The Quadruple Aim: From Understanding to Action

"We can and must take care of ourselves to best take care of those we took an oath to serve."
C. Michael Valentine, MD, FACC, president of the American College of Cardiology.

Cardiology Magazine Image

Nearly 450 ACC members joined together on Capitol Hill from Sept. 30 – Oct. 2 to advocate for patients at ACC's 2018 Legislative Conference. In the days leading up to the Congressional visits, members of the entire cardiovascular team passionately advocated for each other, making it clear that better patient outcomes can best be achieved in an environment that combats burnout and fosters engagement and satisfaction. The Quadruple Aim, a term coined by Thomas Bodenheimer, MD, in a 2014 Annals of Family Medicine paper, is the concept that the three dimensions of Institute for Healthcare Improvement's Triple Aim by Donald M. Berwick, MD – improving the care of individual patients, promoting the health of populations and lowering health care costs – must take into account the wellbeing of health care providers in order to be effective.

Over the past decade, health care organizations have faced increasing pressure due to declining reimbursements, increasing burden of quality reporting, electronic health record requirements, prior authorization and a national shortage of nurses and physicians. Reacting to these external challenges, organizations have reflexively increased productivity expectations for physicians. Additional demands on physicians frequently come without an increase in time or resources, and often, though perhaps unintentionally, at the expense of what physicians cite as the most meaningful aspect of medicine: the doctor-patient relationship.

A recent Medscape survey of 14,000 physicians, researchers found that more than 50 percent of physicians report burnout, described as exhaustion, cynicism and depersonalization. Burnout contributes to dysfunctional relationships, depression, substance abuse and even suicide. Cardiologists are among the least satisfied and least likely to seek help. Widespread efforts to promote physician resilience (though well-intentioned) skirt the crux of the problem, which is that burnout is fundamentally a system problem. Although the ethical obligation to physicians is obvious, there is also a business case to be made for organizational commitment to physician engagement. Studies show that burnout increases medical error, patient dissatisfaction and physician turnover. Moreover, burnout is not limited to physicians. All members of the health care team are affected. The Quadruple Aim is directed at the wellbeing of nurses, advanced practice providers, medical assistants, staff and anyone else involved in caring for patients.

There is no easy fix. There needs to be intentional, comprehensive and sustained efforts to give physicians the skills to cope within the system while simultaneously addressing the systemic issues that contribute to burnout. The solution begins with acknowledgement and a commitment to culture change, particularly at a higher level of leadership.

The College is our professional home and we are fortunate that our president has taken on the challenge of promoting the Quadruple Aim on an organizational, state and national level. This year's Legislative Conference once again reminded us that the College is one of the most empowering platforms for us to come together, share ideas and act as our own champions. FITs are poised to drive these changes. As we enter the workforce, we should strive to develop and implement targeted interventions to create an environment that promotes our cultures and values, helps us find meaning in work and supports work-life integration.

This article was authored by Jenna Kay, MD, Fellow in Training (FIT) at the University of Pennsylvania in Philadelphia, PA.