Flipping healthcare: an essay by Maureen Bisognano and Dan SchummersBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5852 (Published 03 October 2014) Cite this as: BMJ 2014;349:g5852
- Correspondence to: M Bisognano
- Accepted 22 September 2014
More than 25 years ago, a small group of thoughtful, committed healthcare leaders, including Don Berwick and Paul Batalden, began to meet as a group. The questions that brought them together were: Is the quality of healthcare good? Is it excellent? Could it be better? For answers, the group looked outside healthcare to other industries that were implementing innovative ways to measure and improve quality and safety. They learnt from aviation, from commercial manufacturing, and from organisations renowned for their innovation, such as Bell Laboratories, Corning, and Florida Power and Light. The lessons these leaders learnt led to a revolution in healthcare: quality and safety were no longer assumed; they were measured, reported, and improved.1
Twenty five years later quality and safety are universal priorities for healthcare executive teams, boards, and governments. But today there are new challenges. In addition to the quality and safety of the care they deliver healthcare organisations are increasingly held responsible for the overall health of the people they serve. Improving both care and health requires deeper engagement with patients and families. At the same time, the revolution in communications technology has created new opportunities for, and expectations of, a different kind of interaction with healthcare, especially among an emerging demographic of people for whom immediate communication and access to knowledge around the clock is the norm. And the burdens of an ageing population and the rise of chronic disease are stressing healthcare resources more than ever. Meeting today’s challenges requires new models of care and new ways of thinking. As ever, we need to look beyond our industry and our experiences to the paths charted by others. Notably, education has seen tremendous innovation in the past decade.
Flipping the classroom
The internet has upended the way people learn. The proliferation of massive open online courses and their adoption by venerable institutions, such as Harvard and Massachusetts Institute of Technology, herald a new future for education. Another innovation, happening more quietly, also holds tremendous promise—the “flipped classroom.”
The concept of the flipped classroom is elegantly simple. Instead of the traditional model of lectures and instruction in the classroom followed by application of the new knowledge in homework, these activities are flipped. Lectures are made available to students as videos to be watched outside of class. Class time is spent applying what was learnt at home, with teachers attending to students’ questions and challenges. The teacher’s role is commonly described as flipped from the “sage on the stage” to the “guide on the side.”2
In one example described in the New York Times last year, a high school just outside of Detroit experimented with the flipped classroom. It started with one class, but the initial results were so promising that it spread to the entire ninth grade (14-15 year olds) and then to the whole school. The results were transformative. Graduation rates rose to over 90%, graduates attending college rose from 63% to 80%, and the socioeconomic disparity in performance was reduced. The flipped model also helped teachers identify the students most in need of help but least likely to seek it—the so called silent failers.2 Healthcare is in dire need of this kind of radical, 180º change. We need to flip healthcare.
The essence of flipping healthcare, as argued by Michael Barry and Susan Edgman-Levitan, is that providers should ask, “What matters to you?” as well as, “What’s the matter?”3 This flip should inform everything we do as providers. It puts the person, not the disease or the condition, at the centre of improving health and healthcare. Flipping healthcare means flipping the balance of care from the hospital to the community; the balance of delivery from individual providers to care teams; the balance of power from the provider to the patient and family; the balance of costs from treatment to prevention and co-production; and the balance of emphasis from volume to value and from healthcare to health. Truly person centred healthcare must consider and seek to understand the entire spectrum of social and economic factors that affect a person’s health, not merely the narrow slice of how or why a patient presents at the hospital or clinic.
In March 2013 Trevor Torres, a high school student with diabetes (and son of a physician and a physical therapist), recorded a video blog. He called it, “The perks of diabetes.”4 In the video, Trevor describes how having diabetes makes him a more informed and engaged patient, as well as a healthier and more confident person. He also describes how he wants to be treated (with respect and without condescension) by his healthcare providers. In less than five minutes Trevor clearly communicates much of what matters to him. That such information would not emerge in the traditional care interaction is the problem that flipping healthcare is meant to solve.
Months after recording this video, Trevor spoke to one of us (MB) about what health means to him and what he needs from his healthcare team. Trevor defined health as having the energy to do all he needs to do. He’s in college now, and college life is stressful, hectic, and unpredictable. Being able to predict and control his health and his energy level is essential to Trevor’s wellbeing. Trevor was direct in his description of what he wants from healthcare. He wants straight answers, helpful advice, easy access, and no surprises. He likes being able to email questions to his doctor, although as a teenager he would prefer to communicate via text. (He is willing to “cut the old people some slack” until they get used to the latest technology.) Trevor’s dreams for his healthcare are to be able to create and maintain a strong bond with his doctor and care team; to express concerns or ask questions and get answers and advice; and to engage in continuous communication—all without going to the office.
