Beyond The Zero Sum Game
Posted Tuesday, April 22, 2014 by Jim K.

by Jim Kupel

Competitive advantage came up in a call last week with a colleague who has been building large successful software projects. I agreed that we want our approach to "win" in the marketplace, but pointed out that in this segment there is room for more than one approach.  He seemed taken aback when I said that the larger enterprise - improving a type of automation across the U.S. - is not a zero sum game. "We can all win," I said.

The idea of winners and losers is embedded in our culture - and in our code: zeros and ones, black and white, on and off, good and bad. This type of reduction is helpful - our brains don't want to be overloaded by choice. We like patterns. Simple choices help organize our lives.

Unfortunately an "us versus them" perspective is not very adaptive in a complex world with increasing more access to information. It is also an inaccurate view of human progress. Lots of contradictory ideas co-exist on the planet and their juxtaposition is often how we learn and improve.

Human progress is a matter of perspective and it can be measured in quantifiable terms such as infant mortality or the percentage of people who have a good job. As Bill Gates notes in a great interview with Charlie Rose, if we fail to look at our progress and only look at today's problems, we may be reluctant to make the important long-term investments needed to improve the human condition.

Our reluctance is further ...

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When Rules Get in the Way of Good Time
Posted Tuesday, April 8, 2014 by Scott G.

by Scott Good

The healthcare environment is changing rapidly and compelling good people at great community service and healthcare organizations to collaborate. For instance, the Institute for Healthcare Improvement (IHI) is working with several programs across the U.S. to develop and implement Triple Aim goals to improve community health, enhance patient experiences, and lower the costs of care. 

Though programs differ substantially, a common thread is that they all include diverse sets of people trying to work together.  The people providing the variety of services (i.e., care model members) are generally eager to work together, try new things, and take limited risks in order to achieve Triple Aim goals. Many are eager to forge new strategies and develop new relationships. However, interagency collaboration often requires additional legal agreements and guidance.

Programs need to be designed so that patient privacy is fully protected, collaborating organizations can easily work together, and financial matters are clearly understood among all parties - payers, providers, patients, and others. To do so, requires sets of legal documents and related documents.

When designing programs that address healthcare reform requirements or opportunities, development of the legal architecture underlying programs can seem to take an agonizingly long time to complete. Carefully woven legal agreements are the backbone of successful, sustainable program. However, when designing new programs to respond to healthcare reform, how do we synchronize innovation and legal processes?

In order to avoid the pitfalls of program delays due to legal review, consultation, and document development associated with healthcare reform-based activities, consider the following ...

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How to Get Started with Instagram: Lessons Learned from the Maine State Ballet
Posted Tuesday, April 1, 2014 by Kate S.

by Kate Skog

For my very first Crescendo blog post, I'm excited to write about two things that are very close to my heart: ballet and Instagram. It might sound like an odd combination... but trust me, they're more alike than you think.

I started dancing with the Maine State Ballet when I was just three years old. From the moment I stepped onstage as a reindeer in "The Nutcracker," I knew I was hooked.

And I'm still hooked. To this day, I continue to take class and perform year-round with the company. Despite a few injuries over the years, I feel pretty lucky to still be on my toes.


Maine State Ballet Instagram - Don QuixoteIn 2012, I started volunteering my time to help Maine State Ballet with their social media efforts, including the creation of their Instagram page.

With over 200 million users, Instagram is the place to be if you have beautiful images to share. As a performing arts organization, we're never short on content: from the talented dancers to the exquisite costumes, we always have something interesting to share with our audience.

I've found that some of the most beautiful moments occur when dancers are Maine State Ballet Instagram - Don Quixotegetting ready backstage, warming up, or waiting in the wings.


Here are 5 tips to help you get the most out of your Instagram account:

  1. Take photos with your phone's regular camera app – not the Instagram app. This allows you take multiple shots and select the best ones. Once you have a photo to post, simply open ...

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Being Barbra Streisand
Posted Tuesday, March 25, 2014 by Beth A.

by Beth Austin

Here's a secret about me: I love to sing. As a kid I sang in pageants and things, but for the last 30-plus years, my efforts have been limited to shower engagements and - much to the dismay of my family members and neighbors - singing along with my iPod at full volume. But a couple of months ago I revisited this old passion on a more formal level by joining the church choir. After a few weeks, I worked up the courage to sing a solo part.

