Pursuing the Triple Aim E-Book

Maureen Bisognano

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 547

Veröffentlichungsjahr: 2012

Beschreibung

Written by the President and CEO of the Institute for Healthcare Improvement (IHI) and a leading health care journalist, this groundbreaking book examines how leading organizations in the United States are pursuing the Triple Aim--improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care. Even with major steps forward - including the Affordable Care Act and the creation of the Center for Medicare and Medicaid Innovation -- the national health care debate is too often poisoned by negativity. A quieter, more thoughtful, and vastly more constructive conversation continues among health care leaders and professionals throughout the country. Innovative solutions are being designed and implemented at the local level, and countless health care organizations are demonstrating breakthrough remedies to some of the toughest and most expensive challenges in health care. Pursuing the Triple Aim shares compelling stories that are emerging in locations ranging from Pittsburgh to Seattle, from Boston to Oakland, focused on topics including improving quality and lowering costs in primary care; setting challenging goals to control chronic disease with notable outcomes; leveraging employer buying power to improve quality, reduce waste, and drive down cost; paying for care under an innovative contract that compensates for quality rather than quantity; and much more. The authors describe these innovations in detail, and show the way toward a health care system for the nation that improves the experience and quality of care while at the same time controlling costs. As the Triple Aim moves from being largely an aspirational framework to something that communities all across the US can implement and learn from, its potential to become a touchstone for the work ahead has never been greater. Pursuing the Triple Aim lays out the vision, the interventions, and promising examples of success.

Leseprobe

CONTENTS

Preface

Acknowledgments

The Authors

Chapter 1: HealthPartners

Hearing a Call to Change the System

Care Model Process

Diabetes: An Optimal Measure

Evolving to the Triple Aim

The Future

Keys to Doing This Work

Chapter 2: Intel and Virginia Mason Medical Center

Breakthrough at Virginia Mason

Intel Looks to Health Care to Improve Cost and Quality

Intel Uses Purchasing Power to Put the Patient First

Moving Forward

Keys to Doing This Work

Chapter 3: CareOregon and Affiliated Clinics

Crisis 2003

CareSupport

A Collaborative Effort

The Multnomah County Experience

Tackling Disease Management at the Clinic Level

Paying Providers Differently

Results

Social Care

Keys to Doing This Work

Chapter 4: The Alternative Quality Contract

Pay for Quality Not Quantity

A Time for Action

Mount Auburn Hospital and Affiliated Physicians

Atrius Health

Challenges to the AQC

Indications of Success So Far

Keys to Doing This Work

Chapter 5: Bellin Health

A New Path Forward

The Keys to Employee Engagement

Taking the Bellin Method to Other Companies

Breakthrough

The Essential Ingredients

Right Care, Right Place, Right Cost

Pursuing the Triple Aim

A Deep Dive for Determinants of Health

Keys to Doing This Work

Chapter 6: The Patient and Family Centered Care Methodology and Practice

Bridging the Gap Between Engineers and Surgeons

Helping to Lead the Way

Focusing on the Entire Care Experience

Magee: Spreading the Method

Results

Teaching and Spreading the Method Far Beyond UPMC

Keys to Doing This Work

Chapter 7: Kaiser Permanente

World-Class Technology to Improve Health

Innovations from the KP Care Management Institute

KP Innovation Consultancy

Building a Performance System Throughout KP

Creating Nurse Knowledge Exchange

Developing the Garfield Health Care Innovation Center

Looking to the Future

Keys to Doing This Work

Chapter 8: No Excuses

The Leader’s Role in Spread

The Leader’s Role in Changing the Culture

Epilogue: Innovation Everywhere

References

Index

Copyright © 2012 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Bisognano, Maureen A.

Pursuing the triple aim : seven innovators show the way to better care, better health, and lower costs/Maureen Bisognano, Charles Kenney. – 1st ed.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-118-20572-3 (cloth); 978-1-118-22856-2 (ebk.); 978-1-118-24084-7 (ebk.); 978-1-118-26570-3 (ebk.)

1. Medical care–United States–Cost control–Case studies. 2. Medical care–United States– Quality control–Case studies. I. Kenney, Charles, 1950- II. Title.

RA399.A3B49 2012

362.168’1–dc23

2011053063

To the patients and caregivers working to pursue the Triple Aim and to the amazing caregivers who support us all.

