1. Gould, Kathleen Ahern PhD, RN

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William Osler wrote, "Medicine is a science of uncertainty and an art of probability."1 Perhaps one may say the same about baseball.


As I write this month's editorial, the Chicago Cubs baseball team is celebrating their Worlds Series Win-something that had eluded them for 108 years. I stayed awake to watch this improbable achievement, remembering how I felt only a few years ago, in 2004, when my beloved Boston Red Sox accomplished the same feat-breaking an 86-year-old curse. Many things felt similar, as I realized that the Cubs have achieved the Triple Aim of baseball. The best players, the best team, at lower cost. It sounds like the Triple Aim goals for health care improvement.


The similarities began with some familiar faces, especially Theo Epstein, a baseball executive currently serving as the president of baseball operations for the Chicago Cubs. He was also the architect that remodeled the Boston Red Sox and guided them to a 2004 World Series Championship. Could the recipe for ending 86- and 108-year loosing streaks lie within the leadership framework of the Triple Aim?


Achieving the Triple Aim is not easy; in health care, it requires organizations to understand their past and current performance. This focus allows leadership teams to develop a plan toward improvement based on 3 guiding principles: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.2,3


The Triple Aim is a term coined by the Institute for Healthcare Improvement (IHI) leaders. Dr Donald Berwick defined the Triple Aim as a framework for optimizing health system performance. There are 3 components to the Triple Aim: (1) improve the experience of care for individuals, (2) improve the health of populations, and (3) reduce the per-capita costs of health care. Berwick and a group of visionary individuals were committed to redesigning health care into a system without errors, waste, delay, and unsustainable costs. Leaders at IHI realized that both individual and societal changes were needed.3,4 This vision would not be easy, but clearly a shake-up was needed in health care.


It seems that Theo Epstein and his leadership team understood this concept, confirming the premise that perhaps baseball and medicine are not so different. Christopher J. Phillips, PhD, Jeremy A. Greene, MD, PhD, and Scott H. Podolsky described this connection in a 2012 article entitled Moneyball and Medicine. As the New England Journal of Medicine celebrated their 200th anniversary they paused to recognize the 100-year anniversary of Fenway Park, home to my Boston Red Sox.


Phillips and colleagues wrote:


"Baseball analogies and metaphors have been used in discussing surgical practice (1938), pharmaceutical regulation (1961), racial integration in the medical profession (1969), the increasing intensity of hospital complexity and throughput (1982), and even the occasional inability of metaphor itself to capture our anxieties and concerns (2008). Lou Gehrig disease and Tommy John surgery have demonstrated the power of celebrity patients to draw attention to particular syndromes and procedures. And direct epidemiologic correlations between baseball and health were noted as early as 1908, when the Journal's editors pointed to reports that New York's increased rate of death from cardiovascular causes was due to 'the extraordinary excitement prevailing in that city in connection with the baseball situation' (most certainly referring to the epic late-season rivalry between the Chicago Cubs and the New York Giants, rather than the last-place finish of the lowly New York Highlanders-later renamed the Yankees [1908])."5


The New England Journal of Medicine article referred to Michael Lewis's 2003 best-selling book, Moneyball, and describes how evidence-based baseball uses metrics to access the performance or prediction of value to overall team performance and discuses correlations between medicine and baseball as both strive to use evidence in practice.


Moneyball tells the story of Oakland Athletics general manager Billy Beane who used this method. However, Phillips et al describes a "kinship" between the Moneyball theory and medicine as he writes:


"Evidence-based baseball was pioneered by Bill James, who in the 1970s insisted on placing the evaluation of players on sounder analytic ground, focusing on measurable outcomes over the traditional aesthetics of the '5-tool' player (who appears to excel at each of the game's 5 key skills). The inhabitants of Fenway Park eventually came to embody the Moneyball ethos themselves when the Red Sox hired James as a part-time consultant in 2002."5


It is no coincidence that in 2002 Theo Epstein was in Boston building a new Red Sox team. Remarkably, only a short distance away-across the Charles River in Cambridge, Massachusetts-leaders at IHI were focused on teaching evidence-based medicine, at the level of individual interventions, to guide hospital outcomes at lower costs. Both groups understood that they needed strong analytics to continuously measure performance. They also knew that they must have the ability to inspire and motivate people.


The language of metrics and performance-based value brought new meaning to both discussions.


Kathleen Kimmel and Jeremy Smith support this view and conclude that analytics can help us achieve the Triple Aim and remark how both baseball and health care have been transformed by our understanding of numbers.2,6 They reinforce the true relevance of Moneyball to medicine, as quantification of performance can lead to the appreciation of value. Analytics can inform performance in health care and sports and-specifically-help to achieve the Triple Aim.


