What is the Quadruple Aim?

What is the Quadruple Aim?

By Meghan Franklin

The Institute for Healthcare Improvement (IHI) developed the Triple Aim in 2007 to guide health policy. As it stands today, the Triple Aim’s goals are to:

  • Improve the health of populations,
  • enhance the patient experience and patient outcomes, and
  • reduce the per capita cost for care for the benefit of communities.

The Triple Aim reflects the widely accepted belief that the American healthcare system must shift how it cares for populations. Healthcare can no longer simply be about caring for people when they are ill; it must be about health optimization both for individuals and populations.

While the value of the Triple Aim is generally not debated, some healthcare organizations and policy leaders have questioned: Is it enough? Or, are there one or more essential elements missing?

In his article, “Healthcare’s New Quadruple Aim – 3 Key Components,” Dike Drummond, MD says, “Every single contact with patients, test ordered, procedure performed and drug prescribed . . .is predicated on the assumption that your people are happy and healthy and enjoying their work.”

Dr. Drummond argues that the Triple Aim cannot be achieved without adding a fourth component to the aim: “joy in work.”

Dr. Drummond says that preventing things like physician burnout and creating a culture where healthcare workers feel valued and supported is essential if healthcare organizations are to achieve the Triple Aim. How can providers deliver an exceptional patient experience, for example, if they constantly feel overworked and stressed? How motivated will healthcare workers be to creatively problem solve and increase productivity if they don’t feel their efforts are acknowledged or rewarded?

In their 2014 Annals of Family Medicine paper that called for a move from the triple to a quadruple aim, Thomas Bodenheimer, MD and Christine Sinsky, MD came to a similar conclusion as Dr. Drummond: When looking holistically at the healthcare system, the aim is missing an essential component—concern for care providers. Drs. Bodenheimer and Sinsky wrote, “The wide gap between societal expectations and professional reality has set the stage for 46% of U.S. physicians to experience symptoms of burnout.”

For all of the technology, regulations and carefully engineered processes that course through any healthcare organization, Drs. Drummond, Bodenheimer and Sinsky’s argument speaks to an important truth: Healthcare is only as good as those delivering the care.

So, it seems that adding “joy in work” to the Triple Aim to make it the “Quadruple Aim” should be a no-brainer, right?

While many healthcare organizations have expanded their focus to a quadruple aim, it doesn’t appear that the IHI has plans to modify the three-part aim that has stood for over a decade. In a post on the IHI blog, IHI President Derek Feeley explains why.

Feeley says that the IHI understands that some organizations may want to add a fourth component to the Triple Aim to help them deliver on their organizational strategy. Those components differ, however, from organization to organization. Feeley says that the military’s health system, for example, has added “readiness” as their fourth aim. Many other organizations have added “joy in work.” Still others have made “health equity” their fourth aim.

If organizations add additional components to the IHI’s Triple Aim, Feeley says they should be cautious about making modifications that may take focus away from the aim’s highest priority: patients. Feeley also recognizes that popular aim “add-ons” like joy in work and health equity can’t be ignored if organizations want to achieve Triple Aim outcomes. The IHI is even offering a 12-week virtual training all about “Finding & Creating Joy in Work” in 2019 (see details and learn how to register here).

Feeley urges organizations “to interpret the Triple Aim in a way that makes sense for you and your organization and what you need to achieve, but do so in a way that is deliberate and strategic.”

When you think about it, there are many things that can’t be ignored if organizations are to achieve Triple Aim outcomes. The effective use of data and technology and collaboration between healthcare providers and entities are just a couple of examples that come to mind. Feeley’s point, then, I think, is that there are many “essentials” if organizations are to effectively pursue and meet aim goals. As things like technology and reimbursement models evolve, the means by which organizations achieve the aim may also evolve. The goals of the IHI’s Triple Aim, however, will not.

Meghan Franklin is a freelance writer who has worked extensively in healthcare, both as a writer and as a project manager.