Thoughts on Progress, Doing and Being a Nuisance
A farewell message by Susie Dade, Deputy Director, Washington Health Alliance
I have spent about 15 years and more than 30,000 hours in service to the Washington Health Alliance. This has been my second home since arriving on the Alliance’s doorstep, and a very good home it has been. I have found the Alliance to be a place that is defined by mission, purpose, innovation, and commitment. I sincerely thank Dr. Hugh Straley for originally recruiting me, and Margaret Stanley and Lance Heineccius for ultimately inviting me to join the team. This has been the job of a lifetime and it has been my great honor to serve.
The Alliance’s aim: to improve health and health care in Washington state by working together instead of in separate silos, and by generating and using credible information to drive collective action.
Easy to say, but hard to do.
I suppose it’s not surprising that over the years, there have been a few dark and dreary Seattle days when I have gotten stuck, wondering what we are accomplishing. After all, we are trying to change and improve a very complex industry, a quagmire really. But when I pause and reflect, I see clearly the distance we’ve traveled together at the Alliance. Please, take a few moments and join me in a brief retrospective and thoughts for the future.
When the Alliance was incorporated in late 2004, there was nothing like us in Washington (or in most of the country for that matter). For those of us trying to improve health care in our state, there were precious few opportunities for critical conversation comprised of leaders working across stakeholder groups. There was no all payer claims database or any other data source that was broadly used for health care measurement and public reporting. There was little agreement about whether or how to measure the performance of health care, and certainly no Statewide Common Measure Set. There was no transparency about how well the health care system was performing; in fact, as I recall, there was a whole heap of opacity and many (most?) of the wagons would circle when the idea of transparency was contemplated. The term “value” was one used in other industries, but never in health care. If one used the words “waste” and “health care” in the same sentence, they were at risk of being publicly flogged. Affordability was someone else’s problem. Medicalization was front and center, while social determinants of health were a fringe concept. That was then.
A landmark Institute of Medicine report, Crossing the Quality Chasm, had come out in 2001 concluding, “Health care harms too frequently and routinely fails to deliver its potential benefits . . . between the health care we have and the care we could have lies not just a gap, but a chasm.” Here in Washington, this was not only a clear affirmation of what purchasers and patients were experiencing, but a strong call to action as well.
Forward-thinking community leaders came together to launch the Alliance under the leadership of then King County Executive Ron Sims: good folks like Hugh Straley, Ed Wagner, Dorothy Teeter, Greg Marchand, Dan Lessler, Mike Cochran, Steve Hill, and Lloyd David . . . just to name a few.
In the very early days at the Alliance, as we were taking our first steps, there was a foundational belief that if we just focused on health care quality – really made headway on quality – affordability would follow. So, clinical improvement teams (remember the CITs?) were formed to draw together state and national subject matter experts on prevention, asthma, diabetes, heart disease, depression and other high priority topics to formulate a solid, evidence-based footing for the Alliance. This was good work that helped draw us together.
In 2006, we became one of the first pilot sites for the Robert Wood Johnson Foundation’s largest national philanthropic effort, Aligning Forces for Quality, an initiative that would continue for nine years. Through this work, the Alliance built important relationships with dozens of sister organizations across the country, all striving to engage different stakeholders, build transparency and momentum, and make a difference . . . like us. We became part of a national network that has persisted to this day.
In 2006, the Alliance also began building an all payer claims data base, with voluntary submissions of insurance claims data. Although a few may have needed an extra nudge, health plans, employers and union trusts volunteered to share their data because they trusted us to protect it and use it wisely. They had a seat at the Alliance table to help set a course for measurement and transparency in our state. And with this, the state’s first all payer claims database was established by 2007.
The very first Community Checkup published by the Alliance in January 2008 included just 14 volunteer medical groups in the five-county Puget Sound area; these were early and brave pioneers (remember the circled wagons?). This first public report included only 15 quality measures based on Alliance-aggregated data from about a dozen data suppliers that covered about 1.6 million commercially insured lives. But this was absolutely groundbreaking, not just in our state, but nationally! The Alliance was among the first to publicly report quality results for medical groups. We broke through a number of significant barriers to get this done as the country watched.
Fast forward a year or two . . . we had come to understand that an exclusive focus on quality would not be nearly enough to impact the total health care value equation. So, one after another, the Alliance pushed the envelope and launched additional areas of measurement and reporting: (1) disparities in health care; (2) patient experience (Your Voice Matters); (3) health plan performance (eValue8™); (4) geographic variation in utilization (Different Regions, Different Care); (5) Choosing Wisely; (6) inpatient quality, experience and price in a single report (Hospital Value Report); (7) unwarranted differences in pricing of health services; (8) key drivers behind spending trends; and, (9) waste in health care (yup, I said it, no flogging), featuring our nationally recognized First, Do No Harm report series.