Eliciting a patient’s goals, preferences, hopes, and dreams is essential if we are going to flip from treating disease to co-producing health. Trevor’s ideal points to how technology can help create a true partnership between patients and providers. There is also promising evidence that technology can be used to monitor the “5000 hours” that patients spend outside their interactions with healthcare each year, when they engage in the personal behaviours that affect their health far more than the healthcare they receive.5 Innovative organisations are expanding their use of email and the internet to facilitate connections between patients and providers, and patients are increasingly monitoring their own health through an exploding number of health related apps for mobile devices.
Another crucial way in which we need to flip healthcare is to flip the balance of care from the hospital to the community. Acute care will always be an indispensable segment of our care systems, but its share of healthcare resources is disproportionate and unsustainable. It’s in our communities that people spend most of their 5000 hours, and our communities are host to a wide array of assets that can promote health. As healthcare organisations take on responsibility for the overall health of the communities in which they reside, many will start with a comprehensive assessment of the unique health needs of those communities. This is undoubtedly important, but the unique health assets in the community should also be assessed. This approach has been used successfully outside healthcare; asset based community development recognises that communities are not built on needs but on the skills, capacities, and assets of their citizens.6
Traditional healthcare organisations (hospitals, primary care clinics, rehabilitation facilities) are crucial health assets in any community, but so are schools, places of worship, counselling services, and charitable organisations. Devoting resources to the development of these assets and engaging them in a community-wide effort to promote a culture of health is often more important than building a large new hospital or imaging clinic. Even more important is that the positive focus on assets (compared with the negative focus on needs) can help bring people together for collective action. In Memphis, Tennessee, a physician-pastor, Scott Morris, has flipped healthcare for the poorest and least healthy residents of the community. He opened the Church Health Center, where care is delivered by volunteer physicians and other clinicians and linked to the broad definition of health and wellbeing. Care at the centre begins with the question, “What’s the matter?” but goes on to include dialogue, coaching, and support for “What matters to you?” Traditional healthcare delivery is augmented by counselling services provided by the centre, as well as fitness classes and nutritional education. The results are stunning, with fewer hospital admissions, shorter lengths of stay, and reduced costs.7
Another community focused innovation that has flipped a traditional model of healthcare was started in the Netherlands by a visionary nurse named Jos de Blok. Working with community nurses in 2006, de Blok and his colleagues were dismayed that different tasks were performed by caregivers at different professional levels. This fragmentation was driven by what some managers perceived to be “efficient” and by a payment system that paid for care by the task and by the hour. So de Blok designed a new model and called it “Buurtzorg,” which is Dutch for “neighbourhood care.” He created small teams of no more than 12 nurses charged with providing home care to everyone in neighbourhoods of 10 000 people or more. The teams can function autonomously because of their consistent and frequent interactions with their defined populations. This autonomy reduces the need for hierarchy and management structures that increase overhead costs and do little to improve outcomes. The model has spread rapidly; it started with just four nurses in 2006 but now has 8000 nurses and provides more than 60% of home healthcare throughout the Netherlands. All with an administrative staff of only 45. Outcomes have improved, patient satisfaction is the highest in the nation, and staff satisfaction is high enough that Buurtzorg was national employer of the year (based on employee services) in 2011 and 2012. Costs are an average of 40% lower per client than those of other home care organisations, and the model could save an estimated €2bn (£1.5bn; $2.5bn) a year if all home care in the Netherlands was provided in this manner.8
Buurtzorg has flipped from serving the bureaucratic needs of organisations to the human needs of patients and caregivers. In doing so, it provides better care, improves health, and reduces costs, achieving the triple aims in the framework for communities developed by our institute.
In times of challenge, leaders often resort to asking their organisations to work harder, put in longer hours, or cut budgets. But we owe more to our patients and communities. We owe them innovative ways to take advantage of the social gains in the sciences of medicine and nursing, in new technologies, and in new partnerships between patients and providers. Flipping healthcare can provide the way to better care and lower costs.
Maureen Bisognano is president and chief executive of the Institute for Healthcare Improvement. She is a prominent authority on improving healthcare systems, whose expertise has been recognised by her elected membership to the Institute of Medicine, among other distinctions. The ideas and information provided in this essay are derived from the cited sources as well as personal conversations and site visits.
Dan Schummers is chief of staff at the Institute for Healthcare Improvement, and has worked with MB for 10 years.
Cite this as: BMJ 2014;349:g5852
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.