IHI Triple Aim: Women’s College Hospital

The Challenge

In Ontario, the top five percent of the population account for 65 percent of healthcare use and costs. Many of these patients have complex healthcare needs that are better met outside of Emergency Departments (EDs) and inpatient wards.

The Triple Aim approach is a proven way of better meeting their needs, and simultaneously improving patient experience of care and population health while lowering per capita costs. These patients have complex, chronic or long-term health needs, often resulting in a mis-match between patient needs and traditional healthcare services offered.

To improve care for complex and high-cost patients, the Canadian Foundation for Healthcare Improvement worked with the U.S.-based Institute for Healthcare Improvement (IHI) to support Canadian teams’ participation in its Triple Aim Improvement Community (TAIC) and Better Health and Lower Costs for Patients with Complex Needs collaboratives.

As “the hospital designed to keep people out of the hospital,” Women’s College Hospital (WCH) has a strategic focus on complex chronic conditions and health system solutions. In 2013, WCH joined the first cohort of Canadian teams in TAIC to advance these twin goals across the organization. The Triple Aim Initiative at WCH was hosted within the newlyformed Institute for Health System Solutions and Virtual Care (WIHV), a “living laboratory” tasked with developing, implementing and evaluating new models of care, in partnership with the hospital’s Quality and Safety team. WCH identified 3,203 high-needs and high-cost adults in the Toronto Central Local Health Integration Network (LHIN) and Toronto Mid-West HealthLink whose health care needs could be better addressed outside of hospital. HealthLink is an initiative that works with its LHIN, aiming to facilitate the coordination of local care providers for high-needs patients. The Toronto Mid-West Health Link region sees the fastest patient population growth, highest number of “unattached” patients and more patients from outside its geographic boundaries than any other LHIN.

The Improvement: Better care and better health at lower cost

With the help of CFHI and the TAIC, the WCH team developed three complementary improvement projects to advance the Triple Aim for a population segment of high-needs and high-cost adults whose health care needs are better met outside of EDs and inpatient wards.

Promoting Access to Team-Based Healthcare (PATH) brings high-needs patients most at risk of avoidable ED visits into primary care practice at the WCH Family Health Team.

Seamless Care Optimizing the Patient Experience (SCOPE 2) provides primary care providers with high-needs patients access to community resources and specialist care.

1-800-Imaging is a central access point for primary care providers with medically complex patients requiring urgent radiology exams and other informational services to seek radiology consultation to support appropriate referral.

The Results


Project Measures Early results
SCOPE 2 Outcome Measures
  • Health Status (population health)
  • Hospitalization rate (per capita cost)
  • Frequency of ED visits (per capita cost)
  • Patient experience surveys (patient experience)
Process Measures
  • Number of referrals, phone calls by 30 community-based providers in the first year
  • Received 247 contacts to SCOPE
  • 58 PC physicians from 21 practices have registered for SCOPE 2
  • Iterative PDSA cycles have been undertaken to improve the delivery of the model
  • Linked with other programs to improve the SCOPE 2 intervention (e.g. 1-800 imaging, Substance Use Network, Mental health)
PATH Outcome Measures
  • Preventative health screening and uptake (population health)
  • Self-rated health (population health)
  • Patient experience (surveys and patient feedback) (experience of care)
  • ED and walk-in clinic utilization (per capita cost) Process Measures
Process Measures
  • Number of complex patients rostered
  • Provider experience
  • Since February 2014, 24 previously “unattached” patients linked to a regular PC provider and support services
1-800 Imaging Outcome Measures
  • Improved timeliness of care (experience of care)
  • Critical results delivery time from report completion to findings communicated (experience of care)
  • Decreased ED admissions for reasons of urgent medical imaging (per capita cost)
  • Self-reported health (population health)
Process Measure
  • Deliver a pilot of the virtual hub that will provide service to 30-60 community-based providers with high-needs, high-cost patients within the first year of program launch
  • Developed and currently pilot testing a radiology navigation hub that serviced 186 calls in the span of 8 months
  • 87 of these calls were for urgent imaging services; of these, over 40 unnecessary ED visits were avoided


The Spread

Now entering their second year, these projects are well integrated within existing hospital programs and systems. Quality Improvement at WCH has been transformed as a result of implementing the Triple Aim and engaging in these three improvement projects. Participants in the WCH Triple Aim team gained a strong foundation in the Triple Aim methodology and population health perspective and are now applying this knowledge to ongoing and new projects across the hospital.

Team Leadership

  1. Dr. Danielle Martin, VP, Medical Affairs and Health System Solutions (Co-Executive Sponsor Team Lead)
  2. Jane Mosley, Chief Nursing Executive & Health Disciplines, Professional Affairs (Co-Executive Sponsor Team Lead)
  3. Dr. Sacha Bhatia, Director, WCH Institute for Health System Solutions and Virtual Care (WIHV) (Lead Portfolio Manager)
  4. Dr. Geetha Mukerji, Clinical Lead in Quality for WIHV, Physician, Endocrinology and General internal Medicine (Portfolio Manager with Masters Training in Quality Improvement)
  5. Kyla Pollack Behar, Health System Solutions Coordinator (Portfolio Manager)
  6. Sarah Dimmock, Director, Integrated Quality & Patient Experience, and Health Information Management (Portfolio Manager)
  7. Cheryl Woodman Director, Strategy and Performance (Measurement Team Lead)
  8. Monique Crichlow, Health Information Manager (Measurement Team Member)
  9. Laura Pus, Project Manager (Project Team Lead, SCOPE 2)
  10. Jeffrey Zon, Project Manager (Project Team Lead, 1-800-Radiology/JDMI)
  11. Holly Finn, Program Coordinator, Family Practice (Project Team Lead, PATH)
  12. Susie Kim, Project Manager, Primary Care Physician (Physician Lead, PATH)

To learn more about CFHI’s initiatives to spread the Triple Aim framework in Canada, please visit: cfhi-fcass.ca/WhatWeDo/Collaborations/triple-aim or email us at info@cfhi-fcass.ca.