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…
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.
If you’ve read anything about obesity in the lay press over the past week, you already know that there has been a decline in the prevalence of obesity in American preschoolers. The CDC’s latest National Health and Nutrition Examination Survey (NHANES) data, published in the Feb. 26 issue of the Journal of the American Medical Association, show a significant decline in obesity among children aged 2 to 5 years. Obesity prevalence for this age group went from nearly 14 percent in 2003-2004 to just over 8 percent in 2011-2012. This information has been rippling throughout the press this week, with headlines like “U.S. Childhood Obesity Rates Fall 40% in Decade.”
For me, this news is both exhilarating and anxiety provoking. On one hand I have been working throughout that period alongside countless others to achieve a population decrease in body mass index (BMI) and the news that the day may have finally come for one segment of the pediatric population is incredibly encouraging. On the other hand, the rate is still 8.1 percent, as compared to 4.1 percent in the 1971-1974 NHANES cohort, and celebrating too early could distract from the fact that there is so much more work to be done, especially for our most vulnerable children.
The first question that crossed my mind when the news first landed in my inbox is whether the tide has really turned. Experts agree that the sampling methodologies in NHANES are robust and the data are valid. The pressing questions are (a) whether we are really seeing a trend and (b) whether that trend applies to the most vulnerable children.
There are two ways in which I think about data like this. The first is with a gut check—does this jive with what I see in my Community Health Center patients? Although I am not sure that my observation techniques are sensitive enough to see a change from 12 percent in the last cohort to 8 percent in this one, it does seem like recent changes in WIC, SNAP and childcare settings, among others, have made families in my clinic more aware of the impact of healthy eating and active living on the weight and health of their children. And when I saw an obese 2-year-old child this week, I actually thought to myself that I had not seen an obese preschooler in at least a few clinic sessions—certainly a change from five years ago. So is it possible that the tide has turned for preschoolers based on my clinical experience with an underserved urban population? I think so.
But I would be hard pressed to claim that my clinical experience is sufficient to validate public health trends. So I did what improvement junkies do. I went back to the numbers. The most recent data stratified by race and ethnicity has not yet been made available so I was only able to look for a trend among all preschoolers. I plotted the NHANES data from 1999 to 2012 using CDC data to determine if there really is a trend, creating a graph of obesity prevalence over time, what is known in quality improvement as a run chart.
A run chart is designed for the early detection signals of improvement over time through recognition of non-random patterns in the data. The first possible pattern is a “shift,” defined as six or more successive points that are all above or below the median, which in this case is 10.6 percent. If our recent changes in policy and practice had caused a shift beginning in 2005-2006, we would see that the next six points fall below the median. But in fact, the four points from the 2005 cohort to the 2011 cohort alternate between being above and below the median, indicating we don’t have enough data to see a shift and that we don’t appear to be on our way to one just yet. We can also look for a “trend,” defined as five or more consecutive points that are either ascending or descending. Similar to the case of the shift, we neither have enough data points, nor do we have indication that we are on our way to a trend. So despite the change in prevalence, it is challenging to use the data to either establish a new, lower baseline prevalence or to attribute the decrease to the changes we have made to the environments of preschoolers.
So where does that leave me? Trend or no trend, this news means thousands and thousands fewer preschoolers are obese in 2011-2012 vs. 2003-2004 and this fact will have an enormous impact on our health resources and outcomes as they mature. And these data give us hope that sustainable improvement could be just around the corner. In any case, we must continue to invest heavily in activities and policies that promote healthy weight to create a change in prevalence that will persist over time. If nothing else, this is a moment to pause, applaud all of the wonderful changes we have made to date, and energize ourselves for the long road ahead—to the day when we have reversed the trend for ALL Americans, regardless of age, race, or class.
The Olympics were a source of great pride and entertainment for millions of people around the world. I was personally glued to the TV for two weeks and was filled with admiration and respect for these impressive athletes. I frequently found myself thinking about all the hard work and sacrifices needed for them to reach the pinnacle of their sport. I was inspired.
And then the director cut to commercial and I had the displeasure of seeing this ad from Cadillac. In it, actor Neal McDonough glorifies the value of hard work while berating the more leisurely lifestyle of other countries:
Other countries, they work. They stroll home. They stop by the café. They take August off. Off. Why aren’t you like that? Why aren’t we like that? Because we’re crazy-driven, hard-working believers, that’s why.
Then as he revs up his spanking new electric Caddy in the driveway of his ultra luxury home, he ponders the acquisition of material goods and posits they are “the upside of only taking two weeks off in August, n’est-ce pas?”
OK, fine. But what’s the downside? What price does our society pay for discouraging leisure time and mental health days? How much social capital do we lose when we don’t stop by the café? How many families have dissolved under the pressure of our cultural norms? How many children lack the support systems necessary to achieve their optimal health? And don’t even get me started about maternity leave and childcare benefits.
The US has higher rates of infant mortality and childhood obesity than most other industrialized nations and lags behind in breastfeeding rates as well. These statistics are nothing to brag about. When viewed through a disparities lens, they are even more troubling. For example, the risk of infant death for babies born to non-Hispanic black women is more than two times greater than the risk of infant death for non-Hispanic white women. That’s horrific and embarrassing.