Preface

The health care reform debate generates countless areas of dispute yet precious few of agreement. There is, however, a rare and fertile patch of common ground built upon the broad consensus that in the United States today the health care status quo cannot be sustained. Although this notion is well worn, we believe it is also profoundly important, for it leads directly to a foundational question in health care: Where do we go from here? What will the new health care system look like? For if the current pathway cannot be sustained, then there must be a new way.

And there is. In fact, this new pathway is hiding in plain sight.

Even with major steps forward, including the Affordable Care Act and the creation of the Center for Medicare and Medicaid Innovation, our national health care debate is too often poisoned by negativity. Yet a quieter, more thoughtful, and vastly more constructive conversation continues among health care innovators throughout the country. This conversation is focused on how to make the system better for patients as well as clinicians, and more affordable for everyone who pays the bills. It is much more than a conversation, of course. It is a formidable movement of innovators whose hallmarks are ideas, vision, action. These are people finding a new way; innovators achieving measurable progress on the challenges of quality and cost. The reality on the ground is that the breakthrough work in health care innovation flourishes great distances from Capitol Hill. Solutions to national problems are being designed and implemented at the local level.

We believe these innovators can help show the way to solving some of the toughest health care problems we face as a nation. Their ideas and work, if spread thoughtfully and effectively, can go a very long way to solving much of what plagues our system.

For the past twenty years at the Institute for Healthcare Improvement (IHI) our teams have fanned out across the world, working side by side with thousands of health care innovators. We study, analyze, innovate, and in many cases collaborate on their work from the boardroom to the front lines of care. We harvest, spread, and generate new ideas.

The people and places we write about here have tackled some of the toughest challenges at the heart of the American health care dilemma and done so with a level of achievement that makes them models of innovation. In this book you will learn about innovators who are

improving quality and lowering costs in primary care by moving care teams out into the workplace;applying challenging chronic disease control measures with breakthrough outcomes;standardizing excellent care and controlling costs in orthopedic surgery, particularly in the epidemic of total joint replacements;leveraging employer buying power to improve quality, reduce waste, and drive down cost;paying for care under an innovative contract that compensates for quality rather than quantity;finding new ways to care for Medicaid populations while improving quality and reducing cost;building a methodical and energetic internal capacity to innovate, to spread innovations and ideas for improvement throughout an organization, and to sustain those improvements at the front lines of care.

These innovations are succeeding now on the local level where they were conceived and nurtured. And although their impact locally has been significant, their potential nationally can be transformative. We do not underestimate the challenges inherent in the large-scale spread of new approaches. Too often health care is slow-footed about spreading emerging best practices. Yet the urgency of the need for improvement coupled with new techniques for effective spread give us a sense of optimism that an emerging trend in health care will be quicker and more certain adaptation of new ideas.

We have seen significant gains in spread in just the past decade. IHI has in fact served as a catalyst for spreading improvements throughout systems and the nation. Proven tools and strategies along with effective partnerships can fuel rapid and sustained spread of the best improvement ideas. We have seen that in many different forms, including our 100,000 Lives and 5 Million Lives campaigns.

During his commencement address to the Harvard Medical School class of 2011, surgeon, writer, and researcher Atul Gawande observed that “the places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope. . . . We can look to the top performers—the positive deviants—to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.”

If the innovations we write about here were spread throughout the United States, they would almost certainly improve the quality and safety of health care by an order of magnitude.

In this book we focus on a small number of organizations because we believe these stories reveal a great deal about where our country needs to go. What do these organizations share in common? All are led by men and women of vision—leaders with an obsession for improvement, fearless in their pursuit of better, more affordable care. These organizations and their leaders are imbued with a fundamental understanding of and connection to the transformative power of partnership and teamwork. They are aligned with the idea of integrating health care with public health and social services to get at the full range of health determinants. They embrace integration and coordination of care across organizational silos. They are humble and relentlessly patient centered. All the organizations we write about, with a single exception, are not-for-profits, and nearly all are integrated in either structure or practice. They measure with rigor, know where they stand relative to the best, and spotlight variation within their own organizations in an effort to reduce waste and improve the reliability of care. They aspire to the six aims of the Institute of Medicine’s 2001 report—Crossing the Quality Chasm: A New Health System for the 21st Century—striving for care that is safe, effective, patient-centered, timely, efficient, and equitable.