Today, the Alliance’s still-voluntary all payer claims database includes three dozen data submitters, with data going back more than a decade including approximately 1.8 billion records. And because of the trust that the Alliance has earned, the database continues to grow, with more self-funded purchasers and health plans wanting to voluntarily contribute their data.
Today, the Alliance’s Community Checkup, an interactive public-facing website powered by Tableau, includes over 110 measures with results for 39 counties, nine accountable communities of health, 16 commercial and Medicaid health plans and more than 2,000 clinics, medical groups and hospitals across Washington state. The Alliance has earned a well-deserved state and national reputation for trusted reporting on variation in quality, efficiency, pricing, low-value care, and experience.
I could go on and regale you with stories and examples of the work of the Alliance over my years here. Along with my colleagues, I have lived them all and am proud of what we have built and accomplished. Have we done everything perfectly? No, of course not. But we have done it with heart, integrity and good intentions, and we’ve learned along the way.
Upon reflection, when all is said and done, here are the most important questions for me:
Are we making a difference? And, is it enough?
My answer to the first question, are we making a difference, is YES, EMPHATICALLY YES!
Think about where we would be in our state without the foundational and ongoing work of the Washington Health Alliance. It’s been my observation that we too often take this for granted because the Alliance has become part of our state’s landscape. Creating and maintaining trust, successfully convening disparate stakeholders, accessing and aggregating data, reliably measuring performance and making results public, forging new and controversial topics – this has all been a remarkable undertaking that rests squarely on the shoulders of the Alliance’s member organizations and very talented and committed staff. All are absolutely foundational to improving health care value in our state; it would be difficult to move forward without them. So, yes, we are making a difference –we should acknowledge and celebrate that! The accomplishment belongs to all of us.
My answer to the second question, is it enough, is OH HELL NO!
The German writer Goethe said, “Knowing is not enough; we must apply. Willing is not enough, we must do.”
Words to live by at the Alliance.
There can be no doubt that we have collectively come a long way in achieving our initial aim. But looking forward, to make significant and lasting improvements in this quagmire of health care, bold action is essential by everyone. It takes courage to acknowledge that you own part of the problems in health care. But without action, the acknowledgement is a hollow gesture.
We must all DO.
Those who have worked with me, know the passion I have for this work . . . to the point of being a nuisance at times (oh, believe me, I know). But in my book, it’s not only okay, but essential to be a nuisance when it counts. And in health care, it counts.
The Alliance represents something very special. As a collaborative, the Alliance both creates and responds to momentum for change. We are a catalyst, giving voice to the unflinching need to battle complacency and challenge the status quo in health care.
The Alliance is driven by people and relationships. But much more than that, it’s driven by an IDEA. It’s the idea that we are stronger together than apart. It’s the idea that health care, as complex and as flawed as it is, can only be improved by working together through collaboration. It’s the idea that, to improve the health care system, everyone may have to give up some – maybe a lot – to get more. As I take my leave, I encourage you to remember the idea. Stay true to the idea. People will come and go. Relationships will ebb and flow. The flavor-of-the-day issues and acronyms will change. But ten years from now, or twenty, the idea will persist. If you nurture it, it can change the world.
I extend a very heartfelt thanks to all of you: my current and past staff colleagues, as well as all of the clinician and business leaders on the Alliance Board, Quality Improvement Committee, Purchaser Affinity Group, Health Economics Committee and the Bree Collaborative – the groups with whom I have worked most closely over the years. You know who you are and I couldn’t have asked for a better crew with whom to share this journey.
My hope is that all of you will get and stay fired up. We have much to be proud of in our health care system in Washington. We have some of the finest and most innovative health care providers in the country.
But we can and must do much better in our state: quality, appropriateness, affordability, access to care, patient experience . . . all of it.
Be a nuisance. Be loud. Be bold. And do!
During these last several weeks at the Alliance, the effects of COVID-19 robbed me of opportunities to see many of you before I left. In the greater scheme of things, I would place this at the very low end of negative effects of this awful virus. But it has been personally sad for me nonetheless. So consider this a virtual handshake or a great big hug, whichever you’re most comfortable with. And if you want to reach me, here’s my personal email address: email@example.com.
I’m not going far . . . see you around!