Maybe these “other countries” have something figured out about life balance, n’est-ce pas?
But we have a long way to go before we get a gold medal in child health outcomes. I suggest we begin in a humble place – with the recognition that, while we may have much to teach other countries, we also have a lot to learn. Of course, this approach would not be very effective for selling cars.
Recently, I was invited to a meeting of experts to discuss how best to improve patient and family engagement in healthcare at a system level.
As I walked in to the meeting room, I was pleased to see I was slated to sit next to the meeting co-chair, who I had met previously and wanted to get to know even better. As I walked out to stow my luggage, one of the meeting coordinators approached me and let me know that they were moving me because another individual required access to a plug (which happened to be right behind the seat I was initially assigned to). Oh well I thought … I will simply connect with the co-chair later in the day.
Interesting how fate works.
Shortly thereafter I realized I would be sitting next to a brilliant patient advocate, who also happens to have a chronic degenerative neurological disease. (I will refer to him as Neal.) And throughout the day, Neal showed all of the following symptoms of the disease:
Impaired posture and balance
Loss of automatic movements
As the meeting began, I became aware of Neal’s breakfast. How he appeared to struggle with his fruit. How the juice cup in his hand flailed precariously close to being dumped on him, on me, and/or on the table. And I realized I had no idea how to help. I had no idea whether Neal wanted help. Would I offend him by offering help? What was Neal’s preference?
As the day went on, Neal confided in me that he was getting tired and I noted his symptoms worsening. He stood up abruptly and his chair, which was on wheels, flew backward so I grabbed it and held it for him. I saw him stumble and thought he would fall so I reached out and held his arm. Neal brought out a pill container and I thought he was having some difficulty extracting his pills, but decided to hold off at first on offering assistance. Again, I wasn’t sure what he would want and whether he was finding my persistent questioning, e.g., “Can I help you?” “How can I assist?” “Can I get that for you?” bothersome. He retrieved his pills on his own. He then began to lean toward me and I asked again “can I help you,” but received no answer.
A bit later Neal handed me a can of soda and asked me to open it for him, which I was happy to do. And yet as I did so I noticed he also had a cup of ice and based on what I was witnessing I was thinking there was no way he would be able to pour the drink into his cup without spilling. And as I was about to ask him if he wanted me to do it (feeling more comfortable after a number of hours together), Neal leaned over to me and asked me to do so for him.
It’s interesting what thoughts go through your mind during these times.
Feeling that at any moment I could be wearing Neal’s drink, I made a pact with myself that if it does happen I will not show any manifestation of being startled, I will not immediately get up and go clean my suit, but rather I will take it in stride and ensure that I do not cause any sort of scene which would adversely impact Neal. Or, in other words, I will do my best to treat Neal how I would want to be treated in lieu of not truly knowing Neal and his preferences.
At the end of a long day I noticed Neal circling me. He came near and then circled away. He came near and then stumbled (and I supported him) and then circled away again. He then stopped nearby and we made eye contact and he simply said, “Tom, I want to shake your hand,” which we did and I responded, “Neal, it was so great to meet you.”
During a long commute home I continued to process these events.
I was blessed to be sitting with my new colleague. I was fortunate to be further reminded throughout the day of how important it is to develop relationships, to develop trust, to share openly and honestly, and to understand one another’s whole story, preferences, goals, desires, and so much more … and especially so in healthcare. I learned that the more I got to know Neal and understand his preferences the better I felt and the better I was able to respond accordingly and meet his needs more effectively.
Want to improve the healthcare system from a systems perspective?
Develop systems which allow for time, continuity, relationship, trust, authentic sharing, the telling and hearing of the patient’s whole story at each healthcare encounter. Create system change which positions clinicians to use tools such as emotional intelligence and motivational interviewing to ensure optimal sharing and comprehension. And not only collect data from these encounters, but rather turn the data into information and the information into wisdom by co-creating with the patient and family care pathways that are 100 percent aligned with the now understood preferences of the patient. Lastly, develop systems which track progress toward achievement of the co-created care plan (measure the impact).
My daughter loves to read Rosie Revere, Engineer, a children’s book about a young girl who dreams of and practices at becoming an engineer. Rosie nearly gives up that dream when she’s laughed at by some of the people closest to her after her first few inventions aren’t first-time successes. But with some encouragement from her great-great-aunt Rose (homage to Rosie the Riveter), young Rosie keeps at her innovating and engineering, building a flying machine called a heli-o-cheese-copter. In the process, she comes to realize that:
“Life might have its failures, but this was not it. The only true failure can come if you quit.“
I’ve been thinking about innovation a lot lately, in large part due to a renewed commitment at NICHQ to be a hub for creating and spreading innovations. I am so excited about this commitment because I know that new ideas and new approaches—and building them together—will help create a world in which all children achieve their optimal health.
