The Triple Aim
According to the IHI (2012), Triple Aim “is a framework developed by the IHI that describes an approach to optimizing health system performance. It is IHI's belief that new designs must be developed to simultaneously pursue three dimensions, called the 'Triple Aim'.” The Triple Aim is portrayed in Figure 20.5.
The Triple Aim of ACP could be to demonstrate (a) improved health outcomes for patients at the end of their lives in a defined community (including improved clinical decision making with safer and better access to services with more professional/organizational accountability and transparency to the public); (b) enhanced patient experience (the right care at the right time and
FIGURE 20.5 Institute for Healthcare Improvement Triple Aim. place, avoiding harm); and (c) reduced per capita cost of care supported by the financial alignment of payment systems to promote and deliver ACP.
Author and poet Maya Angelou described one of her perceptions on change as, “the need for change bulldozed a road through the center of my mind.” The potential of the Triple Aim to support this case for universal change to improve treatment decisions at the EOL has had the same “bulldozer” effect on me. The need for change delivered by ACP is to stop futile, expensive, and harmful treatments (e.g., chemotherapy, resuscitation, or intensive care) for people who might want and need a natural, good death in a place they prefer (often their home, avoiding hospitalization). ACP, when done well, has the ability to utilize resources in a different way, improve patient flows and access away from expensive and harmful treatment for those who will not gain benefit, supporting a demedicalized and less costly care and death out of hospital. Dignity and privacy for people at the end of their lives is much easier to achieve in a place other than the ER on a gurney. Where there is no AD and/or ACP, doctors sometimes resort to imposing DNARCPR orders too early and not treating the reversible presenting problem or too late, having pursued futile treatment and therefore causing harm and adding cost. In the United Kingdom, DNARCPR orders are not often supported by proper best interests assessments and are implemented without true accountability. Real fear exists in the United Kingdom that there is excess mortality in Trusts/organizations driven by the bottom line. Patients with capacity have the statutory power to make their own legally binding AD, but the evidence tells us that the majority do not do this often. Doctors too often and too late impose do not attempt resuscitation (DNAR) orders, and in the worst-case scenarios discriminate against the frail and vulnerable.
The Physicians/Medical Orders for Life-Sustaining Treatment (POLST or MOLST) programs in North America in part meet the challenge of better decision making with more accountability. These programs are still yet to prove significant benefit at large scale. The application of improvement science to support a Triple Aim program has the potential to achieve this.
In the United Kingdom, there is no validated standard, audit, or other publicly accountable mechanism for decisions about life-sustaining treatment plans. There is no standardized provision for the communication and documentation of clinical decisions that travel with patients across all boundaries (ward to ward, hospital to hospital, county to county). National public inquiries including the Francis Report (2012) have identified significant concerns about the quality and safety of care, including excess and avoidable harm and mortality of older and vulnerable patients. They call for greater transparency and accountability. This should bring the reader back to the seminal IOM consensus reports on To Err is Human (see p. 315 of this chapter).
Kotter's Change Management Tools
Research by leadership guru Dr. John Kotter (Kotter International, 2012) has proven that 70% of all major change efforts in organizations fail. Failure occurs because organizations often do not take the holistic approach required to see the change through. Table 20.2 outlines the Eight-Step Process by Professor Kotter, which helps organizations to avoid failure and become adept at change. By improving their ability to change, organizations can increase their chances of success, both today and in the future. Without this ability to adapt continuously, organizations cannot thrive. It is important for the reader to consider these eight generic steps and relate them to the specific six leadership actions for EOL care set out on page 316 of this chapter.
Eight-Step Process for Leading Change by Dr. John Kotter
1. Establishing a Sense of Urgency
• Examine market and competitive realities
• Identify and discuss crises, potential crises, or major opportunities
2. Creating the Guiding Coalition
• Assemble a group with enough power to lead the change effort
• Encourage the group to work as a team
3. Developing a Change Vision
• Create a vision to help direct the change effort
• Develop strategies for achieving that vision
4. Communicating the Vision for Buy-In
• Use every vehicle possible to communicate the new vision and strategies
• Teach new behaviors by the example of the Guiding Coalition
5. Empowering Broad-Based Action
• Remove obstacles to change
• Change systems or structures that seriously undermine the vision
• Encourage the risk-taking and non-traditional ideas, activities, and actions
6. Generating Short-Term Wins
• Plan for visible performance improvements
• Create those improvements
• Recognize and reward employees involved in the improvements
7. Never Letting Up
• Use increased credibility to change systems, structures, and policies that don't fit the vision
• Hire, promote, and develop employees who can implement the vision
• Reinvigorate the process with new projects, themes, and change agents
8. Incorporating Changes Into the Culture
• Articulate the connections between the new behaviors and organizational success
• Develop the means to ensure leadership development and succession