Since the Institute for Healthcare Improvement was founded by Donald Berwick more than three decades ago, the organization has led the charge organization on critical conversations to determine how our health care system can do more to bolster our public health.
Earlier this month, I was privileged to join this group of dedicated leaders to deliver the closing keynote at their Fall Meeting. Here is my address:
It is a pleasure to be here with all of you today–both those who have been able to gather in person, and the participants who are joining us virtually to advance this important dialogue.
We’ve all come together for one reason. It’s the same reason that Don Berwick founded IHI. The same reason we all joined the organization. The same reason we entered this field in the first place.
It’s right there in IHI’s mission statement: We all want to take every possible opportunity to “improve health and health care worldwide.”
Each of us is dedicated to maximizing the impacts of our health care system. I know that you all dedicate long hours and sleepless nights to finding the best possible way to serve your patients and support overall health in your regions.
Which is why it is so painful for all of us to look at the current situation and see that the status quo is just not working.
The statistics are plain as day.
The United States is the wealthiest country in the world, and we outpace all developed nations by spending nearly 20% of our GDP on healthcare expenditures. But despite this significant resource advantage, the U.S. lags behind most of our industrialized peers in life expectancy.
In fact, over the last two years U.S. life expectancy has dropped by nearly three years, erasing more than a quarter century’s worth of progress.
Meanwhile, many comparable nations have already started to reverse the declines inflicted by the pandemic.
Clearly, throwing more money at the problem won’t solve anything; if that was the case, the U.S. would be leading the pack in outcomes instead of languishing at the bottom of the heap.
As you all know, health care alone cannot overcome the social determinants of health.
Great medical treatment in moments of crisis do not override the impacts of long-term food insecurity, or lack of access to housing, or the continued effects of racism on marginalized communities.
To put it another way: Even if our health care system did its job perfectly, we would not come close to addressing some of the most pressing challenges harming our public health.
Our current approach is producing outcomes that do not align with our values. America’s health care system is not built for the crises we are facing.
For the sake of our patients and our people, all of us here must take this moment as a call to action.
This is the time for innovation. This is the time for leadership. This is the time for large-scale, systemic changes to build a system that better reflects the needs of the population.
We need to build a more accessible health care system that truly grapples with the social determinants of health.
The Harvard T.H. Chan School of Public Health has been attempting to meet this moment by bridging the gap between public health and health care practice.
The fact is that there are a lot of best practices that all of us understand, which simply are not implemented in daily practice—whether due to staffing shortages, budget constraints, or lack of patient follow-up, just to name a few roadblocks.
For example: we know that access to health care is one of the most important social determinants of health, from screenings for serious diseases to routine maintenance of chronic conditions. If patients cannot get timely care on minor issues, it is far more likely that the problem will linger until it becomes critical.
We also know that nearly 80% of rural America is deemed “medically underserved” by the federal government.
That is a problem, and it is only getting worse as rural hospitals continue to shutter and consolidate at an alarming rate—leaving patients to choose between driving long distances for routine care, or simply skipping out on the appointments altogether.
Ten years ago, we created a laboratory to develop solutions to this type of systems failure in partnership with Brigham and Women’s Hospital right here in Boston. We teamed up to create Ariadne Labs, a joint center for health systems innovation. Ariadne is looking at improvement opportunities across the spectrum by exploring the gaps between theoretical practices and real-life implementation.
One terrific example of this approach is Ariadne’s work addressing maternal mortality through a program called “Team Birth.” It’s a straightforward system for making sure that everyone with a role to play in attending to a patient in labor communicates, both with one another and with the expectant mother. It looks astoundingly simple but it is proving extremely effective in making sure that patients are treated with dignity – and that their voices are heard throughout labor, delivery, and recovery.
That, in turn, makes it more likely that clinicians will truly hear women when they raise concerns – even the vague “something doesn’t feel right” kind of concerns — that can signal looming medical issues. And of course, hearing those concerns properly raises the odds that the medical team will be able to treat them promptly, before disaster strikes.
Team Birth is being implemented throughout the country; every labor and delivery floor in Oklahoma, for instance, will soon have it in place. The new documentary “Aftershock,” which is streaming on Hulu, features Team Birth as one promising solution to the crisis of Black maternal mortality.
