The Day the Crayons Quit by Drew Daywalt. (I have a habit lately of connecting my work to children’s books.) As I reread this book, it hit me that Daywalt provides a beautiful illustration of the kind of partnership we hope to achieve in collective impact.
In the book, Duncan’s mission is just to color, but his crayons are sowing seeds of discontent. Purple is going to “completely lose it” if Duncan continues to color outside the lines. Peach feels naked without his paper wrapper and refuses to leave the crayon box. Blue feels overworked and has become short and stubby, no longer able to see. White reports that not being in the rainbow “leaves me feeling… well… empty.” Pink is tired of being typecast as “girly.” And Yellow and Orange have stopped speaking to each other because each one feels they alone are the color of the sun. They share this with Duncan in letters that they sign, “Your naked friend, Peach crayon…Your overworked friend, Blue crayon…”
Duncan is not deterred by the frustrations of his drawing partners. He listens, addresses some of his partners’ complaints (for example, using the overworked Blue crayon more sparingly) and finds a way to bring out the best in all of his crayons.
There is a lot to learn about partnering for collective impact from Duncan’s story. Paul Born, a leading collective impact and community-building practitioner at the Tamarack Institute, describes collective impact as how to “make the work of working together better and more effective.” Duncan and his crayon partners built a more effective working relationship and ultimately Duncan achieved the outcome he wanted—to just color.
Collective impact is in NICHQ’s DNA, although until recently we haven’t had the benefit of this language or framework. In our newest project, we are using collective impact concepts to engage federal, state, and local leaders, public and private agencies, professionals and communities to reduce infant mortality and improve birth outcomes. NICHQ is honored to have been selected to be what collective impact would refer to as the “backbone organization” in this important initiative to save lives with an exceptional group of partner organizations.
A backbone organization is the coordinating center for an initiative, but it is not the only driver of the initiative or the work. In fact, there’s a risk that the backbone organization “owns” the effort rather than the effort belonging to the whole partnership; so it’s important to find the right balance between leading and leading too far.
NICHQ’s mission is to improve children’s health. This mission is so big we couldn’t possibly achieve it alone. It is fundamentally about partnerships, about finding effective ways to collaborate and build on each other. It is a vision that builds on pillars of collective impact to generate collaboration for social change.
We hope to achieve the right balance with our partner organizations that share our mission and we welcome suggestions from our partners for how might continually improve our approach. We certainly do not want to argue like the Yellow and Orange crayons about who is the color of the sun. In our world, the sunshine comes from “collaboration” and “partnership” rather than “ownership.”
Let’s just color!
Your energized friend,
* Karthi and I collaborated on writing this post and on the ideas behind it. More partnership in action!
In the January 2013 NICHQ Leadership message Beyond Bullying, I shared that 42 percent of children in a Yale Rudd Center study reported being bullied by physical education teachers and sports coaches. Yes, 42 percent! Quite frankly I was shocked at this statistic.
That said, another study found that 45 percent of children “said their coaches called them names, insulted them or verbally abused them” and another study, this one from the United Kingdom, found that 25 percent of 6,000 young adults reported that they suffered emotional harm at the hands of their coaches.
Just think about that for a moment. Depending on the study, between 25 to 45 percent of our children who play sports are falling victim to a coach who is habitually cruel and abusing them. Let that really sink in. Up to almost half our children who play sports are being abused by coaches.
As Nancy Swigonski, MD, MPH, associate professor at Indiana University’s School of Medicine, has noted in her piece in the journal of Pediatrics, the damage these coaches are doing to our children is devastating and can be everlasting. “It can impair social and emotional development and cause substantial harm to mental health.”
As noted in Charlie Homer’s recent blog about NICHQ’s name change, there are many broader influences that affect children’s health outside of the clinical setting. This certainly includes the bullying that happens on our ball fields that can lead to physical injury, social problems, emotional problems, mental health problems (e.g., depression, anxiety), and even death. Not to mention bullying can turn children off from physical activities and this can potentially lead to obesity. As an organization that aims for all children to achieve their optimal health, there is much work to be done…together.
So what can parents do?
Interview the coach and his/her staff. Ask about philosophy, priorities, playing time, values and also ask how he/she measures the outcomes of each.
If your child is already on the team and you have concerns, ask your child about his/her experiences, the messages that are being sent, and follow each path your child raises a concern about.