On a scale of 1 to 10, with 1 being abject humiliation and 10 being Barbra Streisand, I'd say my solo performance was maybe a 6.5. Initially that seems rather disappointing, but upon further consideration, I realized it was maybe just a good starting point. The reality is that I'm unlikely to ever do much better than a 7 on this rather broad scale; possibly an 8 if God drops everything else. In short, I'll never be Barbra Streisand.

I also love to run. From time to time, someone will refer to me as "good" runner and I don't know what to make of it. When I run in road races, I'm pretty much at the top of the bell curve with about half the people finishing before me and about half finishing after me. So, from that perspective, I'm a solidly average runner. I'm a 5 on the 1-10 scale. But that's OK. While I always ...

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Mission and the Triple Bottom Line
Posted Wednesday, March 19, 2014 by Jim K.

by Jim Kupel

When I helped John Eldredge, Drew Cheney and others start the Maine Chapter of Businesses for Social Responsibility (now known as Maine Businesses for Sustainability) we spoke a lot at the time of the “dual bottom line” – the idea that your business can “do well by doing good.”

Michael Porter, the seminal business strategist, has taken the idea a step further.  He suggests that business can be good at solving social problems and in fact may be the solution for many of our most vexing social quandaries. In addition to countering the notion that businesses and societal well-being are incompatible, he makes a strong argument that businesses are actually better at solving problems and more motivated than other sectors of the economy (e.g., government).

Central to Porter’s thesis and Maine Businesses for Sustainability’s idea of “expanding the bottom line through sustainable business practices and triple bottom line values - People - Profits – Planet” is the idea of mission.  

Whether they explicitly state it or not all businesses have a mission or purpose and in the words of James Collins and Jerry Porras, “Organizations that enjoy enduring success have core values and a core purpose that remain fixed while their business strategies and practices endlessly adapt to a changing world.

“Truly great companies understand the difference between what should never change and what should be open to change, what is genuinely sacred and what is not.”¹

Last week we held our annual Crescendo “off-site” – a meeting where we look at the coming year ...

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"Covering" Winter Sports
Posted Thursday, January 30, 2014 by Scott G.

by Scott Good

There are some similarities between choosing which Olympics events to watch and selecting healthcare coverage.  The XXII Winter Olympic Games open February 7. Probably like the middle-of-the-bell-curve viewer, I will eagerly watch a few select general interest sports like ice hockey and the Nordic events and watch a few out of curiosity. Then there is the personal interest factor –I watch a few events because I have a personal – though once removed – connection:  I have a couple friends who used to compete at an Olympic level. There are even a couple for which I can say to myself, “That guy is my age! Maybe I can even try that some day.” On another note, the Winter X Games (from Aspen) just wrapped up.  I made a point to watch quite a few events – primarily because these “Young Invincibles” have convinced me that they truly defied at least three laws of physics.

The same approach applies to selecting health coverage. The Affordable Care Act is the law of the land; coverage is an important part of our lives just like the privilege / responsibility to vote, drive a car, or enter the workforce. So what compels us to get in the game of selecting an insurance plan? A “broad area of interest” (i.e., it’s just the smart thing to do), a “personal connection” (e.g., we have a pre-existing condition), our age (e.g., i.e., we are more likely to use insurance to pay medical expenses), or feeling invincible (but still recognizing ...

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Patients & the New World of Healthcare, Part 1: PCOR
Posted Thursday, August 15, 2013 by Beth A.

by Beth Austin

Today's turbulent healthcare environment has brought a great deal of scrutiny on insurers, provider/delivery systems, and the general business of healthcare. In a system poised for major change, America's healthcare consumers will have important new choices and an evolving need for education. In this first of a series of blogs, I'd like to start a conversation about the impacts the Affordable Care Act (ACA) and current industry trends will have on the role of the patient. This post focuses on patient-centered outcome research (PCOR), but other topics - such as Accountable Care Organizations (ACOs) and the Health Insurance Marketplace - will follow.

