Editorial Lessons From the 2016 World Series: Moneyball and MedicineVBaseball and Health Care Leadership Teams Achieve the Triple Aim William Osler wrote, ‘‘Medicine is a science of uncer- redesigning health care into a system without errors, waste, tainty and an art of probability.’’1 Perhaps one may say delay, and unsustainable costs. Leaders at IHI realized that the same about baseball. both individual and societal changes were needed.3,4 This As I write this month’s editorial, the Chicago Cubs base- vision would not be easy, but clearly a shake-up was ball team is celebrating their Worlds Series WinVsomething needed in health care. that had eluded them for 108 years. I stayed awake to watch It seems that Theo Epstein and his leadership team this improbable achievement, remembering how I felt understood this concept, confirming the premise that only a few years ago, in 2004, when my beloved Boston perhaps baseball and medicine are not so different. Red Sox accomplished the same featVbreaking an 86- Christopher J. Phillips, PhD, Jeremy A. Greene, MD, PhD, year-old curse. Many things felt similar, as I realized and Scott H. Podolsky described this connection in a 2012 that the Cubs have achieved the Triple Aim of baseball. article entitled Moneyball and Medicine.AstheNew England The best players, the best team, at lower cost. It sounds Journal of Medicine celebrated their 200th anniversary like the Triple Aim goals for health care improvement. they paused to recognize the 100-year anniversary of The similarities began with some familiar faces, es- Fenway Park, home to my Boston Red Sox. pecially Theo Epstein, a baseball executive currently serv- ing as the president of baseball operations for the Chicago Phillips and colleagues wrote: Cubs. He was also the architect that remodeled the ‘‘Baseball analogies and metaphors have been used in discussing surgical practice (1938), pharmaceutical Boston Red Sox and guided them to a 2004 World Series regulation (1961), racial integration in the medical Championship. Could the recipe for ending 86- and 108- profession (1969), the increasing intensity of hospital year loosing streaks lie within the leadership framework of complexity and throughput (1982), and even the the Triple Aim? occasional inability of metaphor itself to capture our Achieving the Triple Aim is not easy; in health care, it anxieties and concerns (2008). Lou Gehrig disease and Tommy John surgery have demonstrated the power requires organizations to understand their past and of celebrity patients to draw attention to particular current performance. This focus allows leadership teams syndromes and procedures. And direct epidemiologic to develop a plan toward improvement based on 3 guiding correlations between baseball and health were noted principles: creating the right foundation for population as early as 1908, when the Journal’s editors pointed to management, managing services at scale for the popula- reports that New York’s increased rate of death from cardiovascular causes was due to ‘the extraordinary tion, and establishing a learning system to drive and 2,3 excitement prevailing in that city in connection with the sustain the work over time. baseball situation’ (most certainly referring to the epic The Triple Aim is a term coined by the Institute for late-season rivalry between the Chicago Cubs and the Healthcare Improvement (IHI) leaders. Dr Donald Berwick New York Giants, rather than the last-place finish of the V defined the Triple Aim as a framework for optimizing lowly New York Highlanders later renamed the Yankees [1908]).’’5 health system performance. There are 3 components to the Triple Aim: (1) improve the experience of care for The New England Journal of Medicine article referred individuals, (2) improve the health of populations, and (3) to Michael Lewis’s 2003 best-selling book, Moneyball,and reduce the per-capita costs of health care. Berwick and describes how evidence-based baseball uses metrics to access a group of visionary individuals were committed to the performance or prediction of value to overall team DOI: 10.1097/DCC.0000000000000238 March/April 2017 75 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Editorial performance and discuses correlations between medicine bringing the Boston Red Sox and the Chicago Cubs out of a and baseball as both strive to use evidence in practice. drought lasting 86 and 108 years, respectively. There may be Moneyball tells the story of Oakland Athletics general more lessons baseball can share with health care leaders. manager Billy Beane who used this method. However, Alex Speier7 interviewed many people during the Phillips et al describes a ‘‘kinship’’ between the Moneyball 2016 World Series to find out what traits defined Theo theory and medicine as he writes: Epstein as a leader. Perhaps we can embrace these traits ‘‘Evidence-based baseball was pioneered by Bill James, and bring them to our work each day. who in the 1970s insisted on placing the evaluation Intelligence and curiosity: of players on sounder analytic ground, focusing on measurable outcomes over the traditional aesthetics of Ben Cherington, who also held Theo’s old job in Boston, the ‘5-tool’ player (who appears to excel at each of but is now with another team, says that Epstein has ‘‘intel- the game’s 5 key skills). The inhabitants of Fenway Park lectual gifts that allow him to see through complicated eventually came to embody the Moneyball ethos issues more quickly than most but also make adjustments themselves when the Red Sox hired James as a part-time consultant in 2002.’’5 more quickly than most.’’ In addition, he remarks about Theo’s intuitive sense It is no coincidence that in 2002 Theo Epstein was in for people and a sense of humor that allows others to see Boston building a new Red Sox team. Remarkably, only a him as human despite those intellectual gifts. short distance awayVacross the Charles River in Cam- ‘‘He creates a sense of humility and engendering trust bridge, MassachusettsVleaders at IHI were focused on and loyalty from those who work with him and deflects credit to his coworkers in a way that builds a team-first teaching evidence-based medicine, at the level of individual ethos.’’7 interventions, to guide hospital outcomes at lower costs. Both groups understood that they needed strong analytics Small sacrifices: ‘‘Little things may make a difference between a good to continuously measure performance. They also knew that and a great organization; often, it is the things that go they must have the ability to inspire and motivate people. unnoticed, like driving the extra mile to get a last look at The language of metrics and performance-based value a player, or showing up early to do work with a minor brought new meaning to both discussions. leaguer to help him work on his weakness. Or, it may be Kathleen Kimmel and Jeremy Smith support this view a research and development guy pulling an all-nighter to see an idea through, or simply the coaches, players, and and conclude that analytics can help us achieve the Triple managers all working together.’’7 Aim and remark how both baseball and health care have been transformed by our understanding of numbers.2,6 Clarity of vision: ‘‘Supporting a long view for years by building on the They reinforce the true relevance of Moneyball to medi- talent at hand. With the Cubs, Epstein made clear that cine, as quantification of performance can lead to the there were no shortcuts and that sustained success appreciation of value. Analytics can inform performance would come only with a rebuild from the ground up.’’7 in health care and sports andVspecificallyVhelp to achieve Boldness and creativity: theTripleAim. ‘‘Good leaders like Epstein are not afraid of altering a ‘‘In both medicine and baseball, advocates of status quo that isn’t working,’’7 proving that it may be evidence-based approaches argued for the enhanced necessary to rock the boat and shake things up if it is vision of statistical techniques, which revealed what best for the organization. tradition or habit had obscured. The difference between an all-star and an average hitter, for example, works out Attention to detail: to about one hit every other week, a distinction that’s ‘‘When Epstein took over the Cubs after the 2011 almost impossible for even a trained scout to recognize. season, he conducted a series of all-day organizational Statistical power can be as relevant as opposite-field forums on specific areasVone on pitching, one on hitting power in the assessment of players. Early offensive philosophy, one on base runningVthat in- proponents of controlled medical trials similarly pointed volved front-office members, player development staff, to how difficult it was for an individual practitioner to and scouts. One session included an animated debate determine a treatment’s efficacy or distinguish real about whether players should make their base running effects from apparent ones after seeing only a small turns by hitting the bag with their right or left foot. number of clinical cases. Mathematical measurements After a discussion that included coaches running the and calculations were meant to push practitioners away bases to test the theories, the Cubs defined their process: V from naive visual biases a player who ‘‘looks right’’ They would be a right-footed organization when or a therapy that seems to work. Walks are far more turning the bases. Kris Bryant’s flawless right-footed important than they first appear in baseball; walking is 6 turns contributed to a pair of key runs in the Cubs’ more important than it first appears in medicine.’’ game 7 win. The willingness to oversee a lively debate on such a detailVthe significance of which might have Theo Epstein’s place as one of the greatest executives been hard to see at the timeVs a hallmark of how in baseball history is ensured.