Rural Quality Programs Living the Triple Aim

Kap Wilkes and Margo Kulseth

"Wow," was my thought after listening to and talking with the Rural Quality grantees at their annual meeting in May. They are doing great work for improving health in their communities. They are living the Triple Aim and having an impact on the health of the people in their communities. I heard this not only from the select panel members but from around the room in the discussions, conversations, and discourse that took place through the entire gathering; improving care, making an impact on better health, and reducing costs leads to a healthier community!  

The discussion and discourse was particularly robust during the last morning when Margo and I suggested and provided a common vocabulary of key sustainability success factors. We didn't stop there, we also provided an opportunity for the rural quality grantees to practice using these words and ideas in a workshop format. In that workshop rural quality grantees talked about key activities that are specific to sustaining a program. This was followed by a deeper discourse on lessons learned. These lessons learned define the path that any program leader can leverage to sustain impact on the health of their communities.

The term “sustainability” is used quite a bit and can mean different things to different people, for example, financial sustainability, operational sustainability, or outcome sustainability. The definition can shift depending on the person, the project, or the circumstance. However, the basic assumption we presented to the rural quality grantees is that all of these perspectives are the right answer if we define sustainability as "continuing to have impact past the life of the grant.” 

Throughout the rural quality grantee meeting and during the beginning of our workshop, Margo and I heard about a lot of different activities within the defined Key Sustainability Success Factors  that the grantees are accomplishing and are engaged in implementing, including: planning, measuring, collaborating, communicating, documenting, and analyzing. The challenge for Margo and I is not only to identify activities or discover lessons learned; the real challenge for us is to illustrate and convince the leaders of these quality programs that the ultimate success factor is to see these activities through the lens of a system. We are ultimately suggesting it is management of the key success factors, components of a performance framework that is key to sustainability.

We recognize and acknowledge that doing this work of improving health and living the Triple Aim is complicated, but we are convinced that a Performance Framework utilized within a systems approach to manage this complexity is the primary key to sustainability. We also believe this sustained effort on improving the health of communities will lead to a tremendous amount of change and transformation in health care. The National Rural Health Resource Center is using and encouraging other health care organizations to use the Baldrige Performance Excellence Framework as a management tool to focus on quality and performance. The most significant benefit of using a framework within a systems approach is that it provides structure and guidance. This is true of the Baldrige Performance Excellence Framework. It can be trusted and relied on because it has been used successfully for amazing gains in performance and sustaining complex organizations over more than 25 years.

The Baldrige Performance Excellence Framework is a management tool to focus on quality and performance. The National Institute of Standards and Technology, Baldrige Performance Excellence Program describes the history and objective of the Baldrige Program in a 2011 report,  Baldrige 20/20, An Executive’s Guide to the Criteria for Performance Excellence, forward by Rosebeth Moss Kanter. The Baldrige Program “was developed in response to a crisis in U.S. competitiveness several decades ago.” “American manufacturing was losing ground to Japanese companies which had adopted quality improvement systems taught to them, ironically, by an American, W. Edwards Deming, as part of the rebuilding effort after World War II.”  Deming is credited for the Plan Do Study Act cycle. “By the mid-1980s, Japan was an economic powerhouse, and sluggish U.S. companies were under pressure to seek performance excellence and innovation.” “The rise of Japanese industry, from automotive manufacturing to electronics, cannot be written off as due to low-cost labor; it is clearly seen as emanating from outstanding management systems.”

In 1987, the U.S. government created the Baldrige Award based on seven specific components and associated performance excellence criteria, “to encourage American companies to examine their practices, benchmark against the best companies, and make necessary changes to become leaner, faster, and more customer-oriented, and responsiveness to multiple stakeholders; all in pursuit of high performance.” Although it started out as a business framework, criteria for health care organizations were added in 2002. The Baldrige criteria are a much used and respected management tool across multiple sectors including manufacturing, business, healthcare and education.

The results from healthcare organizations that have implemented the Baldrige criteria illustrate the impact of utilizing a performance framework within a systems approach. Quality has improved at one hospital with a 57% reduction in mortality resulting from pneumonia over three years. For another hospital there was a 24% increase in net operating margin over two years. Regarding patient satisfaction, in the year before one health care organization as a whole received the Baldrige Award, they were ranked as “the nation’s no. 1 hospital for overall patient satisfaction.”  Another hospital experienced nearly a 50% decrease of registered nurse voluntary turnover rate over two years.

While no management system can predict exactly what challenges will be faced in the future, using the Baldrige criteria as a framework will mean that you are better prepared to meet unexpected challenges, have a focus on results, have systematic processes in place that are effective and regularly evaluated for improvement, have a system that is responsive to customer and stakeholder need, and is integrated into operational areas.  Margo and I can attest that the Rural Quality Programs are indeed living the Triple Aim. They are making a difference and having an impact.  We are suggesting that to sustain those efforts the next step is to manage their work using a performance framework; a systems approach that will sustain the triple aim; improving quality of care, increasing wellness in our communities, and reducing the cost of health care.