The ACA legislation established the Patient-Centered Outcomes Research Trust Fund, which is the primary funding source for the Patient Centered Outcomes Research Institute (PCORI). The mission and vision of PCORI are centered on helping people make more informed healthcare decisions that will improve desired healthcare outcomes. It's not hard to support these objectives in principle, since if successful, not only do paitents thrive, but providers, insurers, and payors also have the potential to reap indirect benefits. The organization funds research projects that are centered on key patient-centered questions::

"Given my personal characteristics, conditions and preferences, what should I expect will happen to me?"

"What are my options and what are the potential benefits and harms of those options?"

"What can I do to improve the outcomes that are most important to me?

"How can clinicians and the care delivery systems they work in help me make the best ...

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Doubling Down
Posted Monday, August 5, 2013 by Scott G.

by Scott Good

In previous blogs, I have written about Community Health Needs Assessments (CHNAs) and the challenges of meeting regulatory demands in a way that uses resources wisely – offering some methodological details and keys to success. The implementation planning mandate (and the linkage to the IRS Schedule 990H) is an opportunity to engage community leaders and reach out to address prioritized needs.

CHNAs and Implementation Plans (IPs) may meet regulatory requirements but if not conducted in order to meet the “triple aim” goals of improved population health, enhanced patient experiences, and lower costs, they are destined to fail.

By failure, I mean suboptimizing the hospital’s ability to improve community health and operate efficiently.  Let’s be honest, it’s pretty easy to meet the CHNA / IP requirements, but it is more difficult, more expensive, more time consuming, and more risky to really pursue triple aim goals.

It’s time to “double down”

This blog is called “Doubling Down” because the changing healthcare environment is compelling hospitals, health systems, payers, community groups, and people with health issues (including those working to stay healthy) to think about health and healthcare differently.  The CHNA / IP regulations move us in a positive direction. However, going that second step – toward a triple aim solution – is needed to develop a sustainable model to meet our goals of having healthier communities and lower health system costs.

The time has come to – as many hospitals have already realized – make the hard choice and invest in conducting a CHNA and developing an Implementation ...

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Human Rights Issues: Under-reported, Unseen, Unresolved
Posted Thursday, June 20, 2013 by .

by Jordan Rowe

As a society, the United States has come a long way. Many civil and human rights issues have been advanced in recent history, but in some areas, we have a long way to go.

My lack of awareness of an important human rights issue came to my attention only recently, upon my noticing an increased number of people in the Portland area who are experiencing homelessness. Homelessness is a bigger issue than I thought.

My awareness was heightened while working on a client project. A healthcare facility in New England asked us to perform a needs assessment for the homeless population in their target service area. During the research, I learned that homelessness is a majorly unrecognized and often ignored issue; but it surrounds us every day. Other than the few individuals standing on busy street corners, asking for our money and our help, we often just don't see it. The issue of homelessness is multidimensional. Many people attribute homelessness to personality defects, such as laziness, but this perspective is superficial. In the research, I learned that around 70% of the homeless community that I was assessing had been diagnosed with one or more behavioral health disorders. Treatable disorders. And the numbers are expanding.

According to Neil Donovan, executive director at the National Coalition for the Homeless, homelessness is severely underreported. Point-in-time tallies (the estimation of homeless populations based on any given day) vary dramatically from estimations taken over a period of time. Not only are there almost double the amount of ...

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Health, Personal Change and My Blockbuster Drug
Posted Monday, April 8, 2013 by Jim K.

by Jim Kupel

Health coaches or navigators are a great idea – and one that has demonstrated results.  But implicit in Scott’s recent blog is the idea of personal change.  A navigator may get to know the patient’s personal and health goals, help identify barriers (e.g., childcare, transportation, family issues, and others), and help develop a realistic plan to the overcome the barriers and achieve the goals.  But navigators can only help.  We need to do the hard work ourselves.  Patient engagement is at the center of changing the system.    

So, if I have a chronic health condition and have been marginally compliant with what I know I need to do (lose weight, use less salt, etc.) what are the characteristics and activities of the navigator that will make me more likely to follow the care plan?   

This is a very different approach for most of the health care system that has been reactive in nature.     

While Judith Hibbard and others have been saying patient activation is central to improving healthcare for years, the idea has been rekindled by the meme that “patient engagement is the block buster drug of the century.”     