But we believe that at the core, what truly binds the organizations we write about together is their pursuit of the IHI Triple Aim:

Improving the experience of care—providing care that is effective, safe, and reliable—to every patient, every timeImproving the health of a population, reaching out to communities and organizations, focusing on prevention and wellness, managing chronic conditions, and so forthDecreasing per capita costs

Organizations targeting the Triple Aim have gone from looking inward to looking outward, getting outside their walls and reaching out to their communities to improve care overall for populations, whether the population is a panel of diabetic patients or an entire town. And they have gone from paying little if any attention to how money is spent—on tests, procedures, inpatient care, emergency department use, and much more—to recognizing that those dollars are a precious asset for communities, companies, individuals, and our nation. More and more the recognition is growing that pursuing the Triple Aim is not only about a better health care system but also about a sound business strategy and that it is essential to the stability of our national economy.

We want to be clear that no organizations we are aware of have yet achieved the full potential of the Triple Aim—nor, in a relatively short period, would they be expected to have done so. But we write here about organizations that are on the Triple Aim pathway, seriously committed to improving the experience of care and the health of populations and to decreasing costs. And even though none has achieved anything like perfection, all of the organizations we write about have made significant strides.

The Triple Aim is not a new idea although it is a new framework for a growing number of health care organizations. The concept began with IHI’s John Whittington, MD, and Thomas Nolan and has evolved over many years. It was first articulated publicly in December 2007 when Donald Berwick, MD, then CEO of IHI, outlined it during a presentation at the IHI National Forum. In 2008, Berwick, Nolan, and Whittington published an article in Health Affairs titled “The Triple Aim: Care, Health, and Cost,” in which they defined and made a case for the approach. They noted that improvement efforts until then had been focused somewhat narrowly, and they proposed that organizations view the job of health care with the widest of wide-angle lenses. “Most recent efforts to improve the quality of health care have aimed to reduce defects in the care of patients at a single site of care,” they wrote. “Slow progress” is occurring although there is an ongoing struggle “to make highly reliable and safe health care a norm rather than an exception” (p. 760).

The authors had their eyes wide open in recognizing barriers, writing that

the balanced pursuit of the Triple Aim is not congruent with the current business models of any but a tiny number of U.S. health care organizations. For most, only one, or possibly two, of the dimensions is strategic, but not all three. Thus, we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest [pp. 760–761].

They noted that “rational common interests and rational individual interests are in conflict” (p. 761). And that remains true in many places but it is increasingly less so. In just the handful of years since the article appeared, much has changed in the American health care reform movement. Perhaps as much as or more than anything else, financial pressure, exacerbated by the global recession, has pushed the cost issue to the top of the agenda. This in turn makes the Triple Aim more cogent and timely than ever. One after another, health care organizations throughout the country are deciding it is the right path forward.

Berwick, Nolan, and Whittington also articulated how the Triple Aim might work, noting that a population being managed could be, but need not be, purely geographically defined. “A registry that tracks a defined group of people over time would create a ‘population’ for the purposes of the Triple Aim,” they wrote. “Only when the population is specified does it become, in principle, possible to know about its experiences of care, its health status, and the per capita costs of caring for it” (p. 762).

Essential to successful population management, they wrote, was the presence of an entity that would accept “responsibility for all three components of the Triple Aim for a specified population.” This “integrator” role could be played by “a powerful, visionary insurer; a large primary care group in partnership with payers; or even a hospital, with some affiliated physician group, that seeks to be especially attractive to payers” (p. 763).

Success under the Triple Aim would mean thinking differently from the prevailing norm at the time, which was for health care to “respond to the acute needs of individual patients, rather than to anticipate and shape patterns of care for important subgroups.” The authors suggest a shift from a focus on sick care to “assigning much more value and many more resources . . . to the monitoring and interception of early signs of deterioration” in a wide variety of conditions (p. 764).

If it is accurate that there is consensus in the United States around the notion that the current pathway is unsustainable, then it comes as affirming news that “pursuit of the Triple Aim threatens the U.S. status quo health system” (p. 767).

