Maybe Healthcare Needs A Quadruple Aim?

By Danielle Miller, PHD(c), MSN, RNC-OB Chief Nursing Officer, Clinical Applications

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. The framework’s intent seeks a simultaneous pursuit of improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

The Triple Aim has gained wide acceptance as a compass to optimize health system performance, but the question remains: how will organizations obtain the Triple Aim?  Data suggests hospitals need to add another facet in order to be successful at obtaining the Triple Aim, so we are now looking at the Quadruple Aim.

The Quadruple Aim incorporates the healthcare provider into the mix. And by providers, I mean physicians and nurses, but also everyone who supports the care of the patient. Unfortunately, healthcare providers everywhere face burnout which goes hand-in-hand with lower patient satisfaction and reduced health outcomes — it may even increase costs.

A 2012 paper published by the Archives of Internal Medicine found an “alarming” 46 percent of the 7,288 physicians surveyed reported at least one symptom of burnout. This rate is concerning for nurses as well with 34 percent of hospital nurses reporting burnout symptoms according to a 2011 report published by the Journal of Health Affairs. Anecdotal evidence supports this is the case for physician assistants, as well as nurse practitioners. One can only assume the same is felt by all of healthcare staff who support the care of patients, including everyone from dietary to environmental services.

So what does that mean? Providers who are burned out may actually be an obstacle to organizations obtaining the Triple Aim. Expanding to the Quadruple Aim that includes the addition of improving the work life of health care providers, including clinicians and staff, may in essence help with achieving the Triple Aim.

The ability of the hospital organization to obtain the Triple Aim is dependent on its ability to have an engaged workforce, including nurses, physicians, and anyone who provides support to the care of the patient — or pretty much everyone in the healthcare ecosystem.

Overworked staff can lead to burnout, so considering a fourth aim means looking at improving the experience of the provider. If you can impact and improve the experience of the providers of care, you impact the care patients are receiving.

Improved provider experience leads to increased patient care. A happy and engaged workforce leads to a more engaged patient population with better health and better outcomes. Dissatisfied physicians and nurses can likely be associated with lower patient satisfaction, which has a direct impact on employee and patient satisfaction surveys as well as financial reimbursement to the organization.

Organizations are able to have a greater return if they invest in the wellness of their providers of care.  First, evidence shows satisfied, happy, and engaged providers provide a higher level of care to their patients. When patients have a positive relationship with their providers, their compliance with medical regimens improves because they trust their providers have a vested interest in their well-being. Second, patient-provider relationships are a big deal to the people we care for. In hospitals, provider satisfaction — especially among nurses — correlates with patient satisfaction. Third, when healthcare providers face burnout, the risk of adverse outcomes increases. A disengaged provider becomes the catalyst to poor communication and frustrations among other providers, which leads to an increase in the number of adverse patient outcomes. Studies link burnout to surgical errors, major medical errors, and increased liability risk.

Finally, let’s look at the enormous cost of turnover to the organization which could easily be in the millions of dollars. This represents not only a financial loss, but also a loss of productivity for the providers of care.

Healthcare organizations have resources available to reach both the Triple and the Quadruple Aim — resources that are easily available and typically already utilized on a daily basis: information technology.

The lack of an interoperable system makes it very difficult for healthcare providers to access and exchange crucial patient information that impacts patient outcomes. The ability to facilitate health information exchange among providers would allow providers to see a comprehensive, longitudinal picture of patients’ clinical histories and treatments and make healthcare decisions in a timely manner. This results in better patient experiences and better population health — all at a lower cost.

Investing in a fully integrated system offers a platform that allows for health information exchange and interoperability. That same system can also be used to align hospital policies and promote the use of HIT with processes and workflows that focus on value rather than volume, especially in the transition from volume- to value-based reimbursement.

Implementing fully integrated, clinical decision support systems encourages best practices as well as collaborative decision making among providers and can standardize care provided. The care of patients will improve as quality and safety are enhanced. An integrated system allows for all providers to view care received regardless of where it was received in the hospital or post-acute system, or even the clinic setting. Lastly, cost will decrease as providers gain real time data and access that helps prevent unnecessary duplicate testing and the ability to automate many manual processes.

When healthcare providers are fried, consistently overworked, and disengaged, the well-being of the patient relationship and patient-centered approach quickly gain at-risk status. Hospital organizations seeking the Triple aim should consider the essential piece of the Quadruple Aim by embracing the notion that a happy and engaged workforce provides enormous and essential benefits for both patients and healthcare providers.

When organizations are able to fully leverage health IT systems, their providers are able to streamline, automate, and enhance their work. This allows them to spend more time doing what they entered the healthcare profession for — providing care for patients. When all these steps are in place, hospital organizations will achieve not only the Triple Aim, but the Quadruple Aim.

What is your organization doing to increase provider engagement? Please share your thoughts.