Last week at Quality Counts 13, both Don Berwick and Rosemarie Gibson – in separate talks – repeated the notion from Leonard Kish’s blog last summer:

“… it’s surprising that it has taken us this long to focus on patient engagement because the results we have thus far are nothing short of astounding. If patient engagement were a drug, it would be the ...

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America's Changing Healthcare Landscape: Some Basic Points
Posted Monday, April 1, 2013 by Scott G.

by Scott Good

The landscape of healthcare in America is changing – like it or not.  There are a myriad of proscribed changes, yet many of them revolve around a few key issues. One of the issues involves the elusive tripartite goals of improving health, enhancing patient experiences, and better managing costs. 

Organizations such as the Institute for Healthcare Improvement (IHI, are implementing a number of initiatives to help organizations achieve the “triple aim” goals. 

To help focus the discussion, let’s look at diabetes care.  Over 11% of U.S. adults age 20 and older have diabetes, and 27% of seniors.  The total cost of care is approaching $200 billion annually with about two-thirds for direct care and the rest for indirect costs such as lost workdays, restricted activity, and disability due to diabetes ( Care models – like those for most other disease states – typically involve a fee for service approach. 

Projects, such as those being utilizing the IHI approach, are encouraging organizations to revise care models and take more of a population health, proactive approach. However, there are a myriad of operational and implementation challenges.  For example, one of the often used strategies is to add case managers – or “navigators” – to help higher risk patients (those using the greatest percentage of services) adhere to health regimens. Yet, there are not many established evidence-based best practices for their use – not to mention a consistent definition of their role. 

In this time of inevitable change, there is an ...

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Real Need and Redoubling Our Efforts on Healthcare Reform
Posted Monday, March 25, 2013 by Jim K.

by Jim Kupel

Our clients are some of the most dedicated professionals in the world. They believe, as do I, that by changing processes, improving quality and reducing fraud, abuse and waste that we can change the cost curve of this important segment of our economy.


There is also an important discussion starting again about engaging consumers and the use of insurance.  The idea of insurance is simple: we all pay some so that those most tragically affected are not financially ruined by a health catastrophe.  Or as in the case of the following real life story, so those in need do not need to negotiate payment in the midst of a personal health crisis.


 “I finally was able to see my daughter around 1:30AM in the wee hours of Sunday morning. She was hooked up to all the usual monitors in the ICU and had several IV's in her right arm as her picc line wasn't being used in case it was a source of infection. She looked at me and said she'd never been jabbed with so many needles so quickly, but it was necessary to get the fluids and three antibiotics into her immediately. What I didn't know at the time, was that her low blood pressure and high heart rate were symptoms of sepsis, which can be a deadly bacteria in the blood….


“I have to admit while sitting in the ICU, I also had moments of wondering how we got here again and thinking about how ...

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Greater Good
Posted Monday, February 11, 2013 by Scott G.

by Scott Good

I just saw a headline that Pope Benedict XVI is resigning. I am not Catholic but being an “armchair researcher” of the development of early religious institutions, I find his resignation particularly interesting.  The previous time that a pope resigned was about 600 years ago to help resolve the “Great Schism” between the papacy established in Rome and the one in Avignon, France. Without going into a lot of detail, I prefer to stay at about 30,000 feet. To me, regardless of any other factors, the pope who resigned in 1417 (Gregory XII), probably did so for the greater good of the church – most likely, as Benedict is also doing.

So why talk about this on a Crescendo blog? Well, it’s like this … More and more, we are seeing people do difficult things for the right reasons, and this gives me hope. We all know that the face of healthcare is changing (and probably education, soon too – but that will be in a future blog). Increasingly, physicians, payers, healthcare educators, and affiliated community groups are working together to improve patient care, enhance patient experiences, and better manage costs. These decisions to collaborate are difficult because they often threaten revenue streams or channels of power. 

So are people making decisions like these because they are serving the greater good or because they realize that if they do not do so, they may be increasingly vulnerable to future changes?  In the pope’s case, I say that it is for the greater good ...

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Getting Over It
Posted Thursday, January 31, 2013 by Beth A.