Inquire of other parents who currently or perhaps who previously had children on the team.
Look for red flags: According to Kody Moffatt, MD, a pediatrician in Omaha and executive committee member of the Council on Sports Medicine and Fitness for the American Academy of Pediatrics, the number one red flag is a coach who wants “closed practices” where parents and other adults are barred from the practice. “That may be innocent, but as a pediatrician, a parent and a coach, I don’t think any coach should tell an adolescent not to tell another adult something.”
Be sure to attend (or perhaps rotate with other trusted adults) your child’s practices.
If you notice bullying behavior, document it and include specifics.
Identify and map behaviors to team, school and/or league codes of conduct. Use this as a tool to share very specific examples of your concerns.
Address your concerns directly with the coach. Focus on the impact on the children and be specific.
If discussion with the coach is unsuccessful, reach out to the athletic director, school officials (if school based program), and/or league officials, and share your findings. NOTE: It is absolutely crucial to make note of how the coach is treating your child AND it is also critical to keep an eye out for how the other children are being treated as well. These are our communities and regardless of whom the child is these behaviors are unacceptable and it is incumbent upon us all to speak up for those who cannot do so for themselves and make a difference.
Ensure that you also focus on developing warm family relationships and positive home environments so that if your child is bullied the negative outcomes from the bullying will be minimized. According to the study “Families promote emotional and behavioural resilience to bullying: evidence of an environmental effort” published in the Journal of Child Psychology and Psychiatry, “Warm family relationships and positive home environments help to buffer children from the negative outcomes associated with bullying victimization.”
Bullying is harmful and can lead to tragic ends. Together with these 10 steps we can identify it, stop it, mitigate its impacts, and help our children achieve their optimal health—mental and physical.
For us at NICHQ it is the smile of a child. The promise of a brighter future. For all children. For all parents. That is what drives us. That is why we get up in the morning and do our work. We strive every day to help you make the systems that produce children’s health become better and better.
And that is why we are changing our name.
When we started NICHQ our focus was exclusively on improving the delivery of healthcare as the vehicle to better child health. We knew that the healthcare children needed and deserved wasn’t the healthcare they were receiving, and we wanted to make it better. We are gratified that we now share this cause with many, many partners. This work is still far from done and remains an essential part of who we are and what we do.
But “fixing healthcare” alone, daunting a task as it is, isn’t enough. It won’t get us to the goal we seek—for all children to achieve their optimal health. We learned this when we started to focus our energies on preventing childhood obesity. We encounter this when we seek to eliminate disparities in breastfeeding. And we are learning it again as we help tackle infant mortality. Healthcare is important—children need access to high quality care. But children also need safe neighborhoods, parents who are healthy themselves, food that is nourishing, and more. Healthcare can’t stand apart from these challenges either, so quality in health care also needs to include links to community to create the conditions that support and produce child health.
To more accurately reflect our purpose, we are making a change in our name, from “healthcare” to “health.” NICHQ’s purpose has always been to improve children’s health. That is our passion and now our name is aligned.
We’re also making one other change: because we’ve been around for 15 years, and there’s still so much work to do, we are also changing from an “initiative” to an “institute.”
You can still call us “NICHQ,” and find us at www.nichq.org, but now NICHQ means the National Institute for Children’s Health Quality.
Shakespeare asked, “What’s in a name? That which we call a rose by any other name would smell as sweet.”
For NICHQ, these changes may be small in terms of words, but they are large in terms of meaning. Our passion hasn’t changed. We look forward to getting up tomorrow morning and helping you help more children smile.
As NICHQ’s resident infographic artist, I felt inspired by Purple Day to create an infographic about epilepsy awareness and education. Please feel free to share it in honor of children with epilepsy and their families everywhere!
As I’m about to introduce my young daughter to solid foods, I find myself thinking more and more about how I want to avoid using food as a reward—a practice that seems so ingrained in our culture.
There will be no rewards of sweets when my daughter finishes her vegetables or puts her toys away. There will be no lollipops for behaving well during a haircut or any other activity. Yes, I know. More seasoned parents everywhere are reading this and rolling their eyes thinking, “Just you wait.” But is it so crazy to think this isn’t possible? Why can’t rewards be extra outdoor play time or reading another book at bedtime or letting a child pick the family activity for the day, or even an old fashioned gold star sticker?
