From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

Abstract

The Triple Aim-enhancing patient experience, improving population health, and reducing costs-is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff. INTRODUCTION Since Don Berwick and colleagues introduced the Triple Aim into the health care lexicon, this concept has spread to all corners of the health care system. The Triple Aim is an approach to optimizing health system performance, proposing that health care institutions simultaneously pursue 3 dimensions of performance: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care.1 The primary Triple Aim goal is to improve the health of the population, with 2 secondary goals-improving patient experience and reducing costs-contributing to the achievement of the primary goal.In visiting primary care practices around the country, 2 the authors have repeatedly heard statements such as, "We have adopted the Triple Aim as our framework, but the stressful work life of our clinicians and staff impacts our ability to achieve the 3 aims." These sentiments made us wonder, might there be a fourth aim-improving the work life of health care clinicians and staff-that, like the patient experience and cost reduction aims, must be achieved in order to succeed in improving population health? Should the Triple Aim become the Quadruple Aim? RISING EXPECTATIONS OF PHYSICIANS AND PRACTICESSociety expects more and more of physicians and practices, particularly in primary care. Patients want their health to be better, to be seen in a timely fashion with empathy, and to enjoy a continuous relationship with a high-quality clinician whom they choose.3 A patient-centered practice has been described as, "They give me exactly the help I need and want exactly when I need and want it."4 Yet for primary care, society has not provided the resources to meet these lofty benchmarks. PHYSICIAN BURNOUTThe wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of 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. 5,7 According to a recent RAND Corporation survey, the principal driver of physician satisfaction is the ability to provide quality care.7 Physician dissatisfaction, therefore, is an early warning sign of a health care system creating barriers to high-quality practice.We have heard physicians making such statements as:"The joy of practicing medici...

Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey

“…These results resonate with a recent article about the Bquadruple aim,^highlighting the need to address clinician worklife in order to improve morale, turnover, and patient care. 11 Bodenheimer and Sinsky make clear recommendations, including pre-visit planning, team support, standardized workflows, and staff training, 11 all of which would improve work conditions noted by respondents to the ACLGIM survey. We recently described the need to establish clinician wellbeing as an organizational metric, incorporate mindfulness and teamwork into the workplace, directly address EMRrelated stress, provide coverage for predictable life events with float clinicians, and support clinician self-care.…”

Nurses' experiences with errors in nursing

“…Recently, Bodenbeimer & Sinsky (2014) proposed an additional fourth goal to the 'Triple Aim' approach to healthcare introduced by Berwick (2008) which focuses on improving the work life of all healthcare providers. Finally, the number of individuals affected is also unknown because the means to accurately identify the number of nurses who incur significant suffering from medical errors does not currently exist (Hall & Scott, 2012;Paparella, 2011).…”

Physician Well-Being: Expanding the Triple Aim

“…3,4 The Triple Aim is critically important to advancing medical care across the globe. However, considering healthcare innovations without direct concern for the well-being of the individuals providing care seems at best a missed opportunity for engagement of physicians to ensure the success of these innovations and at worst a denigration of the physician role in healthcare delivery as a member of the medical profession.…”

“…This aligns well with earlier calls to incorporate physician well-being into discussions of institutional performance in healthcare delivery, 2 and has the potential to save us from ill-conceived approaches that may advance a Triple Aim goal but are, in fact, counterproductive because of adverse effects on physician well-being and work satisfaction. 3,4 In short, changes to healthcare delivery which do not consider their impact on clinician well-being are unlikely to succeed in the short term and may have significant detrimental effects on healthcare in the long term.…”