By Evan Benjamin, MD, MS, FACP; Bozwell Bueno; Meghan Long, MHA; and Saranya Loehrer, MD, MPH
Over the past several months we have had the privilege of supporting health care organizations across the United States as they respond to unprecedented challenges brought forth by the COVID-19 pandemic. From policy and payment changes at the federal and state level to innumerable changes at the level of health care delivery and operations, seemingly every aspect of health care has been upended by the pandemic. Some of these changes were based on evidence, others a result of ingenuity, and many simply borne out of necessity.
As health care organizations begin to emerge from their initial preparedness and response efforts, many are revisiting decades old policies and practices and asking themselves how they can do better. We sought the perspectives through a survey as well as through crowdsourcing of ideas through social media of public health and health care organization leaders, policymakers, payers, patients, and providers at the frontlines of the pandemic. These leaders came from a cross section of the health care industry that has been leading efforts to improve the value of health care for some time. What follows is a distillation of what we heard into a set of guiding principles to support health care’s current moment of reflection and recalibration.
1. Meet the magnitude of the moment
The pandemic brought long-standing inefficiencies into sharp relief — clinical information systems were unable to extract, analyze, and share data at a pace commensurate with the spread of the virus, vulnerabilities in the supply chain were exposed, and horrific racial inequities were laid bare. Never before have the ways that health care is accessed, delivered, regulated, and paid for been open to such collective examination. The most resounding theme we heard: Do not seek to restore what once was, instead reflect on where it got us, and reimagine what can be. An opportunity for redesign, refocus, and cooperation at this scale may not present itself again in our lifetime.
2. Ensure that equity is central to redesign
The pernicious and pervasive consequences of systemic racism are manifest throughout our society, health care being no exception. Health care must be explicit and intentional about implementing changes that seek to eliminate inequities in access and care outcomes, including a transparent set of measures to ensure that intention translates into desired impact. Improvement efforts must focus on those most at risk of becoming infected with COVID-19 or of adverse consequences related to delayed care. Regrettably, while access to care was an issue in many communities prior to the pandemic, it is likely to be exacerbated by growing unemployment and economic instability. Fortunately, people with the knowledge, skills, and abilities to create meaningful and measurable impacts on equity exist within health care organizations and communities. They must be given resources, support, and recognition commensurate with the monumental ask before them.
3. Protect the health care workforce
Ensuring the physical and psychological safety of those committed to caring for us all is vital. Health care must examine and address critical defects in the supply chain that left many health care workers across the care continuum with inadequate personal protective equipment (PPE). Further, the moral injury experienced by the health care workforce cannot be underestimated. Health care leaders must be proactive and vigilant in identifying and removing any barriers to staff seeking counseling and mental health support, including eliminating stigmatizing questions on state and site specific licensing and certification applications.
To ensure the ongoing health and safety of the health care workforce, organizations should consider which aspects of their operations may be suited for remote work and make adjustments accordingly. Finally, organizations should evaluate internal policies such as ensuring a local living wage, paid sick leave, and other practices that provide a modicum of security to those who may otherwise come to work exposed or at risk.
4. Establish a robust system for learning and evaluation of high value care
While much changed out of necessity due to COVID-19 preparedness, response, and recovery efforts, not all changes may have been welcomed nor beneficial. Health care must be relentless and systematic in understanding which were valued, by whom, and why by actively seeking the input of the patients, providers, and staff most directly impacted. The dramatic reduction in utilization of some health care services observed in the pandemic should prompt health systems to begin to learn which processes actually add value to health care, and which do not. Deference to expertise is essential. Such efforts can be aided by a parsimonious and transparent set of measures to assess impact over time. The Triple Aim may be a useful starting point and should be supplemented with additional measures such as provider and staff satisfaction, impact on equity, degree of institutional will, and where applicable, degree of support from continuum of care stakeholders (EMS, SNFs, etc.).
5. Promote safety, transparency, and a just culture
Given the magnitude and pace of change, health care organizations must remain vigilant to ensure that proposed changes do not introduce new risk of harm into the system or to the physical and emotional health of providers, patients, and families. As more organizations move towards flexible staffing models and cross-training, they must ensure that safety principles such as transparency, fostering a just culture, and celebrating continuous learning are central to onboarding and training efforts. Mechanisms for clear, consistent, and coordinated communication will be key to supporting the operationalization of changes and improvements over time.
6. Modernize payment to align with present and future demands
Changes to better meet the needs of patients, providers, systems, and communities cannot be sustained without underlying changes to payment. Health care organizations and payers must be willing to engage in meaningful conversations about what sustained investments in redesigned care could look like and the metrics by which “success” will be evaluated. Virtual visits in isolation of broader changes to attendant processes, for example, are unlikely to dramatically improve care and outcomes. A more substantial pivot to creating healthier individuals and communities would necessitate changes to payment and incentive structures that better invest in preventive care and social determinants of health.
7. Seek new partnerships and collaborations
The agility and level of cooperation between health care organizations, state and local policymakers, public health, and community members suggest an openness to new and necessary levels of collaboration. Cooperation from the major electronic health record vendors, for example, is critical to ensure data extraction and analysis can be done with ease and at the speed and scale necessary for rapid sharing, learning, and clinical decision making at the point of care. Strengthened trust between health care organizations and all sectors to support evidence-based practices, data sharing, testing, and contact tracing will be instrumental to safe and sustained “reopening” efforts.
We must leverage the lessons learned throughout this crisis to transform the relationship between health care and society. Whether this level of cross-sector introspection, ingenuity, and collaboration can be sustained to the point of true transformation remains to be seen. What the past few months have shown us, however, is that the unthinkable is possible, the immutable movable. As Dr. Don Berwick so powerfully and succinctly stated, “fate will not create the new normal; choices will.”
Evan Benjamin, MD, MS, FACP, is the Chief Medical Officer at Ariadne Labs, an Associate Professor of Medicine at Harvard Medical School, and an Associate Professor of Health Policy and Management at the Harvard T.H . Chan School of Public Health.
Bozwell Bueno is a Project Manager at the Institute for Healthcare Improvement.
Meghan Long, MHA, is a Project Manager at Ariadne Labs.
Saranya Loehrer, MD, MPH, is Head of Innovation at the Institute for Healthcare Improvement.Illustration by kameshkova / iStock