By Beth Austin

With the new year comes new possibilities, new opportunities, and, of course, a slew of New Year's resolutions on which we will make varying degrees of progress throughout the year. People are generally used to making (and breaking) personal New Year's resolutions, but for business leaders, the list should also include goals for their organizations.  One's personal and professional goals are often inter-related - and the process for successfully achieving the milestones is similar for both.

I was reminded of this once again last weekend in the midst of my efforts to make a change in my personal life. It's an important change that is long overdue and I just need to get over it already. I reflected a bit on why my particular issue had been going on so long and I realized that without conscious effort, our approach to addressing either personal or business challenges is often ineffectual. As a critical thinker who favors processes, I almost immediately got a visual in my head that looked something like this:


Cycle of a Failed New Year's Resolution




Since I'm blogging this right now, I can't gauge the reaction, but I imagine that if I shared this in a public forum it would be met with some sheepish looks and nervous laughter -  along with chorus strenuous denials (see Step 1 above).  So, how can this process improve?

Although one should always iterate, measure, and improve once a new process or behavior is put in place, it is ...

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The Healthcare “Reformation”
Posted Friday, December 7, 2012 by Scott G.

Posted by: Scott Good

The Protestant Reformation is one of the more interesting events in European history over the past thousand years - regardless of one's faith-based leanings.  I was recently put in a position where I needed to know enough about the event to lead a public forum on the topic. My talk went fine, and the information - particularly after brushing up on my history a little - was fascinating.  Having a somewhat unique perspective on large issues such as this (i.e., the bifurcation of a major institution), I recognize some of the parallels between bellwether events (such as the one which was the subject of my forum) and the structural changes in healthcare. Although I do not intend to draw any comparisons between Martin Luther of 1517 and the Affordable Care Act, I think that some observations may be appropriate.

Martin Luther was a German monk who had some life changing events and then - through some unintended consequences - was put into a position of making some very difficult decisions. In his case, it involved the cataclysmic decision of splitting off from the Catholic Church. Except for the "German monk" and "Catholic Church" parts, some participants in a recent healthcare-related focus group that I moderated had stories that paralleled Luther's tale. For them, the life changing events related to a life threatening illness with their son; the unintended consequences were related to a series of responses by the health plan and care providers.  The difficult decision was the need to sell family business (small ...

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Discipline, Gratitude and Thankfulness
Posted Tuesday, November 20, 2012 by Jim K.

posted by Jim Kupel

Strange as it seems, there is an incredible amount of thankfulness in the latest Ken Burns special on the Dust Bowl.  As I watched, I saw the essential American juxtaposition of thankfulness and discipline.  Dustbowl farmers were irate at their neighbors who didn't work hard to adopt good land management.  Simultaneously they were incredibly thankful that their neighbors and the federal government could offer assistance.

The other revelation is that gratitude can also change our body chemistry and actually help us through our present difficulties. The Harvard Mental Health letter explains that "in positive psychology research, gratitude is strongly and consistently associated with greater happiness. Gratitude helps people feel more positive emotions, relish good experiences, improve their health, deal with adversity, and build strong relationships."

My eldest daughter, while far removed from the dust bowl, has shown me a simple, but much appreciated connection between discipline and thankfulness.  She and her friends are using Facebook to share their thankfulness during this Thanksgiving season. 

It reminds me of the three-blessings exercise described in an ABC story about how thankfulness is linked to positive changes in brain and body. "One of the most well-known practices uncovered from this research is known as the Three Blessings exercise," said Renee Jain. "Each night before going to bed you write down three good things (ordinary or extraordinary) that happened to you during the day. Studies reveal those who continue this exercise for one week straight can increase their happiness and decrease depressive symptoms for up to ...

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Tell Me More
Posted Friday, October 26, 2012 by Beth A.

Posted By Beth Austin

It's "Trade Show Season." Marketers out there will need no explanation for this, but for the rest of you, the fall is a busy time for many of us due the preponderance of trade shows and conferences that happen in September and October. This season has been a busy one for the folks here at Crescendo, as we have been attending shows everywhere from Bangor, Maine, to West Palm Beach, Florida and a number of places in between. Over the last couple of months, I've had the opportunity to present at several conferences and, as always, I'm reminded of what a great learning opportunity it is. Although it seems somewhat counterintuitive, but the times when you'd think I'd really be doing all the talking is when I get some of the best listening in. The reason for this is because of the one-on-one conversation and information sharing that follows a talk. Regardless of the subject matter is, attendees will always approach me after a presentation and share their story about the topic at hand. I find this part of the job to be the most rewarding.  

