Piloting Health Care Delivery Innovations from Abroad: A Systematic Approach
While there is considerable debate about the impact of free-trade treaties on the U.S. economy, there should be little controversy about the potential value of transnational exchange of health care innovations. Populations across the industrialized world are aging and living with chronic illness, and policymakers face mounting pressure to provide access to expensive new drugs and medical technologies; improve the quality, safety, efficiency, and equity of care; and ensure that delivery systems meet the needs and preferences of patients. This is particularly true in the United States, where per capita spending on health care is more than double that in most other high-income countries, but health system performance on measures of access, quality, and efficiency often lags.
What’s more, transfer of ideas across national borders has become second nature in the automobile, manufacturing, and technology industries, and yet U.S. policymakers have resisted adopting ideas from other nations’ health care systems, in part because of major differences in the organization and financing of care.
We believe there may be fewer barriers to international exchange on the front lines of health care delivery than in policy circles. For starters, there is already a well-established tradition of international knowledge exchange through medical journals, the Web, conferences, and fellowships. Providers around the world recognize that they face similar challenges in delivering the best possible care to, for example, a frail 80-year-old patient with diabetes, hypertension, COPD, and depression who is on 11 medications — whether they practice in Stockholm, Berlin, Auckland, or Detroit.
In January 2015, the Institute for Healthcare Improvement (IHI) and the Commonwealth Fund launched the IHI/Commonwealth Fund International Program for U.S. Health Care Delivery System Innovation to stimulate the transfer of health care delivery innovations from other developed countries to the U.S. The underlying premise of this initiative was that it would need to be “client-driven” to succeed. For this reason, the problems were defined and the innovations selected and prioritized by a regionally and institutionally diverse group of leading U.S. delivery systems (see table) that committed to vetting the innovations and sharing their experiences as part of a learning community.
Collectively, the health systems that are part of this Innovators Network care for around 30 million patients annually. Members of the Innovators Network identified four intractable problems for which innovative solutions were needed:
- overuse of low-value tests and treatments
- shortfalls in patient and family experiences of care
- gaps in care coordination across settings and the care continuum, and
- insufficient support for patients and families in managing their conditions.
We set out to find international solutions to these four problems by establishing an international panel of 200 experts (including IHI and Commonwealth Fund Harkness Fellowship alumni), who brought firsthand knowledge of health care systems in 30 different nations and expertise in both health care policy and delivery. The expert panel scanned industrialized countries for promising innovations — generating a pool of almost 100, which were then vetted by the Innovators Network. Through an iterative process, four innovations were selected as subjects of case studies. The case studies offer detailed descriptions of the innovations, implementation strategies, patient experiences, care pathways and protocols, use of health information technology, required resources, and evidence of their effectiveness:
- Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines
- Experience-Based Co-Design of Health Care Services
- Postal Service “Call & Check Visits” for Isolated, Frail Elderly in the Community
- Discharge to Assess: “Flipping” Discharge Assessment from Hospital to Home.
In addition, representatives from the U.S. delivery systems (including a head of innovation, chief medical officer, pharmacist, and nurse manager) joined the IHI project team on site visits to each of the four innovations to see the model in action. These visits led to important insights. For example, originators of the “flipped discharge” innovation in the NHS (England) pointed to the use of a Toyota Production System “Big Room” (Obeya) as critical for convening staff to solve problems and make decisions. But representatives of the U.S. health systems perceived the critical elements of this innovation to be a standardized approach to identifying patients at the time of hospital admission, discharging them as soon as medically ready, and using a rapidly assembled team to arrange the support and services they need at home.
IHI and Commonwealth Fund staff then worked with members of the Innovators Network to assess the feasibility of applying the innovations in their delivery systems. This involved assessing organizational willingness and capacity to pilot the innovation, analyzing potential enablers and barriers, identifying champions and project leads, and estimating the costs.
In January 2017, 12 of the Innovator Network organizations (see table) agreed to pilot-test at least one of the four delivery system innovations. We will be sharing their experiences and lessons in a future toolkit and report.