April 18th, 2013
The author is president and CEO of the Fannie E. Rippel Foundation, a national health philanthropy located in Morristown, New Jersey.
In 2007 the Fannie E. Rippel Foundation set out to understand why changes that we know need to take place in the health system don’t regularly happen and what can be done to remedy that. We were driven by the words of our first president, Julius A. Rippel, who wrote about an unsustainable health care system; the need for hospitals to be patient-centered and smaller, as opposed to profit-driven; and the need for medical education reform. He advocated a dual system focused simultaneously on health and health care as the only path to sustainability. Mostly he talked about the need for new ways of thinking and acting to change the inevitable path we were on.
Sound familiar? This could be a speech by Don Berwick today. In fact, Julius began writing about these issues in 1959, almost fifty-five years ago!
To find some answers, the Rippel Foundation decided to look outside of the medical system. We started by convening a group of leading change agents from across an array of sectors to explore ideas from other industries and perspectives. Known as ReThink Health, Rippel’s early gatherings included a few national health care leaders (Don Berwick and Elliott Fisher), but also included experts in innovation (Laura Landy), authorities on how to plan for different possible organizational futures (Jay Ogilvy), leaders in the creation of learning organizations (Peter Senge), researchers on how we can be collaborative stewards of shared and limited resources (Elinor Ostrom), academics known for their use of models and games for change (John Sterman), leaders in community and political organizing (Marshall Ganz), prominent political pollsters (Celinda Lake), and scientists grounded in alternative energy (Amory Lovins) and alternative medicine (Russ Jaffe).
A key lesson from this group, which met regularly over more than two years, was that at the core of any change is getting the right people around the table to talk and interact in a different way—one that builds trust and solidifies relationships. The growing ReThink Health team, which now includes many protégés of our original ReThinkers, has continued honing the processes for skillful convening with leaders and teams in communities across the country. A growing set of tools, approaches, and principles is now making this work more efficient, more effective, and more accessible as we partner with local teams to shift fragmented approaches to health and care toward integrated and directed enterprises. The powerful approach that started ReThink Health has proven its value in multiple regions.
Convening to engage citizens. In Columbia, South Carolina’s Eau Claire neighborhood, where diabetes-related amputations are the highest in the country, one challenge was to overcome the distrust and dismay that came from years of well-intentioned groups doing things “for the community” or “to the community,” with limited success. The goal was to see if it was possible to work “with the community” to make a difference.
Here, again, convening was key. Starting first with a leadership team that represented payers, health care providers, the federally qualified health center, local government, the hospital, the University of South Carolina, and key community and religious organizations, ReThink Health’s team focused on how to primarily use organizing techniques to build relationships, develop effective teams, and structure quick successes to build upon for larger and longer-term initiatives. Intensive training and coaching created shared understanding and new relationships, built new skills, and broke down traditional boundaries. As a result, the initial team has now grown into a diverse and committed group of stakeholders, and new community-based health programs are bringing creative approaches to prevention and also bringing care to area residents. This Healthy Columbia campaign has developed into a staffed effort and is now going statewide. As one medical leader said, “Doing things with the community makes all the difference.”
Convening to develop a systemwide strategy. In Pueblo, Colorado, a community where health care premiums are rising three times faster than wages and health outcomes are among the worst in the state, a group of health system leaders formed a coalition and became part of the Institute for Healthcare Improvement’s Triple Aim program. Local government, the community health center, regional medical centers and hospitals, the mental health center, and Kaiser Permanente were all in the group.
While they were making investments in health and health care and working hard to make a difference, they knew their efforts weren’t well aligned. They questioned whether they were using their resources well. They also recognized that those who deal with crime, education, employment, and other determinants of health were not in the room. Working together as a team and with ReThink Health, the group in Pueblo used ReThink Health’s System Dynamics Model as a focus for convening, building shared understanding of the health care system as a whole, and examining everyone’s role in the system.
Using the interactive model that was calibrated to specifically reflect the Pueblo community, the group came up with a plan that requires an investment of just 1 percent of their total health care spending over five years—that is, a total of $50 million. They have now formed a nonprofit organization to help them maintain their collaboration and focus on achieving their aspirational scenario. which would reduce deaths and costs by about 19 percent, lower non-urgent emergency department use by about 70 percent, and boost workforce productivity more than 20 percent. The plan also would bring more services to those in the community who now have difficulty getting access. It will even generate savings or free up resources—potentially hundreds of millions of dollars—that could be used to improve education, infrastructure, the environment, and the economy.
The ReThink Health Model for an “average” US region can be accessed here.
Convening to launch the conversation. In the Upper Valley of Vermont and New Hampshire, a third model of convening is now under way. In a region where collaboration around health and health care has historically been absent, the first goal was to see if leaders across the community were committed to doing something different. Bringing together an initial group representing Dartmouth College, the Dartmouth-Hitchcock Health System, major area employers, social service agencies, and local residents, ReThink Health drew on work in leadership, stewardship, and effective teams to support the capacity of these leaders to coalesce around a shared goal and reach out to engage others in the community. After a series of interviews and outreach efforts, more than eighty area leaders from a wide array of perspectives are convening in the coming weeks to create a vision for the community and to begin to create the structures to make that vision a reality.
Convening to repair relationships and foster shared values. Finally, in New Jersey, a highly siloed and competitive health care environment, Rippel and ReThink Health have supported two powerful new efforts to bring people together in ways that can move us along the path to reform.
Using data from nine area hospitals, a diverse group focused on a three-county, middle- and upper-class region in northern New Jersey—the Morris Health Referral Region from the Dartmouth Atlas of Health Care. This group has just completed an analysis of where the most frequent users of emergency and inpatient services are in the region, their diagnoses, demographics, costs to the system, and their use of multiple hospitals. Sharing the results of that data analysis with the nine hospitals in the region has generated a commitment by the leadership to get together to explore for the first time in recent history how they can learn and work together.
Similarly, a statewide initiative was begun by bringing together the directors and select board members of the medical society, the association of the health insurance companies, and the hospital association. Through a skillful, facilitated process that mended long-broken relationships, a focus on leadership and collaboration has evolved. That effort has now grown to include more than twenty-five leaders from the three organizations who are committed to working together over the coming year to determine what they might do together to strengthen health-sector leadership and improve health, care, and costs in New Jersey.
Drawing on the insights of the founding ReThink Health members, we have been able to adapt and refine their experience in ways that work in our complex health system. While approaches such as these are certainly only one piece of a complicated puzzle, we have learned that thoughtful, respectful, and provocative convening, as well as support of effective cross-stakeholder teams, can be powerful in fostering rethinking and building efforts that lead to real change. The hard work of developing shared understanding, shared visions, and new relationships really pays off. Without it, we should expect nothing more than the continuation of our current unsustainable health care system.
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