REFORM: IHI's Triple Aim Rolls into DC: Part II - Population Health

Yesterday we focused on the who-what-why of the Institute for Healthcare Improvement's seminar titled "Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Health, Ideal Care, and Controlled Costs." Now let's focus on the first aim: population health.

During the early part of the event, we were shown a pie chart titled "Determinants of Health and Their Contribution to Premature Death," with data adapted from this Health Affairs article by Michael McGinnis and colleagues (subscription required). Measured as "Proportional Contribution to Premature Death," behavioral patterns constitute 40%, genetic predisposition is 30%, social circumstances 15%, health care 10% (!), and environmental exposure 5%. It would normally be ambitious to say that a person's local health care provider influences both behavior and care, adding up to 50%—but as the seminar progressed we were encouraged to think (pardon the phrase) "outside the box"—what are the social circumstances? Why not partner with community leaders to reduce homicides, like one pediatric surgeon did when he helped found the Cincinnati Initiative to Reduce Violence (CIRV)?

This pediatric surgeon had become sick of seeing so many children become victims of gun violence. He decided to "go upstream" to stop the killing. He partnered with the city government, Procter & Gamble (based in Cincinnati), schools, Cincinnati Children's Hospital, and even ex-convicts willing to go back into their community to stop the violence. The city began fully prosecuting offenders, and at the same time a "Community Works" program began to help support job training, employment, education, and social services. Goals include reducing shootings, helping residents feel safe, decreasigng drug sales and helping residents train for and hold jobs. All these goals can be measured with crime and survey data. All have a health component.

The results? This initiative really got off the ground about halfway through 2007, and 2007 became the 2^nd lowest homicide year in the past six years. 2008 is also rather low thus far. This is not due to Cincinnati Children's investing in new technology or adding 100 new beds. Rather, they have worked with other organizations in the community to improve the health of the people of Cincinnati.

"Go upsteam" was spoken by Dr. Bonnie Zell of the Centers for Disease Control when she was describing the program in Cincinnati, but she was referencing a story told by a someone from Genesys Health System, where their CEO tells people to imagine themselves at Niagrara Falls. Let's say you see a person down at the bottom of the falls, struggling. You have the means to save them and you do so. But just as soon as you do, you notice a couple more people at the bottom of the falls. You're able to keep up rather well saving the many people in the water—but shouldn't you be asking yourself why so many people are going over the falls? Perhaps the answer isn't more life jackets, but a guardrail upstream.

I'll be back tomorrow to look at how to improve the patient care experience.