In 2008, Donald M. Berwick, Thomas W. Nolan, and John Whittington introduced a new term into the health care lexicon — the “Triple Aim.” In their seminal article for the Institute for Healthcare Improvement, not only a new term but also a transformative new approach was introduced to improve population health. The Triple Aim has become foundational to value-based care.
In the article entitled “The Triple Aim: Care, Health, And Cost” the authors state, “In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.”
The Institute for Healthcare Improvement (IHI) developed the Triple Aim to optimize the overall performance of healthcare systems. According to IHI, the goal of the Triple Aim is to improve the experience of the patient while under care, improve population health, and lower per capita costs of healthcare. IHI emphasizes that the Triple Aim strategy is a single aim with the following three dimensions: patient care, population health, and healthcare costs.
The strategy has performed well in achieving the optimization of healthcare systems since its inception in 2008. Recently, an additional component has been embraced by many healthcare administrative thought leaders. The new fourth dimension is the improvement of the clinical experience for the healthcare providers, i.e., the doctors, nurses, technicians, and medical support staff. This fourth component has led to the formulation of the Quadruple Aim. The motivation for the additional dimension is the realization that without an improved clinical experience for healthcare providers, the patient-centric dimensions cannot achieve maximum potential.
What are the dimensions, or components, of the Quadruple Aim?
#1: Improve the Patient Experience
Improving the patient experience is accomplished by enhancing the quality of patient care and focusing on individuals and families. This patient-centric approach was the core goal of healthcare prior to the formulation of the Quadruple Aim. It derived from Crossing the Quality Chasm, a publication of the Institute of Medicine. The publication delineated six foci essential to healthcare quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
This component concerns itself with the individual experience of care and how to achieve high-quality, effective care subjectively and objectively. An improved patient experience is one in which the patients are more knowledgeable about their diagnosis and understand their condition. Patients are equipped and functional with the tools to more effectively manage their own care and personally improve the overall outcomes. Initially focusing on improving the patient experience starts the other two patient-centric dimensions on a course that culminates in fulfillment.
#2: Improve Population Health Outcomes
The Quadruple Aim engenders the goal of improving the overall health of a given population.. An improved patient experience that includes patient education will positively impact population health as the patient population can actively and more effectively manage and participate in treatment strategies and outcomes.
Improving the health of populations requires taking the improved patient experience and applying it across the whole population. As society faces an increase in chronic diseases, applying evidence-based, effective protocols to all patients within a specific disease cohort, will result in a reduction in the severity and widespread occurrence of chronic diseases in that cohort and achieve an overall improved management of chronic diseases in that population.
#3. Lower Costs
Healthcare costs as a percentage of GDP are expected to continue rising. The Quadruple Aim intends to achieve an improved patient experience along with improved population health while reducing the per capita cost of health care.
Keeping the cost reduction dimension linked with improved patient experience and population health ensures that while costs are actually reduced, the quality of care is not sacrificed. The goal is to improve population health and reduce patient visits to providers. When patients do seek care, it will be less expensive and, hopefully, more affordable.
#4. Improved Provider or Clinical Experience
The three dimensions addressed above are essential in maximizing the performance of a health system. However, an essential dimension was absent from the Triple Aim configuration: the healthcare providers. As value-based care becomes more widespread, the provision of quality care becomes essential. The point of departure is the provider. The pressure brought to bear on clinicians is immense and leads to negative outcomes that can adversely impact the quality of care provided to the patient.
High physician burnout is an indisputable reality. Decreased staff engagement decreases patient satisfaction, impedes positive health outcomes, and increases costs, all of which work directly against the original Triple Aim. To offset this cascading negative impact, an improved clinical experience should be added to the Triple Aim, making it the Quadruple Aim.
In 2014, Thomas Bodenheimer, MD and Christine Sinsky, MD explained, “The Triple Aim has provided society with a compass, pointing the way forward for our health care system. The positive engagement, rather than the negative frustration, 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 compass points of better care, better health, and lower costs.”
Value-based health care has embraced and enhanced Direct-to-Employer health plans, Centers of Excellence, accountable care organizations, and the utilization of innovative technologies to track and improve population health. The Quadruple Aim brings the health care endeavor more full-circle, making the practice of medicine a better experience for the patient and hopefully a better experience for the health care provider. Approaches that neglect or fail to include the fourth dimension ultimately fail. Forward-thinking strategies that embrace the needs of healthcare providers will energize the healthcare enterprise.