Spread, Scale, and Sustainability in Population Health: Workshop Summary by Theresa Wizemann

Author:Theresa Wizemann
Language: eng
Format: epub
Publisher: The National Academies Press
Published: 2016-01-14T00:00:00+00:00

DISCUSSION

During the brief discussion that followed, participants reflected on getting started and having time-specific goals and on summative versus formative evaluation. Participants also discussed the concept of exceptional initiatives as a learning system and reiterated the issue of misalignment between the payment system and population health as a barrier to scale and spread.

In considering the need to get started rather than spending time developing comprehensive strategies, George Isham of HealthPartners recalled the examples and lessons from the panel on tobacco control regarding the spread of ineffective initiatives. McCannon agreed that there can be big miscalculations in developing large strategies, and he suggested that this supports the wisdom of getting started, but starting small. This is not to say that there is not time for deliberative thought and design, he said, but one should set a short timeframe for when the initiative will begin (e.g., 6 months).

Isham concurred with McCannon’s comments on the need for time-specific goals. He noted that the Institute of Medicine consensus studies have made time-specific recommendations for improving population health. He cited the first recommendation in the report For the Public’s Health: Investing in a Healthier Future, which recommends that the secretary of health and human services set targets for life expectancy in the United States to be achieved by 2030.6

Paul Jellinek of Isaacs/Jellinek suggested that a rigorous summative evaluation of the prototype can pay huge dividends in terms of the subsequent rollout. Compelling cost–benefit or cost-effectiveness data can help secure financing going forward. Formative evaluation is then more appropriate for the project rollout. It is a sequential process, he said. McCannon agreed, but added that people sometimes confuse a summative evaluation with randomized controlled trials, and there are many other valuable forms of summative evaluation that may allow for greater appreciation of the texture and the context of the innovation.

David Kindig of the University of Wisconsin pointed out that the components of exceptional innovations outlined by McCannon form what Donald Berwick of IHI has referred to as a “learning system.” Berwick has also observed that in the most effective initiatives, there is someone in charge to manage the learning system. This work is so deeply multi-sectorial that often there is no one accountable for the outcome. Kindig asked how a diffuse-accountability, multi-sectorial system can still perform in these exceptional ways. McCannon responded that there does need to be an entity or organization (or representatives from multiple organizations) that will be responsible for the learning system. A learning system supplies people with data that allow them to change and improve themselves or else gives them the ability to collect those data and make change themselves. There is a surveillance function that is designed to see what is happening around the system and that is able to identify what is good, distill it, repackage it, and redistribute it very quickly. The learning system does not catalog or create databases; it focuses on tacit knowledge rather than explicit knowledge. A learning system that works is created and managed intentionally by a core group of people, he said.

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