Pursuing the Triple Aim in a Higher Education Setting

Marjorie Malpiede / October 15, 2018

A learning and action collaborative

Pursuing the Triple Aim in a Higher Education Setting: A Learning and Action Collaborative
There’s something big going on in higher education. This month, eight schools will begin participating in a two-year learning and action collaborative based on improvement science and focused on “the Triple Aim” – a term well known in health care policy and delivery but not yet widely applied to the health and wellbeing of college students.

The Triple Aim is the simultaneous pursuit of three goals: best possible health outcomes; best experience of care; and lowest cost. This seemingly simple formula has been proven to improve the health of individuals and population groups around the globe, and through ways that extend far beyond traditional health care.

The Triple Aim was developed by the Institute for Healthcare Improvement, (IHI), an international organization focused on transforming health and health care. With origins in process improvement, IHI’s paradigm-shifting methodologies are not for the small-minded or those that like to stay in their lane. It is exactly this kind of “out of the box” thinking that leaders of the new collaborative hope will infiltrate higher education.

“What would it look like for an entire college or university to say we hold ourselves accountable for the health and wellbeing of students?,” said Ninon Lewis, Head of Content Portfolios for IHI, leader of the Triple Aim initiative, and advisor to the collaborative. “These are the kinds of questions we will be asking.”

Ninon acknowledges that IHI has never worked explicitly on the health of students as a population of focus until approached by New York University (NYU), the convener of the collaborative and the backbone for the Network for Improvement and Innovation in College Health (the Network), within which the effort is organized.

NYU downplays its leadership role, deferring instead to the distributed leadership model adopted by the Network. But, in many ways, NYU is the ideal leading laboratory for the Triple Aim. While the learning can be applied to any school of any size or resource capacity, NYU has a lot of infrastructure to work with. It has a large student health center in New York with a well-staffed counseling arm and specialty services like on-site optometry, physical therapy and health promotion. It provides health, health promotion, and counseling services to students at the dozen or so NYU campuses around the world.

NYU also has forward-thinking leadership in Associate Vice President of Student Healthcare, Dr. Carlo Ciotoli, and Allison Smith, the Assistant Director of Population Health. Together, they have worked on a number of initiatives aimed at creating a culture of health at the school, including a university-wide, population health framework called LiveWellNYU (nyu.edu/live-well-nyu).

Smith sees her role as both local and national.

“First is to improve the health, wellbeing and health equity of the 50,000 students at NYU;” she said, “and we also have an opportunity to catalyze change in this area for the 20 million college students in this country.”

It was Ciotoli and Smith’s work with previous collaboratives that established the Network and led to the Triple Aim. These inter-institutional initiatives, which included four collaboratives on improving depression outcomes and two on improving immunization rates, involved up to 40 schools at a time and utilized the “breakthrough series model,” also created by IHI. According to Smith, the work of the previous collaboratives brought together multiple sites focused on a common aim and provided a structure that helped the schools take evidence and apply it to their systems in sustainable ways.

“At the end, the hope is you have a breakthrough improvement, that you have radically redesigned those underlying systems that are contributing to your outcomes,” she said.

When the five-year strategic plan that created LiveWellNYU was coming to a close, Ciotoli and Smith wanted to do something even more ambitious that would also involve a consortium of schools. They were drawn to the Triple Aim for a variety of reasons, starting with the fact that it represented an open frontier, as opposed to just the application of evidenced-based practices. One of the big distinctions between IHI’s two change theories is that the breakthrough series methodology is usually around issues that have a high degree of evidence, a strong belief in what works, whereas the Triple Aim is about innovating and testing new approaches.

For NYU, the key word in Triple Aim’s simultaneous pursuit of three goals is simultaneous. “We want better outcomes, we want better conditions and service experience, and we need to begin to mitigate the rise in cost because adding more and more staff and space is not sustainable and won’t meet all of our students’ needs,” said Ciotoli who sees mental health and health disparities as key areas to explore.

Smith saw the Triple Aim and the partnership with IHI as a way to catalyze systemic change in higher education. It met her vision for putting the student at the center and working to identify all of the components in the system that are influencing student health and wellbeing. But enlisting IHI meant convincing the institute that college students were a population worthy of this kind of examination.

If Ninon Lewis had any doubts about whether this population met the criteria, she has since become a convert. Initially drawn to the fact that college students were an under-examined population in public health, Lewis was also intrigued by the opportunities for improvement in college health and healthcare given the fact there was not a significant amount of regulation in the field, particularly around quality improvement. The other dynamic that Lewis identified was the opportunity to take a more holistic view for managing the health of students beyond the traditional walls of the college health center.

“There is a whole ecosystem within an institution to think about health and wellbeing and I think currently there is a lot of trapped potential in the system.”

Addressing cost seemed to be an obvious opportunity, and not just from the standpoint of what is reflected in student insurance claims. Hidden costs related to student health, particularly emotional and behavioral health, show up in other parts of the system such as graduation rates, retention, and admissions competitiveness.

The experience dimension of the Triple Aim is something Lewis believes will be particularly interesting to study, given its interplay with the others.

“Most of the programs and services students access are controlled and driven by what the institution has put in place.” said Lewis. “That’s not the same for other populations. We have never worked with a population segment for which the experience dimension has a disproportionate effect on the other two dynamics.”

The impetus for this work, together with their confidence in NYU, convinced IHI that utilizing the Triple Aim in higher education settings held enormous promise. They hope the combined effort will produce a major shift in the mental model of student health in a way that will move the field forward.

“When this Collaborative is over,” she said. “We hope people will say ‘something happened here that changed the way things moved,’” she said.

The Journey Begins
With IHI behind them, the Network began recruiting schools earlier this year seeking a numerical sweet spot of participants. Too big a group diminishes the ability to coach through change; too small means you won’t have enough different experiences to learn from.

Recruitment materials stated the impetus for the Collaborative to be “the need to develop new paradigms and approaches for how institutions of higher education address the increasingly complex and costly health issues on our campuses that are impacting students’ wellbeing, learning, degree attainment, and overall success.”

These are themes that resonate with all campus stakeholders in all schools across the country but for the Collaborative conveners, engaging schools, in which college student wellbeing is a shared institutional value and there is a commitment to innovation and transformational change, was a priority. Getting the commitment of the Vice President of Student Affairs, or equivalent, was a requirement of the application process. If sustainable change in student health stems from an examination of all its determinants, then it must be a university-wide priority.

Ciotoli says he was delighted with the eventual mix. Starting in October 2018, the collaborative kicks off with eight partner institutions including Case Western Reserve University, Cornell University, New York University, Rochester Institute of Technology, Stanford University, Texas A&M University, University at Albany – State University of New York, and University of California - Los Angeles. The two-year commitment includes four face to face sessions, a series of web conferencing sessions, and action periods, which, in the Triple Aim world, is where the real work is accomplished.

The partner institutions’ first challenge will be learning the Triple Aim methodology and then will focus on testing the application in their own settings, exploring what works, in which settings and why. By the end of the two-year process, the goal is for each partner institution to make significant progress in building their infrastructure, capability, and capacity to lead and sustain impactful change within their own spheres of influence, ultimately transforming their institutions’ approaches to improving student health and wellbeing.