Another great example of Ariadne’s work is currently playing out in Utah, where Ariadne is taking expertise homed in urban areas like Boston and transplanting it to rural communities. The lab is currently engaged in a pilot program with University of Utah Health to provide acute care for patients in their homes—patients who would otherwise fall through the cracks.
By utilizing existing technologies and connecting patients with far away doctors, this system eases serious burdens for rural residents who cannot travel to a medical appointment. The result is more timely, better personalized care for some of the country’s most at-risk patients—exactly the type of outcome we are all seeking.
There’s a lesson there: If we want to make care more available, we have to meet people where they are. And I don’t just mean physically. I also mean socially.
We need to tap into existing community relationships to help patients confront the real-world problems that impact their health beyond the hospital or the exam room. That is why Harvard Chan School is also working with the Lukan Group to connect community-based organizations and faith leaders with hospitals and health systems.
Our proposed program builds on the Memphis Model, which drew on the credibility, connections, and leadership of faith-based congregations to prevent disease, protect health, and promote well-being in marginalized communities.
In the original initiative, a patient admitted to one of seven Memphis-area hospitals would meet with a hospital-employed patient navigator and a liaison from his or her church before being discharged.
These trained church volunteers then helped the patient progress through their “journey of health” by providing support for services including transportation, meal delivery, and social visits.
The results were simultaneously dramatic and unsurprising.
Health outcomes improved. Death rates dropped. Patients went longer without returning to the hospital. Overall costs declined. That is a win-win-win-win – for patients, providers, payers, and communities.
Our collaboration with the Lukan Group seeks to revive this model, with a twist. The proposed program would keep the community-based approach that is critical to build trust but would also add in a well-networked national partner—like possibly the United Way.
This new partner would help scale the local model in communities across the country, expanding the overall impact and increasing the ability to collect and disseminate data and lessons learned through the project.
The reason that I’m so optimistic about this project—and why the Memphis Model worked in the first place—is because the initiative takes a clear-eyed look at the obstacles facing marginalized communities and provides patients with the support they need to navigate the challenges of daily life. The reality—as you all know, all too well—is that we live in a deeply inequitable society, and we must engage with those inequities.
That means that medical professionals must not only acknowledge the importance of equity, but actively work to extend fairness to all.
These partnerships have been some of our key approaches as a school of public health. Your opportunities as leaders of major health care systems may be different, though I would commend you to seek out partnerships—because we all go farther together.
At the same time, I know that you all know your communities better than anyone. You know the most common causes of death, the major external factors driving health issues, the problems that linger and the attempted solutions that fall short.
You can, and should, use that knowledge to drive positive change. Don Berwick has articulated a compelling and convincing case for how we can make that change, both in several speeches and in a recent article for the Journal of the American Medical Association.
I wholeheartedly endorse his Ten Teams approach—though I would advocate for making it a nice, round Eleven Teams by including efforts to confront gun violence.
I’ve seen some heads nodding throughout my speech, which doesn’t surprise me. I am in a room of leaders who are well-aware of the obstacles facing the health care system. In fact, I wouldn’t be surprised if you are already engaged with projects similar to the ones I’ve just mentioned.
I’m also not surprised because I am surrounded by innately good people, who have dedicated their lives to making a difference.
Even during the most challenging of times, you are always looking for opportunities to better support your patients.
I know your hearts are in the place. But we all know that is not enough.
We need your budgets to be in the right place too.
Your resources, your priorities, your teams—they all must shift to confront the major health problems that happen outside of your doors.
If you don’t, we’ll be resigned in the status quo forever, because excellent health care cannot outwork a lifetime of hunger or homelessness. It can’t single-handedly overcome hardship or heartache.
These old ailments need new remedies. These old ailments need a commitment to promoting, protecting, and preserving health and wellbeing.
We can do more. We need to do more. All of us.
I, along with my public health colleagues, are here to work with you as we walk this path.
Let’s come together and make a difference.
Let’s tackle the inequalities that hold our society back.
Let’s build partnerships, and collaborate, and share data, and advance the reforms that show promise.
Let’s work together, to improve health and health care.
Thank you all very much for your time and attention.