The Stew BLOG

Pumps, Pipes, and Population Health: Bold Philanthropy for Systems Change

Laura Landy, President & CEO | 04/10/2017

(Part 3 of 3) — In her third and final post on “bold philanthropy,” President & CEO Laura Landy describes how the Rippel Foundation is investing in tools to help leaders take on the challenging work of system integration and redesign. Read Part 1 and Part 2 of this series. If you’re coming here without reading the previous posts in this series, we think it’s important to note, as Laura did in Part 1: “though we use the Flexner Report below as an example of impactful catalytic philanthropy, it’s not perfect—in fact it is controversial because of its disproportionate impact on medical education and opportunities for women, minorities, and ‘alternative providers.'”

In 2007, the Rippel Foundation began two years of convening a diverse group of extraordinary experts and change agents from healthcare, economics, politics, business, and energy. Their charge? To determine what it would really take to sustainably improve people’s health; assure access to quality care; and enhance equity, productivity, and community vitality. They were our pioneering “ReThinkers,” and their best ideas became the founding principles for our core initiative, ReThink Health.

One of these ReThinkers was  John Sterman, the Jay W. Forrester Professor of management and director of the MIT System Dynamics Group. In October 2009, I attended his presentation, Catalyzing Change: Systems Thinking to Transform Health Care and the Public’s Health, at the Grand Rounds series hosted by Columbia University’s Mailman School of Public Health. He said that, if we want to take significant strides toward improving the public’s health, we must break through the silos and coordinate an integrated response. System dynamics models, he asserted, can help us see how to find our way through the complexities, revealing what our brains alone cannot comprehend.

To help us understand system dynamics, and how it relates to health, John talked about pumps and pipes in manufacturing companies. Pumps, as I understand it, are among the most expensive and energy consuming elements of many manufacturing processes. They also keep the whole operation going. Good managers have two choices when investing in the “health” of their pumps. There is the option to do routine “preventive” maintenance. But this costs money–money that a manager may not want to spend if the pump is not broken. And then there is the “acute” approach of rushing in to repair the pumps once the machine breaks down. John asked us: when figuring in idle workers, stops in the manufacturing flow, labor intensive repair efforts, expensive parts, the damage to otherwise healthy pumps, and more, which might be the better strategy?

Amory Lovins, another pioneering ReThinker, had also talked about pumps and pipes at the Institute for Healthcare Improvement’s Annual National Forum on Quality Improvement in Health Care in 2007. Amory is a MacArthur Fellow and consultant physicist, and is among the world’s leading innovators in energy and its links with resources, security, development, and the environment. He is also chief scientist and chairman emeritus of the Rocky Mountain Institute, a nonprofit research and educational foundation aiming to foster efficient and sustainable use of resources. In his keynote, Amory told a story about designing pumps and pipes for greater efficiency in a building.

A key element of the design is the physics–what it takes to move air or fluid from point A to point B. Every time a pipe makes a 90-degree turn, the amount of force required of the pump goes up and efficiency goes down. But isn’t that the way almost all pipe systems are designed? To hug the walls and go around corners? So Amory designed a building using an idea that seems quite obvious: pumps and pipes would go in a straight line from A to B, no right angles. He sold the customer on the idea that efficiency would go way up, costs would go down, and the goal would be achieved. But the pipe and pump installer, new plan in hand, put the pipes along the wall–with right angles. When asked why, the answer was, “Because that’s the way we do it.”

There are many lessons in these two stories:

  •      You can’t change a system if you can’t see and understand it.
  •      There are intended and unintended consequences of actions in complex systems.
  •      Better insight about potential consequences of particular actions can lead to better decisions.
  •      Prevention is often the better but more difficult path.
  •      Even with insight, it is hard to get people to change.
  •      Money is a major driver of decisions and short-term decisions are not always the best ones.

These insights have influenced the Rippel Foundation’s focus on the ReThink Health initiative. Through research, convening, tool development, and coaching in three core domains–stewardship, strategy, and sustainable financing–we inspire and support leaders’ commitment to systems thinking and redesign. Here’s a look at some of what we do in this vein:

ReThink Health System Dynamics Model

As another founding ReThinker and winner of the 2009 Nobel Prize in Economic Science,  the late Elinor Ostrom, put it, “complexity is not the same as chaos.” Systems are sometimes necessarily complex, but how can we help leaders better understand them so they can make informed decisions about the consequences of potential decisions and investments? With our award-winning team of MIT-trained system modelers, we have created the interactive  ReThink Health System Dynamics Model of a regional health system. It shows leaders what can be achieved and clearly demonstrates that there are things they can do that would make a huge impact. The model allows leaders from different sectors–health, care, communities, business, and government–to come together and explore how various financing and investment strategies can help shape their programs and policies, and what the impact of those strategies would be on health, care, costs, equity, and productivity.

Providing a tool that helps more people to engage in systems thinking has been well worth the investment. ReThink Health has used the model with thousands of people, mostly in community meetings with multi-sector partnerships. For some communities, we customize the model, and with others, we use a version based on an “average” U.S. community of 300,000 residents. We also have used it with boards of directors, including Robert Wood Johnson Foundation’s (RWJF) board and Dartmouth-Hitchcock’s board. The latter set up a population health innovation fund after looking at alternative ROIs revealed by the model. Multiple universities use it as a component of public health, health system science, and other academic programs.

ReThink Health Ventures Project

In our  Ventures project, funded by RWJF, we are working in six carefully selected regions to support leaders in creating the conditions that allow different players with different interests to work together to transform our system for health–not just incrementally improve on the system we have now. We do this in part by using the ReThink Health Pathway, which helps regional coalitions see where they are in the system more clearly and understand the pitfalls and momentum builders before them. We also are developing tools that will help partnerships develop a real and compelling value proposition, create meaningful engagement and governance, and build new attitudes and approaches to sustainable financing.

ReThink Health Systems Mapping

We are working with multi-sector partnerships to develop system maps that deepen our collective understanding of leverage points in a system, instead of making guesses. The maps help leaders explore effective ways of intervening in the system and/or modify resource investments to achieve different outcomes. In Minnesota in 2016, ReThink Health worked with various communities as well as the state government to help them prepare a report to the legislature regarding the impact of incarceration on health. We  guided them, in real time, to create a whiteboard model that illustrated the relationship between health and incarceration for families of incarcerated people and communities. The insights and experience were profound, leading to a deeper understanding of the connection between policy, resource allocation, and health. We are now bringing this approach to a new project in Michigan to explore the relationship between health and economic development.

Rippel’s investment in ReThink Health is bringing us into stronger relationships with leaders from other key sectors in the system–corporations, philanthropy, states, communities, and more. Just like the pipes and pumps, everyone has a role to play in keeping the system working and choosing how best to deploy our time and money. Our investments are helping more leaders see this truth, and our work is increasing their willingness and capacity to explore what levers to pull to simultaneously solve multiple problems at the core of our health challenge.

But we’re not stopping there. At the Rippel Foundation, we believe that we are in a moment of revolution–akin to the scientific and industrial revolution of 100 years ago when the Carnegie and Rockefeller Foundations redefined modern medicine through commissioning and leveraging the  Flexner Report. With changing populations, unpredictable employment patterns, the impacts of technology and globalization, and more, the solutions of yesterday will not solve the problems of today and tomorrow. The time is now for philanthropy to boldly take the lead in igniting our most creative thinkers to determine our new paradigm and the system that will make it come to life. We’re only just getting started.

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