“But questions are tricky, and some hold on tight…”
Further advancing my excitement for innovation, NICHQ was recently awarded a cooperative agreement by HRSA’s Maternal and Child Health Bureau to lead the national expansion of the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality. This initiative provides a platform to transform children and their families’ lives, drawing on quality improvement, collaborative improvement, and innovation to do so. We feel privileged to join with an incredible group of partners and build on the work of CoIIN participants in the first 19 states in which this initiative is already underway. As we spread the effort to up to 31 new states and eight territories, we are honored to hold on tight to the tricky question (as young Rosie would say) of how to reduce infant mortality, improve birth outcomes, and address health disparities in this country. We hold onto that question because we are committed to the vision of a nation in which every child celebrates his or her first birthday. (If you are, too, and especially if you’re already working in this area, please comment on this blog post so we can follow up.)
One of the reasons that I hold onto this question is that my cousin, Luke, never got to see his first birthday. In 2010, 24,586 families experienced the life altering heartbreak that my family experienced. We can do so much better. For every family to celebrate their child’s first birthday, we will learn and work in partnership, we will improve where the path is clear, and we will innovate where it is not.
“You did it! Hooray! It’s the perfect first try! This great flop is over. It’s time for the next!”
I invite you to join our conversation and join in our work. As Rosie knows—she has a closet full of parts for building her inventions—and as Steven Johnson writes in Where Good Ideas Come From, “the trick is to get more parts on the table.”
What might that look like, exactly? To start, NICHQ will be putting more of our parts (and combinations of parts) on the table externally in, for example, more blog posts like this one. We invite you to join the conversation and help us make the next great flying machine (tell us if we’re flopping and how to fail forward!). Bring some parts to put on the table (maybe even guest blog about them!), follow us on social media like Twitter (@NICHQ, @mariannephd). Our table is not just the one in our office conference rooms. That table is in our conversations with those who, like we at NICHQ, are committed to a world in which all children achieve their optimal health. We recognize that those parts may come from healthcare, or from architecture, or from children’s literature. So please, come to our table and join the conversation, and invite others to join it, too.
“It crashed. That is true. But first it did just what it needed to do. Before it crashed, Rosie…Before that…It flew!”
As Rosie taught me, getting parts on the table means that some combinations of those parts won’t work, either on the first try or ever. Just as I’m committed to NICHQ putting more parts on the communal table as we iterate and innovate, I’m committed to us sharing what combinations haven’t worked. In the months that I’ve been leading our innovation initiative and learning a TON as I go, I’ve held onto a few things:
Innovation is rare. Because it’s so rare, it’s both a destination and a journey. And that journey involves a lot of great flops on the way to the flying machine.
Innovation is not a solo flight. (See above re: parts on the table in public!)
Innovation has a lot of buzz, but it’s buzz worth striving for, especially if it means that just one more child will have her first birthday, that just one more family will have a safe outdoor space for their child to play, or that just one more adolescent receives timely treatment for substance abuse.
So, what is your heli-o-cheese-copter? What is the next one we’ll build together? Join us at the table, and please bring some parts.
Marianne McPherson is the Director of Applied Research and Evaluation at NICHQ.
Earlier this week, members of the public health community rejoiced at a major victory for healthier Americans. After years of lobbying and the activism of public health professionals everywhere, we realized the fruits of our labor and paved the way for our children to live longer lives. I would have done cartwheels if I were coordinated, athletic, and wore proper cartwheeling shoes.
No, I am not talking about CVS’ decision to stop selling tobacco (although that’s pretty ground-breaking too).
I’m talking about this story. “Fewer U.S. children dying in car crashes.” According to a CDC report released on Tuesday, deaths occurring to children under 12 due to car crashes decreased by 43% from 2002 to 2011. Since crash deaths are the leading cause of child death in the country, this is a big deal.
As a public health advocate, there is nothing more I like better than seeing this kind of headline. But it was accompanied by this statistic: one in three children who died in car crashes 2011 were not wearing a seat belt. That means 3,000 car accident deaths of the 9,000 that occurred over the last decade might have been prevented if seat belts had been worn.
Even more startling was this study finding: Almost half of all black (45%) and Hispanic (46%) children who died in crashes were not buckled up. That’s 1 in 2 children between 2009-2010.
So how can we make sure we continue this downward trend in child deaths due to car crashes in the next decade? The evidence is very clear on public health strategies to prevent child deaths in car accidents. Parents should use appropriate car seats, booster seats and seat belts on every car trip. Strategies to reduce disparities in car accident deaths should also be developed and tested.
At NICHQ, we have applied quality improvement to some of the most daunting public health problems facing children, including childhood obesity, asthma, and sickle cell disease. When we start a project, it begins with a bold aim statement: What are we trying to accomplish?
Healthy People 2020’s objective is a good place to start: Increase age-appropriate vehicle restraint system use in children aged 0 to 7 years by 10% by 2020. But how can we get this done faster? How about 20% or even 30%? Let’s expand this goal to children aged 12 and under. Because 9,000 children is too many.
Weigh in on your ideas to realize this goal in the comments section. Or join our Facebook page and share your opinion!