The population health journey: A change framework and lessons learned in a large clinically integrated network
Abstract
Traditional change models, while valuable, often lack the structure and flexibility needed to address the complexities of today’s healthcare environment. The adoption of population health requires a coordinated, systematic approach with executive leadership sponsorship and a well-articulated change management strategy. The Ambulatory Quality Improvement Collaborative (AQIC) is a framework to drive populationlevel change to meet quality initiatives, including accountable care organisation (ACO) all-payer reporting models. The framework’s design includes an oversight committee of executive leaders utilising a unified change management strategy supported by an experienced project management team. The AQIC model emphasises a multidisciplinary, collaborative approach, bringing together stakeholders from across the healthcare system to drive system-wide quality improvement. The framework’s structure is detailed, outlining its important workstreams and their roles in driving change. Using case studies focused on hypertension control and depression screening, the effectiveness of the AQIC model in translating system-wide goals into tangible clinical improvements is demonstrated. This work highlights the critical role of data aggregation, performance management and health equity considerations in driving successful change initiatives. By leveraging data to identify disparities and track progress, the AQIC model enables targeted interventions and promotes equitable care delivery. The importance of continuous improvement and the AQIC model’s adaptability in addressing evolving healthcare challenges are emphasised.
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Author's Biography
Nancy Beran Nancy R. Beran, MD, MHCDS, FACP, CPE, is an innovative leader and the Vice President and Chief Quality Officer for Ambulatory at Northwell Health. As Ambulatory, Dr Beran develops and implements programmes and projects to improve efficiency and achieve ambulatory quality improvements. She serves as the Quality Director for Northwell Health Accountable Care Organisation (ACO). Currently, she is designing the system-wide approach to important population health measures, focusing on hypertension, diabetes and depression screening and management. Dr Beran works collaboratively to address patient access, diversity, equity and inclusion. As a transformational leader, she has built ambulatory group practices, extensive quality reporting and improvement initiatives, and transition of care and case management programmes. Dr Beran has completed the Executive Leadership Development Program (Northwell/Cornell), the Physician Academy, Physician Leadership Program; has a master’s in Health Care Delivery Science, from Dartmouth College; and is currently participating in the Northwell/Intermountain Crossroads Leadership Exchange.
Ramsey Abdallah , DHA, MBA, FACHE, PMP, CMQ/OE, CPHQ, CPPS, FACHDM, is the Associate Vice President for Process Improvement for the Northwell Health ambulatory network overseeing reporting for the ACO and system-level implementation projects. He has experience in programme development, performance improvement, project management and data analytics and held numerous roles in implementing large-scale population health programmes in clinically integrated health systems. Ramsey is the project leader for the system transformation project aimed at improving ACO measures and clinical outcomes. He is also leading the health system’s ambulatory eCQM implementation programme. He is a leader of the Mentorship and Professionalism in Training programme for early and mid-careerists at Northwell Health, a member of the National Association for Healthcare Quality (NAHQ) Item Writer’s Workgroup, and the Co-Chair for the Programs Committee for the local NY ACHE chapter, Healthcare Leaders of New York. Ramsey holds a Doctor of Health Administration degree in healthcare leadership and an Executive Master in Business Administration degree in healthcare administration.
Lora Giacomoni , RN, MSN, F-AB, is the Vice President of Quality & Performance Improvement for Northwell’s large ambulatory footprint. Lora has vast experience in quality administration at several healthcare organisations. Her diverse background in healthcare includes Quality, Regulatory and Accreditation, Lean Management, Strategy, Clinical Risk Management, Performance Improvement and Patient Safety. Lora is committed to implementing the most current strategies, methods and processes. She completed the Cornell/HANYs Academy for Health Care Leadership Advancement, the Advisory Board’s Executive Leadership Fellowship programme, and the Executive Leadership Development Program, a joint effort between Northwell and Cornell.
Citation
Beran, Nancy, Abdallah, Ramsey and Giacomoni, Lora (2025, February 13). The population health journey: A change framework and lessons learned in a large clinically integrated network. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 9, Issue 3. https://doi.org/10.69554/MVOW6361.
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