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Title V Technical Assistance Meeting

 Overcoming CoIIN Fatigue to Tackle a Core MCH Challenge

By Caroline Stampfel
Director of Programs
AMCHP

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I've been hearing from many of you about CoIIN fatigue in the maternal and child health field, and I totally get it; at AMCHP we're involved in six CoIINs right now. But there's some good news: we're finding that the Collaborative Improvement and Innovation Network approach really works when applied to the right challenge, and I'm going to tell you about how we're applying it to one of the most fundamental challenges in MCH – addressing social determinants of health (SDoH).

We're addressing SDoH through a newly-launched, 13-state collaboration to reduce infant mortality. We took on this project because addressing the social determinants of health (SDoH) is at the heart of what we aim to do in public health. As maternal and child health (MCH) professionals, we all play a role in addressing the structural and social determinants that impact the lives of women, children, and families. What is not always clear is where we start this work.

Let's begin with a definition: What does it mean to address SDoH? The technical descriptions of the social determinants include terms like socioeconomic status, material environment, segregation, structural supports, and macroeconomic factors. But quite simply, health starts where we live, learn, work, and play. That is the concept of social determinants in a nutshell.

But that makes addressing SDOH a really big goal, and it can feel impossible to take even a single step beyond the boundaries of MCH that we know so well. We started by narrowing our focus and applying the CoIIN approach to our strategies to address infant mortality. We know that some infants are at higher risk of dying in their first year of life than are others. Many of the disparities in birth outcomes, and the inequities that underlie those disparities, can be traced back to SDoH – where women, children, and families live, learn, work, and play.

AMCHP shares the goal of the U.S. Health Resources and Services Administration's Maternal and Child Health Bureau (MCHB): more first birthdays. The CoIIN model, applied to social determinants, lets us look critically at the problem and dig deeper. What are the causes of infant mortality that are rooted in the places we live, learn, work, and play? What are the opportunities for change that take us beyond our usual strategies? How can we align our work with others who might have more influence than we do over the conditions in those places?

That's what we seek to answer through our social determinants-focused IM CoIIN, a three-year, $1.5 million cooperative agreement awarded by the MCHB. To understand the CoIIN model better in the context of the social determinants, let's look at each component of the CoIIN acronym. The terms give us insight into how this model works, not just as a set of tools and resources, but as a method to move us beyond our comfortable boundaries.

Collaborative – CoIINs are all about working together at the national level and modeling this work for states, local jurisdictions, and state-local partnerships. CoIINs are true collaboratives in that they use the collective impact framework. This means we have shared goals and shared measures, not just an agreement to work together. The collective impact framework opens doors to partnerships; it creates space for us to ask, "Have we achieved true buy-in from stakeholders to the goals, the approach, and the measures?" Collaboration takes us deeper into the social determinants – our partners help us understand who we are serving because they complete the picture of where people live, learn, work and play.

Improvement – Engineer and QI guru W. Edwards Deming said, "Every system is perfectly designed to get the result that it does." It follows, then, that if we do not like the results we are getting, we have to change the system. The Improvement part of the CoIIN creates the space for us to ask, "Where do we see opportunities to change how we do things? What are the tools and levers we have to impact these areas?" Improvement strategies draw heavily on the available evidence – what worked well elsewhere that we can steal shamelessly? Improvement science allows us to do this in a systematic way. For the social determinants, we will draw on a range of tools and resources that help us understand root causes, find opportunities to make changes, and understand our stakeholders better by taking a walk in their shoes.

Innovation – This component of the CoIIN model draws on new ideas and proposes new applications of existing ideas. Incorporating innovation in addition to improvement allows us to test theories, to try (and possibly fail) on a small scale, and identify successes that can be scaled up. As with the strategies we use in improvement work, we need to put in place a series of measures to understand how we will know if a change moves us toward improvement.

Network – The network component a defining feature of what makes CoIIN work different from what we were doing before. The CoIIN operates under the premise that working in isolation is working harder, and working as a network is working smarter. Participants in the network maximize the power of the collaboration by seamlessly sharing successes and challenges to allow us to make gains faster. Participants can look to peers to learn about what makes a change sustainable so that gains made in the CoIIN process are maintained.

AMCHP's new CoIIN on the social determinants has as its shared aim "to create systems change through developing, adopting, or improving at least two policies or practices at the state or local level which will directly impact SDoH affecting women and men of childbearing age". We are drawing on the previous SDoH Learning Network as well as the wealth of knowledge that the state teams bring and the expertise of the steering committee. I look forward to sharing our progress with you as we work together to improve the lives of infants, mothers, and families and celebrate more first birthdays.

"We seek to transform public health practice via our shared vision, which will advance fairness and increase access to quality health care for all by acknowledging historic patterns of institutional bias and discrimination which continue to negatively impact the health of marginalized communities. 

The foundation of our approach includes the social and environmental determinants of health. Our aim is anchored in systems change. It is our goal that this aim will increase opportunities for innovation at the state and community-level, including partnerships within jurisdictions as well as other sectors to collaboratively reduce health inequities." - AMCHP's SDoH CoIIN Project