These conversations provide a great opportunity to make a connection. Sometimes the information shared is no different than what we've learned from our research or what you might be able to find on the internet, but that person-to-person networking and the opportunity to "hear it from the horse's mouth" makes it all the more powerful.  

One of the topics ...

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Solving the Economic Paradox
Posted Friday, October 5, 2012 by Jim K.

posted by Jim Kupel

A recent New York Times headline read: "Economy still weak, but more feel secure." This is an apparent paradox to many. I'm not sure it is all that much of a paradox. There may be a simple answer to the question of why the economy is growing slowly and consumer confidence is increasing solidly.

Could it be that Americans have adjusted their expectations and are getting along with their lives without listening to the media doom & gloom or looking towards the government to solve all their problems?  We're looking hard for better jobs, helping our kids with their school work, and learning to enjoy life despite substantial difficulties.  

I'm sure there are larger economic changes we don't yet understand, e.g. baby boomers retiring. But there is something we do know: Americans know how to push ahead with a good attitude despite lots of difficulties. 

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10 Levers for Successfully Recruiting Physicians to Rural Areas
Posted Tuesday, September 25, 2012 by .

posted by Ron Skarka

We've all heard the statistics about physician geographic distribution away from rural areas. Yet Triple Aim achievement requires physician recruitment success. Our communities must attract care team leadership with vision, compassion, and communication skills as well as the necessary clinical diagnostic and therapeutic skills. In other words success mandates both intellectual intelligence as well as emotional intelligence. We need "value" recruiting, not just "volume" recruiting. How do we convince these superstars to join our rural communities?

Having been a healthcare executive at small community hospitals for the past 25 years, I've had to pull a few rabbits out of my hat to win the competition for physician leaders.  Here are ten "levers" that can help in this process:

  • Listen: Start by asking the physicians about their ideal practice setting and ideal location for their family (single physicians aren't usually enamored of rural areas but there are always exceptions). You might be surprised to hear the priorities. Many times I hear the following: "collegial environment, not cut-throat, personable colleagues, pleasant work environment, appreciative patients, opportunity to make a difference..." Regarding a place to live: "Balance of life, low crime, great schools, outdoor activities ...." Sounds like something we can provide in small towns.
  • Big Fish in a Small Pond: You won't be a number here. People will look up to you.
  • Educational Assets: Are your schools highly rated? A nearby college?
  • Access to Culture: You can persuade those undergoing the urban-rural transition that there is access to culture (summer theatre ...
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    Why Not Do Something that Changes the World?
    Posted Monday, September 17, 2012 by Scott G.

    Posted by Scott Good

    Sometimes it just takes someone to put "the obvious" into a simple paradigm. Doing so catches people's attention, critical momentum is gained, and lives are changed.  Life, liberty, and the pursuit of happiness" (Declaration of Independence, 1776); "Liberty, equality, brotherhood" (French Revolution, 1789); "Healthy, wealthy, and wise" (John Clarke, 1639; Ben Franklin, around 1745). 

    In 2007, the Institute for Healthcare Improvement (IHI) launched its "Triple Aim." Triple Aim is a simple paradigm that with three purposes: (1) improving population health outcomes, (2) improving the quality of patient experience, and, (3) reducing costs. This isn't rocket science - we all want to stay or get healthy, feel comfortable with the process, and save money for ourselves and the healthcare system - but that doesn't mean that it is easy either. 

    On a practical level, I compare the Triple Aim to long distance running. I am a very, very slow runner, but I can run long distance when I'm in shape. I've run five or six marathons in the past few years, and am planning to run one more in 2013 and then a seventh in Miami 2014. My problem is that I am impatient in my training. After running no more than two or three miles in nearly a year, I decided to go for a 13.6 mile run (yes ... stupid on many levels) because I really dislike the four to six weeks that it normally takes me to get up to that distance.  Did this make sense in ...

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