Blog Post #1—the IHI Summit on Improving Patient Care

Lesson 1

Essential assets for population health programs include:

  • community partnerships (with good governance to manage roles and responsibilities)
  • champions
  • data
  • research

Don’t take relationships for granted or forget to track outcomes and improvements!

Lesson 2

The Southcentral Foundation (Alaska) Nuka System is a relationship-based, customer-owned approach to transforming health care, improving outcomes, and reducing costs. Some gems from presenter April Kyle:

  • ‘Do the right thing, figure out how to pay for the right thing—build the canoe you need first.’
  • You can’t proceduralise relationships.

Other participants drew attention to the SCF Nuka wellness care planning approach for high needs users.

Lesson 3

Presentation of a Population health framework with equity at the centre with four portfolios:

  • physical and mental health
  • social and spiritual well-being
  • community health and wellbeing,
  • communities of solutions.


Investing in the health of communities must go beyond community engagement to governance, investing in a local workforce, addressing institutional racism, and working in genuine partnership with other community organisations

Lesson 4

The Oregon experience of ‘Transitioning to Value-based Care through system-level, evidence based guidelines’ was presented. A strong correlation to HealthPathways in New Zealand and Australia was noted.

Lesson 5

For healthcare change agents, the utility of a tool for helping to set goals for a balanced portfolio of population health was noted. Check it out at!

Lesson 6

The American Academy for Ambulatory Care Nursing presented on training for primary care registered nurses to increase skills for care coordination and transitions of care. ‘Making a difference for the patient’ was the assessment, ‘solving the fragmented puzzle’ the process! More here.

Lesson 7

Helping to improve care and reducing burnout by sharing the load was presented by Bellin Health. A video showing team coordinators working with doctors to achieve this is available here.

Lesson 8

The group heard from Hopkins Medicine’s Jennifer Bailey on the role Lean Training in Primary Care performance improvement plans. This aligns with work AHHa is leading with PHNs.

Lesson 9

‘San Diego has been wonderful opportunity to meet primary doctors and nurses interested in better care, teams and patient-centred medical homes improvement’—Chris Bollen, BMP Consulting

Lesson 10

Dr America Bracho (Executive Director of Latino Health Access, a centre for health promotion and disease prevention in Santa Ana) challenges IHI Summit particpants: What is the role of professionals in the health equity agenda?

More from Dr Bracho:

  • ‘Equity 101 for hospitals and health services: patient-family as part of team; schedules that support participation; space for priorities and points of view; language and jargon; and ways of communication.’
  • ‘The anatomy of successes will tell you more than the anatomy of failures.’
  • ‘If we want people to age in the community, we need to invest in communities: a US perspective relevant also for Australia.’