The Quadruple Aim

Quadruple Aim: Context

According to “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider,” the IHI Triple Aim of improving population health, cutting expenses, and improving the patient experience is necessary but insufficient. Burnout is associated with lower patient satisfaction, poor health outcomes, and increased healthcare costs. Thus, the authors of this article recommend that the Triple Aim be expanded to the Quadruple Aim, adding the goal of improving the work life of healthcare providers (BodenheimerT, Sinsky C. Ann Fam Med 2014;12:573-576).

 Physician burnout in perspective

Burnout occurs when work and/or personal demands exceed a caregiver’s ability to cope. The Maslach Burnout Inventory measures three components: emotional exhaustion, depersonalization (decreased empathy), and lack of personal accomplishment (Cohn et al. “Workplace Burnout” in Cohn KH. 2005.Better Communication for Better Care., 56-62)

Practical steps for addressing the fourth aim include:

  • implementing team documentation, so that physicians can focus on patient care
  • using pre-visit planning and pre-appointment laboratory testing to optimize time spent in the office
  • allowing nurses and medical assistants to assume responsibility for preventive care and patient coaching using physicians’ standing orders
  • standardizing workflows for prescription refills
  • co-locating teams so that physicians work in the same space as other members of their team
  • making sure that assisting medical staff members are well-trained in their supportive roles and understand that they are contributing to patients’ health in a re-engineered practice setting (Bodenheimer op. cit, 575)

For those who feel that their organization is unwilling to invest in adequate personnel to support the Quadruple Aim, they cite a  study from Group Health, where the return on investment was 150%, resulting from an engaged workforce, which boosted patient satisfaction and cut hospital admissions and ER visits.

I would be remiss if I did not mention four additional field-tested strategies that boost physician engagement:

  • Physician-led business planning for new ventures:  The section chief of Urology at a community teaching hospital approached me for assistance in carrying out his vision for improved care of newly diagnosed patients with prostate cancer.  He felt that if the hospital developed a multidisciplinary cancer center, he could shorten the time for patients to receive treatment. Over the course of two months, we wrote a business plan, which became the blueprint for a multidisciplinary Cancer Diagnosis and Treatment Center (Cohn 2002)
  • Using healthy competition to promote improved clinical and financial outcomes: The medical director of a cardiac catheterization laboratory threatened to display results by individual physician if members of his group could not come to consensus on supplies and costs. Within 4 months, differences in outcomes for his six-person group shrunk to one standard deviation. “None of us wanted to be an outlier except on the positive side.” (Cohn 2005)
  • Linking a physician-administration compact to the strategic plan
  • Working together with the Chief Medical Information Officer to hardwire gains made by physicians limiting Pharmacy expenditures into current medical decision-making (Cohn 2009)

What do you think? Please share your feelings with me about the need for a quadruple aim and contact me anytime that I can be of service to you.

Kenneth H. Cohn, MD, MBA, FACS

© 2014, all rights reserved

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