This post is part one of a series on care model innovation.
Before I set out to examine care model innovation in maternity care, I wanted to take a look at innovative care models in our broader healthcare system. I knew silo thinking was one thing I needed to get away from in this project, and the first silo I could remove myself from was the pregnancy and birth silo. Also, I have found that my best insurance against cynicism is to find inspiration in real change, and the broader my scope, the more chance of finding signs of transformation.
I knew right away where I would look for two of my readings. I had read Atul Gawande’s “Hot Spotters” when it came out in 2011, and wanted to reread it through a new lens. I also knew I wanted to read something by Don Berwick, one of my healthcare heroes ever since I read, “What Patient-Centered Should Mean: Confessions of an Extremist.” After Googling around and following some links, I landed on an article that summarized Berwick’s recent lecture ambiguously titled, “H4”. I decided to watch the entire lecture on YouTube.
For my my third reading, I decided to download Betsy Bradley and Lauren Taylor’s, “The American Healthcare Paradox.” Dr. Bradley spoke at the Yale Healthcare Conference last spring and I was completely taken in by her economic analysis of American healthcare spending, and her description of innovative care delivery models that address social and behavioral determinants of health.
Lastly, I decided to look for something in the management literature about service delivery innovation, and was delighted to find an article that addressed this very topic, with healthcare as one of the examples the authors threaded through the piece (financial services being the other). That article was, “Four Ways to Reinvent Service Delivery” by Kamalini Ramdas, Elizabeth Teisberg, and Amy L. Tucker.
Two major themes emerged in these readings: the concept of health creation (also known as salutogenesis) and the related notion that wellness or illness is far more a function of how we live our lives than how we access healthcare. To understand how to approach care model innovation, we need to unpack these themes a bit.
Health Creation: The forgotten goal of our healthcare system
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Both Berwick and Bradley & Taylor ponder this definition from the World Health Organization, and the yawning gap between this vision and what the U.S. healthcare system is designed to deliver. In “H4,” Berwick pulls the curtain back on the ever stronger evidence that the three realms of health – physical, mental, and social – are highly inter-connected, and that you can’t achieve the former without attending to the others. Our medical care system’s exuberance for fighting disease and infirmity have left the promotion of “physical, mental and social well-being” to the margins – easily dismissed as “woo.” And while there may be plenty of woo in so-called alternative medicine, there is quite a bit of science to support the role of stress reduction, social cohesion, and healthy diet and exercise in creating, maintaining, and restoring health.
Berwick argues these should be central to our healthcare system, but they are all but absent. He quotes physician Wayne Jonas to say, “Salutogenesis should be the defining concept for a new healthcare system. We must facilitate healing processes that focus on people’s resources, on their capacities to create health. Salutogenesis is the missing complement to pathogenesis.”
What really impacts health: how we live
Bradley & Taylor examine why we’re not creating much health with our massive expenditures on healthcare in the United States, and offer a novel explanation and plenty of evidence to substantiate their hypothesis: it’s because healthcare isn’t really what creates health. Social care does. It turns out that the ratio of health care spending to social spending is a far better predictor of a nation’s health than the level of healthcare spending alone, and the United States is far behind most of our peer nations in investments in social services like housing and food assistance and employment programs. In a diverse set of case studies in their book, along with the innovative programs depicted in Gawande’s “Hot Spotters,” we begin to see signs of hope in programs that completely dismantle the walls between healthcare and social services, and orient care and support totally around the individual. We see dramatic examples of healthcare’s elusive “Triple Aim” – better health, better experience, and lower costs. More importantly we see lives transformed and health created in the cracks and crevices of our society where hopelessness and despair had previously flourished.
Approaching care model innovation through a new lens
The master orator that he is, Berwick weaves science and personal narrative to eventually arrive at a history lesson about the significance of “H4,” the title of his talk. In the 18th century, John Harrison, invented several clocks over many years, incrementally improving precision and reliability from so-called “H1” to “H2” to “H3”. But eventually he rethought the very foundation of his inventions, and this ability to transform his vision rather than iterate on his invention led to improvement of leaps and bounds in quality, reliability, and efficiency: “H4”.
How do we get the kind of innovation that bears almost no resemblance to the status quo? How do we get from H1 to H4 in healthcare?
To answer this question, the management literature offers a helpful framework. Ramdas and colleagues suggest examining four factors and asking a series of questions to unearth assumptions and practices that limit service quality or efficiency.
1. The Structure of the Interaction:
- Does creating shared experience or shared information among clients add value for them?
- Do your clients need tight communication among multiple providers?
2. The Service Boundary:
- Does a segment of your clients use a very similar set of complementary services?
- Do problems with complementary services affect customers’ outcomes?
3. The Allocation of Service Tasks
- Does employees’ expertise match their tasks?
- What tacit assumptions influence task assignments?
4. The Delivery Location
- Does the location limit clients’ access or success?
- Have communication and information needs changed?
As it turns out, I’ll be examining these each in turn. The structure of the interaction: Why not group prenatal visits? The service boundary: Why not connect women with a care navigator to help her access services, learn skills, and bolster her support system? The allocation of tasks: Why are we one of the only industrialized nations relying on obstetricians rather than midwives to deliver the majority of maternity care? The delivery location: Why not assess, support, and care for women in their own homes? I’m looking forward to digging into these questions and evaluating effective care models already brewing across the maternity care landscape. But before I do, next week I will make the case for why we need transformation in our maternity care system in the first place.