Reflections Along the Journey of Health Care Improvement

Aaron McKethan | November 29, 2011


Time flies when you’re having fun. As my tenure as the Director of the Beacon Community program draws to a close, I have reflected on some of the early lessons that the Beacon Community innovators and implementers around the nation have taught me in the last couple of years.

Here are a few:

1. Start with a vision of optimal care: Effective health care organizations design care processes that depict optimal care from the patients’ perspective, identify roles and responsibilities for patients’ care teams that support the consistent deployment of those processes, and then design or tailor technologies that support care teams in delivering and evaluating those care processes.

Among others, Dr. Jim Walker from the Keystone Beacon Community has organized his Beacon Community’s efforts by leading with a vision for optimal care, with technology design coming last. This sequence is incredibly important, though it’s easy in this technology-centered world of iPhones and other gadgets to get this sequence precisely backwards.

2. Develop complete hypotheses about what spurs change: Changing health care requires a deep appreciation for the myriad micro-changes necessary to affect provider and consumer behavior in a meaningful and lasting way. The Beacon Communities that have impressed me the most are those that pay special attention to deeply and objectively studying how and why health care processes work as they do, and then having the capacity to nimbly adapt in implementing changes to those processes.

Patrick Gordon and Julie Schilz at the Colorado Beacon Community, in their work with 75 physician practices, health centers, and hospitals, have truly demonstrated how to do this well by getting very deeply into the weeds about what effective change will require in a diverse rural/frontier community whose doctors are separated by large mountains and diverse perspectives about health care and the role of technology. As Patrick and Julie have taught me, changing health care is not easy, so if the logic models informing new projects appear to be inadequate or naive, they probably are.

3. Recognize the opportunities and limits of the community as the unit of analysis: Community-level coalitions excel in bringing diverse interests together to develop a common vision for what optimal care looks like, identifying measures of performance to track progress in achieving that vision, and convening learning and dissemination activities to share successful strategies. Yet health care delivery organizations in those communities have different needs and internal cultures, are uniquely structured and motivated, and will proceed in pursuing the community’s vision reflecting those differences. It is important to understand and be explicit about the roles and responsibilities of community-wide health care improvement collaboratives versus the local care delivery organizations and other groups that support them. This dynamic can vary by community, but successful communities find a way to draw on the unique strengths of both.

The Southern Piedmont (NC) Beacon Community – whose lead organization is Community Care of North Carolina – and the Greater Cincinnati Beacon Community – whose lead organization is HealthBridge – have mastered this important balance particularly well. They have created important community forums through which health care leaders from different and often competing organizations can come together to collaborate on health IT and care improvement activities while preserving the ability of individual hospitals and physician practices to pursue their own specific strategies for achieving the community’s vision.

4. Focus on sustainability from the outset: We have spent a great deal of time since the earliest days of the Beacon program framing the “program sustainability” issue as one that centers on demonstrating objective value rather than, for example, seeking further government grants to sustain ongoing operations after the initial grant period ends. The care delivery improvements that are most worth sustaining are those that can demonstrate improvements in outcomes while also slowing the growth of health care spending. Beacon Communities continue to pursue clear ways of credibly measuring cost, and they need to understand and have access to the data that are necessary to perform and actively use those measurements. And, relatedly, they need to marry their effective health IT and care delivery changes with payment reforms that continuously lower the net costs of improvement. While it’s ambitious and the path is not easy, this is our model for sustainability.

The Tulsa Beacon Community has both some of the most innovative and exciting technology and interventions and the most sophisticated approaches for measuring costs and utilization in ways that are transparent to payers, employers, and consumers.

5. Focus on Meaningful Use: Every community in America can be a Beacon Community by taking full advantage of the roadmap for care improvement offered by the Meaningful Use regulation. For advanced communities already on their way to improvement, the Meaningful Use approach can serve as a means to consistently measure care processes and outcomes using technology. For organizations whose health care improvement journeys have started more recently, Meaningful Use can serve as a set of competencies on which they can initially focus. As many of our Beacon Communities have already shown, Meaningful Use is a critical foundation for delivery system improvement and, increasingly, payment reform.

6. Be patient and realistic: Health IT and quality improvement projects are complex, and they take time. Having access to large amounts of federal funding cannot fully overcome these facts. Similarly, payment reforms are necessary, but even under the most optimistic scenario, they will not produce immediate or necessarily consistent results in every environment in which they are tested. Those of us in the health care “change management” business need to remain mindful that modernizing the health care system through making meaningful use of health IT will take time.

Looking ahead, we will eagerly watch as the seeds that have now been planted in Beacon Communities grow into changes in providers’ practices and consumers’ behavior across successively larger populations, and then bloom into concrete and lasting improvements in health care outcomes. The Beacons are well on their way!

As this work unfolds, I remain incredibly grateful for the men and women across the country and in Washington who are deeply committed to harnessing the full power of technology to improve health care.