Why It Matters
The following is adapted from Appendix C in A Guide for Health Systems to Save Lives from “Deaths of Despair” and Improve Community Well-Being. This guide was developed in partnership with the Well Being Trust (WBT) to support WBT's strategic goal to save 100,000 lives from “deaths of despair” (i.e., deaths due to drugs, alcohol, and suicide) and dramatically increase healthy life years over 10 years.
IHI’s recommended approach to improve well-being and save lives from deaths of despair blends improvement methods with tactics for achieving the Triple Aim (improved health for populations, improved experience of care, at lower per capita costs). IHI uses the Model for Improvement as the framework to guide improvement work. The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement. This model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.
What Are We Aiming to Accomplish — for and With Whom?
To achieve equitable results at scale for populations, we must first identify a population of focus for improving health, well-being, and equity. We recommend focusing on populations or population segments that have been disproportionately affected by inequities, such as deaths from despair, and where health status has considerable room for improvement. After selecting the population of focus, next steps include deepening understanding of the needs and assets of the population utilizing segmentation; analyzing data stratified by race, ethnicity, gender; and engaging individuals within the population to understand the lived experience of the inequities. This understanding of the population will lead to a decision on concrete aims and goals for improving equitable outcomes. Without shared purpose and concrete aims, efforts to improve deaths of despair and equity may serve narrow purposes and perhaps build trust, but do not move an entire organization, community, region, or nation toward improved outcomes. The identification of a population of focus will also drive the creation and/or alignment of leadership and governance structures to champion and drive the work over time. Pursuing health equity — which is realized when each individual has a fair opportunity to achieve their full health potential — requires change in a system’s culture and infrastructure, as well as specific changes in aspects affecting the community-wide issues that are to be addressed. A number of different individuals and groups are required to effectively adapt and implement these changes, including individuals with lived experience of deaths of despair and the inequities you wish to improve. IHI also recommends that there is an opportunity — and a responsibility — for health care to set some bold aims to drive toward a transformed system. We have not proposed such aims within this guide because that is work that must be co-designed with those most affected by deaths of despair.
How Will We Know if the Changes We Make Are Creating the Improvements and System Transformation We Seek?
How will we know if lives are being saved? Identifying a cogent set of system-level measures for population health and equity is necessary to help organizations and coalitions evaluate their progress. These measures must be aligned to the identified population and aims and will help guide priority areas of improvement.
What Changes Can We Make That Will Result in Lasting Improvements and Saving Lives From Deaths of Despair at Multiple Levels?
A guiding purpose, concrete aims, and system-level measures are long-term guideposts, for a period of three to five years or longer. Accomplishing this long-term purpose requires a portfolio of interventions and initiatives in addition to associated projects and investments that can be addressed in the shorter term, which will together achieve population health and equity. Selected projects and investments may center on an entirely new care/service design and/or care coordination model. Another option is to build on an existing project within the organization or region, where appropriate. The portfolio of interventions should tie to an explicit theory or rationale for system-level changes for the population of focus and align with identified population-level measures.
Guiding Iterative Learning
To drive the outcomes over time toward spread and scale-up, a comprehensive learning system is needed that fosters intentional testing and learning, provides feedback loops to compare performance with specific aims and measures for the designated population, and integrates the assets of leaders and organizations. This includes learning by iterative testing (e.g., Plan-Do-Study-Act [PDSA] cycles, sequential testing of changes, Shewhart time series charts), using informative cases to “act with the individual; learn for the population,” and selecting leaders to manage and oversee the learning system, with particular focus on rebalancing the portfolio of work overtime. The population-based improvement approach to improve well-being and save lives from deaths of despair that is described in this guide has four overarching components, each with a set of guiding questions (that always include advancing equity) that build on one another. This approach embeds learning and improvement skills within and across systems and communities, and at both the individual and group levels, to support sustainability.
For more details, please review the “Population-Based Improvement Approach to Save Lives from Deaths of Despair” section of A Guide for Health Systems to Save Lives from “Deaths of Despair” and Improve Community Well-Being.