In 2007, IHI launched an initiative with fifteen health care organizations that were formally pursuing the Triple Aim (thirteen in the United States and one each in Sweden and England). These organizations committed to applying five design concepts that IHI staff believed would put them on the Triple Aim path: (1) focus on individuals and families, (2) redesign of primary care services and structures, (3) population health management, (4) understanding and changing the drivers of costs to limit or reduce increases across the system, and (5) creating new structures and systems to design and execute changes across entities, cost control platform, and system integration and execution.

After only a few months—by the summer of 2008—the number of groups working on the Triple Aim with IHI climbed from fifteen to more than forty. In recent years the Triple Aim has been the focus of a great deal of our work at IHI. By 2011, we were working with nearly sixty organizations located throughout much of the world on Triple Aim initiatives.

More recently Tom Nolan and others (2010) have made a strong case to pursue the Triple Aim “in a population defined by regional boundaries,” according to a recent IHI paper. “Focusing on geographic regions represents a major opportunity to develop new systems of health and health care services that are affordable and sustainable. Regions that succeed in designing high-value health systems will enjoy important advantages—residents of the communities will be healthier and more productive; the communities will be more attractive to new businesses; health care will represent a smaller financial burden on employers, state and local budgets, and individuals.” IHI’s Triple Aim initiative requires organization-wide commitment along with well-defined parameters and structure. But the Triple Aim is also an idea, a goal, a general framework, and a kind of ideal. It is a fresh perspective on how to think about health care, and it has captured the imaginations of thousands of stakeholders throughout the country. Some are engaged in the rigor of the initiative itself whereas others are guided by the approach less formally but are in pursuit of the aims nonetheless.

Important thinkers, notably David Kindig, MD, PhD at the University of Wisconsin, have pointed out that the Triple Aim’s cutting edge is pushing health care organizations to focus on health and to collaborate with partners in public health and other fields to address the non-medical determinants of health. For those of us working in health care, it is toward this part of the Triple Aim that we have the furthest to go. It will take more than effective improvements in quality and cost to improve health. The innovations at Bellin Health discussed in chapter five and at Kaiser Permanente discussed in chapter seven point to the kind of transformation needed to make a genuine and lasting impact on health.

In the following chapters we relate stories about inspired people doing important work. The innovations in this book are important for their positive impacts in their own communities. Beyond that, they hold promise for helping others find improvement pathways forward.

Although the details of these stories are instructive, they tell only part of the story. That is why we also seek here to get inside the heads of these innovators to understand what their thought processes are and have been throughout their improvement work. We seek to understand how they think, how they frame their approach when confronted with difficult challenges. What mental framework did they use to puzzle through problems? What or who influenced and guided their thinking? Have particular theorists, practitioners, writers, or organizations provided a spark or urged them in a new direction? How did they hear the voice of the patients and caregivers, and what changes did these voices prompt? How did they form and execute their new plans? What were the barriers, and how did they think about getting past them? What do they identify as the essential elements of their success? How did they change their organizational cultures and by what means?

Because our ultimate goal here is a practical one—to encourage and inspire others to copy some of this work—we write about what you—as an individual, team, or organization—might need if you wish to emulate work described here. If you are a clinician or administrator and aspire to replicate some of the work, what are the essential ingredients you would need to get started? What are the initial questions you might reflect upon? We make an effort throughout the book to provide clear answers to all of these questions At the end of each chapter we identify components of the work that the innovators themselves believe are essential to their success.

With the spread of the Triple Aim—both the initiative and the idea—we have an increasing sense that it is becoming a sort of true north in health care. For the reality in the United States today is that our country is counting on the health care sector to pursue the Triple Aim and, at some point in the not-too-distant future, to achieve it.

Acknowledgments

At HealthPartners, we are grateful to Mary Brainerd; Brian Rank, MD; Nancy McClure; Beth Waterman; Beth Averbeck, MD; David Caccamo, MD; George Isham, MD; Rae Ann Williams, MD; Tom Kottke, MD; Art Wineman, MD; and Nico Pronk.

At Intel, we are grateful to Pat McDonald; Richard Taylor; Kevin Carmody; Brian DeVore; Don Fisher, MD; Steve Megli; Wendy Fedderly; Patty Murray; Ian Crisp; Matthew Brownfield; and Mani Shiue. At Tuality Healthcare, we are grateful to Dick Stenson; Janet Meyer, MD; and Amy Sherwood. At Providence Health, we are grateful to Tom Lorish, MD; James Harker; Kristina Herron; Joseph Siemienczuk; Jennifer Bly; Julie Morse; and Mindy Hangsleben. We are grateful to Joan Kapowich, administrator of the Oregon Public Employees’ Benefit Board and the Oregon Educators Benefit Board.

