Unpacking the Quadruple Aim

David Bach

Berwick and the Institute of Healthcare Improvement introduced the Triple Aim in 2008 as a framework to propel health system transformation. The three integrated aims seek to improve patient experiences of care, address health population needs and reduce per capita healthcare costs. Since then, it has been widely adopted across organizations as an overarching strategy and foundation to deliver high quality care. 

A primary barrier in achieving the Triple Aim however, has been the experiences and well-being of healthcare providers. The statistics are alarming—more than half of US physicians experience burnout and dissatisfaction. What’s more disturbing is that numerous studies have linked healthcare workforce dissatisfaction to lower patient experience levels, worsening clinical outcomes for patient populations, and higher costs of care—all threatening the original tenets of the Triple Aim. As a response, there have been calls for a fourth inclusion of improving the work life of providers and staff, into what is now termed as the Quadruple Aim.

Understanding the System 

Pursuing the Quadruple Aim isn’t as simple as tacking on another aim onto an existing framework. Healthcare is a complex system, comprising of different components and varying degrees of interrelationships. It’s easy to get lost in its inherent messiness, constraints, and regulations—the consequences of which, if not careful, result in the inevitable throw in the towel. 

Without properly understanding the system at hand, it’s unrealistic to assume these four aims can be simultaneously addressed. When we talk of the Quadruple Aim, we need to first deconstruct the system into its elements, interconnections and purpose and see how each of these components relate to providers. It is only after doing so, can we leverage points in the system to produce more of what we want and need in the pursuit of high quality health care. 


Addressing System Components

Providers are crucial elements in the system that provide and deliver care to patients. True employee engagement starts with truly listening to their concerns, understanding needs and designing environments that will elicit future, positive behaviours and experiences. It isn’t about just providing them with wellness plans and occasional picnics (though important!), but addressing what they do each day. To bring back the joys of medicine, providers need to be set up for success, and be empowered with tools that allow them to take ownership of their practices and processes. Consider existing workflows and assess whether changes simplify practices and allow providers to focus on providing care for patients.

In order to deliver true quality care, providers rely on organizations that are interconnected with other organizations and the communities where patients reside. Why? No one organization does it alone, and each play unique roles along each patient journey. Partnerships enabled across different channels, support providers with the tools and relationships to effectively address population health needs and experiences. A key consideration is how system connections can support better providers via coordinated organizational and community-based approaches to care. Organizations need to remove barriers that impede information and program exchange, and instead move towards a model of shared responsibility.

On a broader scale, health system purposes and goals need to be reimagined and realigned in partnership with providers. This fundamentally means bringing health system planners, funders, providers and patients at the same table to agree on mutual outcomes beneficial for both providers and patients.

Metrics and measures are mainstays in almost every single health system and yet, providers are overwhelmed with too many reporting requirements, and far too few that capture their own lived experiences. Careful consideration needs to be made as to whether we are focusing on the right things—find measures that truly matter for patients and reflect the realities of providers delivering care.

A Call to Action

Change and redesign doesn’t happen overnight. Despite challenges, we need to be curious, creative and courageous in seeking better models that may not exist now. When we refuse to sit idle and accept the status quo, we can truly propel healthcare to reform.



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