These same issues seem to follow us into adulthood. In almost every office I’ve worked, treats always seem to magically appear on Fridays as a defacto reward for making it through another week. Or, how about the promises to buy a friend a drink if they help you out with a favor. Instead of rewarding behaviors with food, what about a manicure or downloading of a new phone app. Surely food (or drink) isn’t the only motivator for people.
As NICHQ CEO Charlie Homer points out in his recent blog post about viewing health as a system, if we really want to improve children’s health, we need to focus not just on improving the quality of care children receive when they go to the doctor’s office; we need to change all influences that affect a child’s health. This includes modeling and practicing healthy behaviors at home, in school and in the community.
Are you willing to break the food reward chain with me? Start small. Pick one time this week when you would have traditionally used food as a reward and pick a non-food reward. See how your reward-receivers (your child, your spouse your coworkers) react and share your experience in a comment on this post. I’ll bet nearly 100 percent of people crave the satisfaction of being rewarded in any form, not necessarily by the food that serves as the reward. Once it works, pick another time and another time to swap in non-food rewards.
If enough of us practice this new behavior, as adults with other adults or as adults with children, it won’t seem so odd after a while and we can start to break the chain.
I will never forget the first time we met Mr. Weinstein, the first grade teacher for three of my four children.
It was open school night, September 1998. He was still a young man, but he was already quite celebrated in our school district. Even then his reputation was so large that I half expected Superman to walk into the class.
My wife and I and all the other parents were awkwardly seated in the little kiddie chairs, our knees in our chests, in a semi-circle at the front of the room. After introducing himself, the teacher opened with these memorable words: “Let me begin by telling you about my big goals for this year.”
Big goals for first grade? Seriously? I immediately began searching my assumptions about what I expected my child to achieve in first grade. My mind went to the usual suspects, the three R’s: some reading, some writing, some ‘rithmetic. But the teacher had a different agenda.
“My first big goal,” he said, “is that they become good citizens of this community. Because that’s what we have here in this classroom – a little community – and I want them to learn how to get along with one another, appreciate each other, and be productive members of the community.”
Wow, I thought. Hard to argue with that. What else has he got?
“My second big goal,” he said, “is that they develop a love for learning – because once they have that, the reading, writing and ‘rithmetic will all follow.”
So true, I thought as the chills started crawling up my back. What could possibly top this? What’s left?
“My third big goal,” he continued, “is that I want your children to fail.” Huh? He went on: “I want them to develop resilience for failure. Because that’s how they learn – by trying and failing.”
I was dumbfounded. His words were so simple, so true, so right on.
But more important than his words were his actions. We had the daily pleasure of seeing his big goals play out in every assignment, every decision, every moment in that classroom. His strong leadership vision was clearly articulated and he followed-through. Without question, the experiences in that classroom changed our children’s lives.
My eldest son is now 22 years old (hard to believe!) and yet I remember that day a decade and a half ago like it was yesterday. So inspired was I by the simple wisdom and clear vision of this special teacher.
These many years later, the life lessons I learned from this teacher are still profoundly influential, especially when viewed through the lens of quality improvement, a framework I would learn later in life:
Think big and set bold aims.
See the big picture and don’t get stuck in the small stuff.
Share your vision with others so we can journey together.
Make the complex simple so everyone can be inspired.
Ensure your daily actions support your long-term vision.
Don’t be afraid to fail because that’s how we learn and grow.
The journey is as important as the destination.
Take care of the people with whom you share your journey. In the end, it’s all about them.
And I will add one more: don’t be surprised to learn lessons from unexpected sources. After all, who would have thought I could learn so much from my kids’ first grade teacher?
More than a decade ago, the Institute of Medicine declared that the purpose of the US healthcare system was to continuously improve the health of the American people. Yet, for a long time the focus of many remained narrowly within the constraints of healthcare—addressing themes such as patient safety, clinical effectiveness and patient centeredness that are critically important but of themselves not likely to change the overall health and well being of the population.
Gradually, and now with increasing force and pace, a movement is building that seeks to recognize the broader influences on health, often summarized as “social determinants of health.” For example, The Robert Wood Johnson Foundation is reframing its strategic focus to emphasize a “culture of health” and the National Quality Forum has several working groups on both measuring population health and moving the nation to health. Hooray!