At Virginia Mason Medical Center, we are grateful to Gary Kaplan, MD; Robert Mecklenburg, MD; Kathleen Paul; Diane Miller; Andrew Friedman, MD; C. Craig Blackmore, MD; Darlene Corkrum; Sarah Patterson; Kim Pittenger, MD; Charleen Tahibana; and Cathie Furman.

At CareOregon, we are grateful to Dave Ford; David Labby, MD; Rebecca Ramsay; and Debra Read; and also to Rachel Solotaroff, MD, at Central City Concern; and to David Shute, MD, of GreenField Health in Portland. We are grateful to Douglas Eby, MD, of Southcentral Foundation in Anchorage and to the leaders at Multnomah County Health Department in Oregon, including Susan Kirchoff; Amit Shah, MD; and Mindy Stadtlander.

At Blue Cross Blue Shield of Massachusetts, we are grateful to Andrew Dreyfus, Dana Gelb Safran, Deb Devaux, Patrick Gilligan, John Fallon, MD, and Jay McQuaide. We are grateful to former Blue Cross executives Robert Mandel, MD, Peter Meade, and John Schoenbaum. At Mount Auburn Hospital and the Mount Auburn Cambridge Independent Practice Association, we are grateful to Jeanette Clough; Rob Janett, MD; and Barbara Spivak, MD. At Atrius Health, we are grateful to Rick Lopez, MD; Kate Koplan, MD; Les Schwab, MD; and Marci Sindell.

At Bellin Health, we are grateful to George Kerwin, Pete Knox, Randy Van Straten, Jacquelyn Hunt, Amy Seymour, and Patti Eisenreich. We are also grateful to Sarah Novak at Marinette Marine Corporation/Bay Shipbuilding, Fincantieri Marine. At the Orthopaedic Program at Magee-Womens Hospital of the University of Pittsburgh Medical Center (UPMC) and at the broader UPMC system, we are grateful to Tony DiGioia, MD; Gigi Conti Crowley; Leslie Davis; Elizabeth Concordia; Judy Herstine; and Lou Alarcon, MD.

At Kaiser Permanente, we are grateful to Alide Chase; George Halvorson; Marilyn Chow; Lisa Schilling; Jack Cochran, MD; Yan Chow, MD; Louise Liang; Holly Potter; Chris McCarthy; Christi Zuber; Estee Neuwirth; Danielle Cass; Yasmin Staton; Judith Kibler; Teri Whiffen; John August; Diane Waite; Samantha Quattrone; Andrea Buffa; Jennifer Liebermann; Aaron Hardisty; Jed Weissberg, MD; Jan Dorman; Jennifer Lieberman; and Faye Sahai, MD.

We owe a debt as well to a number of men and women at health care organizations throughout the world. We have learned from many health care professions in Jönköping County, Sweden including Göran Henriks, Mats Boestig, MD, and Agneta Jansmyr. In England, we have learned from Helen Bevan, Bernard Crump, and Jim Easton as well as from Derek Feeley, Frances Elliot, Jason Leitch, and Pat O’Connor in Scotland, and Wim Schellekens from the Netherlands. We have learned as well from Uma Kotagal, MD and Lee Carter at Cincinnati Children’s Hospital Medical Center; Jim Reinertsen, MD; Jim Conway; Jamie Orlikoff; and Paul Levy.

We are grateful to IHI faculty members Ian Rutter, Catherine Craig, Joanne Lynn, Bruce Bradley, Matt Stiefel, Bonnie Zell, and Trissa Torres.

We are deeply grateful to our friends and colleagues at the Institute for Healthcare Improvement (IHI), including the leaders of the Triple Aim work: Carol Beasley, Karen Boudreau, Martha Rome, Ninon Lewis, Kathryn Brooks, Meghan Hassinger, Kevin Nolan, and others who have invented, innovated, and inspired, including Andrea Kabcenell, Lindsay Martin, and more. We are grateful as well to other IHI colleagues, including Jeff Selberg, Pierre Barker, Penny Carver, Pedro Delgado, Frank Federico, Donald Goldmann, Paul Hamnett, Carol Haraden, Joanne Healy, Amy Hosford-Swan, Andrea Kabcenell, Madge Kaplan, Bob Lloyd, Katharine Luther, Patricia Rutherford, Ken Tebbetts, and Markus Josephson.