"In both medicine and baseball, advocates of evidence-based approaches argued for the enhanced vision of statistical techniques, which revealed what tradition or habit had obscured. The difference between an all-star and an average hitter, for example, works out to about one hit every other week, a distinction that's almost impossible for even a trained scout to recognize. Statistical power can be as relevant as opposite-field hitting power in the assessment of players. Early proponents of controlled medical trials similarly pointed to how difficult it was for an individual practitioner to determine a treatment's efficacy or distinguish real effects from apparent ones after seeing only a small number of clinical cases. Mathematical measurements and calculations were meant to push practitioners away from naive visual biases-a player who "looks right" or a therapy that seems to work. Walks are far more important than they first appear in baseball; walking is more important than it first appears in medicine."6


Theo Epstein's place as one of the greatest executives in baseball history is ensured. He will be remembered for bringing the Boston Red Sox and the Chicago Cubs out of a drought lasting 86 and 108 years, respectively. There may be more lessons baseball can share with health care leaders.


Alex Speier7 interviewed many people during the 2016 World Series to find out what traits defined Theo Epstein as a leader. Perhaps we can embrace these traits and bring them to our work each day.


Intelligence and curiosity:


Ben Cherington, who also held Theo's old job in Boston, but is now with another team, says that Epstein has "intellectual gifts that allow him to see through complicated issues more quickly than most but also make adjustments more quickly than most."


In addition, he remarks about Theo's intuitive sense for people and a sense of humor that allows others to see him as human despite those intellectual gifts.


"He creates a sense of humility and engendering trust and loyalty from those who work with him and deflects credit to his coworkers in a way that builds a team-first ethos."7


Small sacrifices:


"Little things may make a difference between a good and a great organization; often, it is the things that go unnoticed, like driving the extra mile to get a last look at a player, or showing up early to do work with a minor leaguer to help him work on his weakness. Or, it may be a research and development guy pulling an all-nighter to see an idea through, or simply the coaches, players, and managers all working together."7


Clarity of vision:


"Supporting a long view for years by building on the talent at hand. With the Cubs, Epstein made clear that there were no shortcuts and that sustained success would come only with a rebuild from the ground up."7


Boldness and creativity:


"Good leaders like Epstein are not afraid of altering a status quo that isn't working,"7 proving that it may be necessary to rock the boat and shake things up if it is best for the organization.


Attention to detail:


"When Epstein took over the Cubs after the 2011 season, he conducted a series of all-day organizational forums on specific areas-one on pitching, one on offensive philosophy, one on base running-that involved front-office members, player development staff, and scouts. One session included an animated debate about whether players should make their base running turns by hitting the bag with their right or left foot. After a discussion that included coaches running the bases to test the theories, the Cubs defined their process: They would be a right-footed organization when turning the bases. Kris Bryant's flawless right-footed turns contributed to a pair of key runs in the Cubs' game 7 win. The willingness to oversee a lively debate on such a detail-the significance of which might have been hard to see at the time-s a hallmark of how Epstein operates."7




"Epstein's own work ethic, competitiveness, and passion inspired all around him, never taking success for granted."7 He loves what he does and does what he loves.


Empowerment and delegation:


"Epstein engaged interns and staff and made them feel like part of the established staff. He encourages brainstorms and creative ideas and creates idea factories. He drives his employees to work hard and entrusts responsibilities to others, encouraging them to grow personally and professionally."7


The results proved to be well aligned with health care goals: better individual performance, a better team for Chicago, with cost-effective management, the Triple Aim framework at work. It appears that the leadership teams in baseball and at the Institute for Healthcare Improvement have a common vision - a great model for all of us!




1. Bean RB, Bean WB eds. Sir William Osler: Aphorisms From His Bedside Teachings and Writings. New York: H. Schuman; 1950. [Context Link]


2. Smith JN. When 'Moneyball' meets medicine. UpShot. New York Times. Accessed October 30, 2016. [Context Link]


3. Whittington K, Nolan K, Ninon L, Torres T. The Milbank Quarterly pursuing the Triple Aim: the first 7 years. 2015;93(2):263-300. Accessed October 25, 2016. [Context Link]


4. Institute for Healthcare Improvement. History. 2016. Accessed November 2, 2016. [Context Link]


5. Phillips CJ, Greene JA, Podolsky SH. Moneyball and medicine. N Engl J Med. 2012; 367:1581-1583. [Context Link]


6. Kimmel K. How analytics will help you achieve the Triple Aim. Health Catalyst. 2016. Accessed November 2, 2016. [Context Link]


7. Speier A. What are the secrets to Theo Epstein's success? Boston Globe. 2016. Accessed November 3, 2016. [Context Link]