HealthSeptember 05, 2017

Moving from Triple to Quadruple Aim

Nurses and other providers must not forget to care for themselves.

The Institute for Healthcare Improvement (IHI) first developed the Triple Aim framework in 2007. The idea is to work to advance the patient care experience, improve the health of a population, and reduce per capita health care costs at the same time.

Triple Aim is a single goal with three dimensions. The IHI has developed a set of high-level measures that operationally define each dimension of the Triple Aim. Pursuing Triple Aim is an extremely ambitious objective that will not be achievable without major buy-in and organization-wide support.

Care team well-being

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Working on these three elements does not come without setbacks. Members of the health care workforce have reported widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs.

Thus, employee burnout can jeopardize the success of Triple Aim. The IHI and other groups have recommended expanding Triple Aim to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.

Burnout among the health care workforce can threaten the success of Triple Aim by lowering patient satisfaction and increasing the possibility of errors. Caregiver burnout among nurses and other team members may contribute to the overuse of resources and increased costs of care.

Achieving the 4th Aim

How can health care organizations work toward the fourth aim, improving the work life of clinicians and staff? The following list suggests some practical steps from the Annals of Family Medicine:

  • Implement team documentation: nurses, medical assistants, or other staff present during the patient visit, enter some or all documentation into the EHR, and assist with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.
  • Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results.
  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders.
  • Standardize and synchronize workflows for prescription refills, an approach which can save physicians five hours per week while providing better care.
  • Co-locate teams so that physicians work in the same space as their team members. This has been shown to increase efficiency and save 30 minutes of physician time per day.
  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice.

The Triple Aim is paving the way forward for our health care system. Positive engagement of the health care workforce is of paramount importance in achieving the primary goal of the Triple Aim—improving population health.

Leaders and providers of health care should consider adding a fourth dimension—improving the work life of those who deliver care—to the ensure better care, better health, and lower costs.

How seriously does your facility consider the work life conditions of clinicians and staff? Do you think they are doing enough to ensure that nurses take care of themselves?

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