A special thanks to Val Weber, Dan Schummers, and Jane Roessner for editorial guidance, expert coaching, and a very special colleagueship.

We owe a debt of gratitude to the IHI board of directors: James M. Anderson, former chairman and CEO of Cincinnati Children’s Hospital Medical Center; Michael Dowling, president and CEO, North Shore–Long Island Jewish Health System; Terry Fulmer, dean, Bouvé College of Health Sciences, Northeastern University; A. Blanton Godfrey, dean and professor, College of Textiles, North Carolina State University Raleigh; Jennie Chin Hansen, CEO, American Geriatrics Society; Ruby P. Hearn, senior vice president emerita, The Robert Wood Johnson Foundation; Brent C. James, MD, chief quality officer, executive director, Institute for Healthcare Delivery Research, Intermountain Healthcare; Gary S. Kaplan, MD, chairman, and CEO, Virginia Mason Medical Center; Dennis S. O’Leary, MD, president emeritus, The Joint Commission; Rudolph F. Pierce, Goulston & Storrs, PC; Nancy L. Snyderman, MD, chief medical editor, NBC News, associate professor of otolaryngology, University of Pennsylvania; Robert Waller, MD, president emeritus, Mayo Foundation; Diana Chapman Walsh, president emerita, Wellesley College; and Paul Batalden, MD, a founder of IHI and a continuing visionary.

Our greatest debt, of course, is to the three men who conceived the Triple Aim: Tom Nolan, John Whittington, and Don Berwick. Their vision will change the lives of so many.

The Authors

Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement (IHI), previously served as IHI’s executive vice president and chief operating officer for fifteen years. She is a prominent authority on improving health care systems, and her expertise has been recognized by her election as a member of the Institute of Medicine and by her appointment to the Commonwealth Fund’s Commission on a High Performance Health System, among other distinctions. Bisognano advises health care leaders around the world, is a frequent speaker at major health care conferences on quality improvement, and is a tireless advocate for change. She is also an instructor of medicine at Harvard Medical School, a research associate in the Brigham and Women’s Hospital Division of Social Medicine and Health Inequalities, and serves on the boards of the Commonwealth Fund, the ThedaCare Center for Healthcare Value, and Mayo Clinic Health System-Eau Claire. Prior to joining IHI, she served as CEO of the Massachusetts Respiratory Hospital and senior vice president of the Juran Institute.

Charles Kenney is the author of twelve books, including The Best Practice: How the New Quality Movement Is Transforming Medicine, which the New York Times described as “the first large-scale history of the quality movement.” He is also the author of Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, for which he received the 2012 Shingo Research and Professional Publication Award. He has served on the faculty of the Institute for Healthcare Improvement National Forum on Quality Improvement in Health Care.

Chapter 1

HealthPartners

Care Model Process and Continuous Healing Relationships

HealthPartners, based in Bloomington, Minnesota, is the largest consumer-governed, nonprofit health care organization in the United States, employing twelve thousand workers serving 1.3 million people in Minnesota and surrounding states. It is an integrated system, combining a health plan with a medical and dental group that includes eight hundred physicians, four hospitals, and fifty clinics. HealthPartners operates in a state that is home to some of the most innovative health care reform laboratories in the nation, including the Mayo Clinic and Park Nicollet. The overall quality of care in the state is excellent, and costs run about 30 percent below the national average for Medicare patients. HealthPartners costs run even lower—up to 10 percent below the state’s average.

In this chapter we focus on HealthPartners’ transformative work in primary care, targeted at reliability and the Triple Aim, and we place particular emphasis on the breakthrough work HealthPartners has done on chronic conditions, particularly diabetes.

At IHI, we have worked side-by-side with HealthPartners on a variety of initiatives for more than a decade. We believe it is one of the great health care organizations anywhere in the world. In its pursuit of the Triple Aim, HealthPartners has built a care delivery system based on a rock-solid foundation of reliability, customization, access, and coordination of care. A conservative estimate suggests that spreading HealthPartners’ best practices throughout the nation has the potential to save