NICHQ of course has long had a broad focus on health, strongly driven by our work on addressing childhood obesity. In this work we recognized early on that clinical care is an extremely important element AND that addressing childhood obesity required coordination and integration between the clinic and community to change the context and provide effective services. I suspect that addressing the obesity epidemic is part of what has driven not just NICHQ but the broader health and healthcare community to see the need to bridge healthcare and health in a new way.
What Is the System that Produces Health?
Improvement science teaches us to view outcomes—such as health—as the inevitable product of a system, with the implication that achieving improved outcomes requires changing the system itself. A deep understanding of the system and how it functions can enable smarter decisions about selecting high leverage changes in order to improve system performance.
In this case, what is the system that produces the health of a population? How might we describe it and so choose promising points of intervention?
The most common framing that I see is that originally developed by McGinnis and modified by Kindig in creating county health rankings. In this model, the influences on health are broken down into a few simple categories—you might even call them “drivers.” The relative impact of these drivers are then estimated, with healthcare merely 10-20 percent, health behaviors a much higher 30-40 percent, and other factors in between.
All models are simplifications of reality; good models are useful in enabling understanding and driving action. The Kindig model is useful in broadening focus and, presumably, investment from health care to community or, more thoughtfully, assuring that community actions—from highway construction to food pricing—include health considerations if we want to alter societal health.
Yet as a system thinker and a pediatrician inherently oriented to think longitudinally and developmentally, I find the model inadequate. At least in its typical graphic representation, the model fails to emphasize the interaction and interdependence of the factors that when attached to percentages seem independent. Social factors clearly influence the physical environment in which one lives (how many bus depots are adjacent to luxury housing?). Similarly health behaviors—such as healthy eating—are strongly influenced by economic factors and, under ideal conditions, at least marginally influenced by high quality health care.
Envisioning a More Complete Model
So how can we improve the model? I’m early in the process of thinking about this, and thought I’d share my thinking and get some crowd-source reactions and feedback at this early stage.
I initially started to add elements. For example, if we put “personal resilience” in as a driver, we can start to see how supportive relationships can drive better health. If we add a driver for “earlier health status” we can begin to recognize the longitudinal nature of health. Here’s a snapshot of my white board brainstorm:
But, ultimately the linear driver framework seems to be an insufficient illustration of the system to truly help set priorities for action. This type of model doesn’t emphasize the interactions among the drivers, nor does it truly address the importance of timing and trajectory (there’s that developmental thinking again!).
Seeking a Systems Model
System diagrams and system modeling may be a more effective approach to framing the complexity of the influences on health, and especially to incorporate the critical role of development and what system modelers might call lagged effects, i.e., the effect of an intervention at one point in time on outcomes at a much later point in time. System modeling has been applied to community health, but the models I have seen don’t adequately account for the later or long-term effects of interventions at earlier points in time, particularly the protective effects of interventions at critical points in development as well as the cumulative effects over time.
Here’s my first rough attempt at a system diagram for health outcomes, presented for others to comment on and improve:
Cleaned up, it looks like this, more legible but still a draft:
What I’ve represented as the outcome is “health now.” A key influence of health now is health at an earlier stage, with this earlier stage health influenced by numerous drivers—many of which are not dramatically different than those in the McGinnis/Kindig model. The distinction is the emphasis on the interaction of these drivers and of the critical impact of health at an earlier stage on later health—in either a virtuous or vicious cycle.
Even this graphic model doesn’t adequately emphasize the particular importance of influences on health at particular times—such as infancy and late adolescence/early adulthood. Yet it does start to elevate the importance of interventions to improve health at an early stage in life—interventions both through health care (e.g., for those at great biologic vulnerability such as extreme prematurity) AND through enhancing the economic and social conditions and capabilities of parents and community.
Getting this right isn’t just an academic exercise. Without attention to time, policy makers may focus all of their efforts on behaviors and conditions at a late (adult) stage and fail to achieve the desired health impact that earlier childhood interventions might have. Similarly, without attention to the interaction among these factors—such as the impact of environmental exposures on epigenetics or the potential for healthcare to influence health behaviors—the potential benefits of some interventions or potential harms of exposures will be vastly underestimated.
I look forward to your help in improving the model and truly focusing all of our efforts on improving health.