17 October 2019

Triple Aim – making it manageable

Reflections from the second Triple Aim support session at ILP

Conversation and reflection at the second Triple Aim learning session in the Improvement Leaders’ Programme (ILP) focused on how to get on top of your strategy and make the work feel manageable.

All QI work can be tough in this respect, but Triple Aim work can feel particularly huge and overwhelming. When you start thinking about a population, rather than a single quality issue as in QI projects, and then go out to learn about assets and needs of that population (as we have done with our 3 part data reviews) you end up with programmes of work on a really big scale.

Think about your own life; what contributes to you feeling like you’re thriving? What can play a part in bringing you down? When I think about this, I know there’s a pretty long list of things that affect my wellbeing; from things that are internal to me including self-esteem and health, personal factors like my network and relationships, and things out there in the community. All these things may be helping or hindering me, depending on how I’m experiencing them.

Likewise, when we’ve gone out to have these conversations with people from our populations, they’ve identified a large array of factors, which have then been organised into the big Primary Drivers. We talk about “big buckets” when we refer to primary drivers in QI training, but in Triple Aim projects these are more like industrial sized vats!

Where do you start, for example, if like the Learning Disabilities (LD) team in Bedfordshire, you’ve identified Working together better for people with LD, Being Supported Well, Inclusion and experience in society and Recognising and Empowering the person as your primary drivers?

Well, although this can feel overwhelming, what you need to do at this point is stand back and do two things:

Firstly, recognise that you do definitely need to prioritise and come to a conclusion about where to put your focus

You and your team are not superhuman. We have to be realistic about our limited resources and ensure that we don’t spread ourselves too thinly. This might mean we only tackle one or two initiatives at a time, but it is far better to put your energy and capacity into this and do them well, than to do lots of things piecemeal.

Secondly, start where you’re going to have the most impact

This is, in fact, just the same guidance we’d give to QI projects. Regardless of what level you’re working on, you can never do it all at once, so you need to use a systematic approach to strategise and develop your focus.

So, following from that, the million dollar question, of course, is how do you do that?

Steps for prioritising your Triple Aim strategy

We reflected on 3 key steps that we could use in our Triple Aim work:

1. Firstly, think about whether you can identify a sub-population in your work

Identifying a sub-population might help you to refine your population down further to make it more manageable, or it might enable you to target your change ideas and track improvement better. The key point is the basis on which you narrow down; crucially it needs to help you identify a sub-group of your population who are in greater need.

An option for how to approach thinking about this is when people from your population fall through the gaps in our system – when we fail to meet their needs – where do they go? For some populations this is A&E. For others, it might be repeat attendances at primary care. Could you work with partners to identify, say, the 20 people from your population who most frequently attend A&E or who have had the highest primary care use in the last 3 months? If you did that, do you think it might give you a different lens on what are the most important issues to try to resolve?

Alternatively, you might find it helpful to go back to your quantitative data, to see if it can tell you any more about how to break your population down. Tower Hamlets Community Health Services have done this, and have identified different groups who are likely to have distinct needs within their population of people who are housebound with Type 2 diabetes. They are looking at how factors like gender and ethnicity impact on the experience of their population and will be identifying a sub-group for testing, like Bangladeshi women.

2. Secondly, what do you know from the broader evidence base to help you refine your strategy and prioritise what is on your driver diagram

Is there any evidence to indicate which drivers are likely to be the most important to work on, for example in research literature? Are there any models/initiatives that have been successful elsewhere which mean we can have a stronger degree of belief that they might work in our context/with our population?

For example, many of our Triple Aim projects have identified reducing loneliness and increasing social connections as a key factor in people’s experience. This is certainly backed up by the evidence. In 2017 the New Economics Foundation estimate the costs of loneliness to the economy of being in the region of £2.5 billion per year . Public health evidence suggests that loneliness, living alone and poor social connections are as bad for your health as smoking 15 cigarettes a day (Holt-Lunstad, 2015).

3. Finally, draw on Quality Improvement tools to help you develop consensus amongst all the people you have involved in steering your work, in terms of where to focus

Tools like multi-voting, rank-ordering and 2×2 matrixes can be really powerful to ensure you understand the perspectives of groups of people and then narrow these down into priorities for action. For example, below is an image of a 2×2 grid used with Learning Disabilities in Bedfordshire to process change ideas from a big engagement event of 40+ people. The project team reflected on the ideas in terms of 2 key dimensions;

• To what extent are they high or low impact?
• To what extent do they feel easy or difficult to do (i.e. how clear are they)?

The results of this then gave the team a sense of what things might be straight-forward “quick-win” tasks, that could just go straight onto an action list to work through (the high impact/easy to do ideas), verses which would need testing and learning through PDSA (the high impact/not easy to do ideas). Ideas which are low impact can obviously be deprioritised for now.

There’s still too many things in the high-impact/not easy to do ideas to know which PDSAs or projects to initiate first. So this is when the team can use rank ordering to get everyone’s perspectives on what’s priority 1, 2, 3, 4, etc and add that all together to work out in what order they should approach the ideas for testing.

We’ve got really big ambitions with our Triple Aim population health work. We’re taking brave steps in saying that we’re responsible, not just for people’s experience when they’re under our services, but also what happens to them more broadly to affect their health outcomes and quality of life. When you start trying to answer these big questions, things can start feeling overwhelming, but there are clear steps to take and lots of useful and straightforward tools that can really help you.
So, keep all this in mind and call on your Improvement Advisors to help you navigate your way forwards!

The Tower Hamlets team are exploring potential groups to focus on by reflecting on different needs, using this approach, for example people from the Bangladeshi women

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