The Quadruple Aim

Cardiology Magazine ImageDonald M. Berwick, MD, MPP, FRCP

Over the last decade, health care has seen a shift in the way providing care is addressed. Changes in regulations, patient access to information and technological advances have led to an increased focus on patient experience. During this transition, there has been focus on the Triple Aim, an approach to optimize health system performance.

In 2008, Donald M. Berwick, MD, MPP, FRCP, and colleagues provided this Triple Aim as a framework for the delivery of high-value care. It centered around three overarching goals:

  1. Improving the patient experience of care (including quality and satisfaction)
  2. Improving the health of populations
  3. Reducing the per capita cost of health care

As health systems were grappling with the challenge of improving population health while simultaneously lowering health care costs, the Triple Aim was adopted as a set of principles for health system reform.

Working on the three elements of the Triple Aim has not been without its challenges. Although each of the components is necessary to succeed in the new era of health care, a key component is missing – the care providers. The backbone of any effective health care system is an engaged and productive workforce, and members of the health care workforce have reported widespread burnout and dissatisfaction.

Burnout among the health care workforce can threaten the success of Triple Aim by lowering patient satisfaction and increasing the possibility of errors. Caregiver burnout among nurses and other team members may contribute to the overuse of resources and increased costs of care.

Professional burnout is characterized by loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment, and is associated with early retirement, alcohol use and suicidal ideation. According to a 2013 RAND Corporation survey , the principal driver of physician satisfaction is the ability to provide quality care.

In a national survey conducted by Physician Wellness Services and Cejka Search, 87 percent of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63 percent indicating that stress is increasing. In a survey conducted in the Annals of Family Medicine , 43 percent of physicians reported spending over 30 percent of their day on administrative tasks.

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Physicians spend more time on non-face-to-face activities (in-box management of labs and documents, messages and medication refills) than with patients. The 2013 RAND Corporation survey showed 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care.

A more recent professional life survey of ACC members found EHR challenges continue to keep clinicians up at night, along with work-life balance, maintenance of certification, reimbursement challenges, prior authorization and quality reporting.

Burnout affects not only physicians but also other members of the health care workforce. Studies show that 34 percent of hospital nurses and 37 percent of nursing home nurses report burnout, compared with 22 percent of nurses working in other settings.

On the front lines of practice, receptionists also have stressful jobs, with 68 percent reporting verbal abuse from patients. Most receptionists feel that physicians do not appreciate the complexity of their work. They report that sources of their stress include finding appointments for patients as well as feeling caught between doctors and patients demands.

A 2013 survey of 508 employees working for 243 health care employers found that 60 percent reported job burnout and 34 percent planned to look for a different job. Reasons included heavy patient loads, small staffs and high stress levels. Provider and staff dissatisfaction can easily feed on each other.

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A burned-out staff member may not be doing his or her job, resulting in more stress for the provider. On the other hand, provider satisfaction is enhanced by adequate numbers of well-trained, trusted and capable support staff with low turnover.

Since the Triple Aim does not explicitly acknowledge the critical role of the workforce in health care transformation, the Quadruple Aim was ushered in with its goal of improving the work life of health care providers, including clinicians and staff. How can health care organizations work toward the fourth aim, improving the work life of clinicians and staff?

The ACC is undergoing its strategic planning for years 2019 – 2024, and one of the four goals specifically addresses member well-being. Work is currently being done to address how to achieve the Quadruple Aim, and a task force is addressing how a health care system can create conditions for the workforce to find joy and meaning in their work and improve the experience of providing care. More details to come as the strategic plan is introduced and implemented.

ACC President C. Michael Valentine, MD, FACC, also addresses the Quadruple Aim and the importance of professional well-being in a recent Leadership Page in the Journal of the American College of Cardiology . "For the majority of physicians, we practice medicine because of our passion for improving and saving the lives of patients," Valentine writes. "We can and must take care of ourselves to best take care of those we took an oath to serve."

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This article was authored by Dipti Itchhaporia, MD, FACC, cardiologist at Hoag Memorial Hospital Presbyterian in Newport Beach, CA.