Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The triple aim must turn into the quadruple aim. Here’s why.

Yul Ejnes, MD
Policy
January 24, 2016
Share
Tweet
Share

A guest column by the American College of Physicians, exclusive to KevinMD.com.

The election year has finally arrived. Even though the candidates have been on the trail for what seems like forever, I wanted to wait until the traditional time to announce the launch of my campaign.

Don’t worry, I’m not running for office. My campaign is an initiative to get us to start talking about the “quadruple aim” instead of the “triple aim.”

You’ve heard about the triple aim. It’s mentioned at least once in almost every talk or article by a health care leader these days. Not mentioning the triple aim is like a politician forgetting to end a speech with the words “God bless the United States of America.”

In case you haven’t heard the term, the triple aim is a concept developed in 2007 by Dr. Donald Berwick and the Institute for Healthcare Improvement (IHI). Its three dimensions are “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 guided the development of many of today’s initiatives to improve health care, including private insurers’ efforts to reform payment, Medicare’s accountable care organizations (ACOs), and medical groups’ programs to improve quality and reduce cost.

Improving the care of individual patients, bettering the health of populations, and lowering health care expenses — that covers everything, right? Not so, according to Drs. Thomas Bodenheimer and Christine Sinsky. In 2014, they published a paper in the Annals of Family Medicine titled “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” In it, they very effectively made the case that our ability to achieve the triple aim is jeopardized by the burnout of physicians and other health care providers. They proposed adding a fourth dimension to the three in the triple aim: “the goal of improving the work life of health care providers, including clinicians and staff.”

Last summer, an editorial in the British Medical Journal made a similar suggestion, describing the fourth component as “improving the experience of providing care.”

The topic of burnout is not new to readers of this blog — many contributors have posted compelling, heartbreaking, and sometimes gut-wrenching stories of career dissatisfaction, early retirement, depression, and suicide, involving physicians at all levels of training or career. Contributing factors to burnout have been around for decades: long hours, not enough time with patients, increasing demands from patients and insurers, professional liability concerns, payment inequity, loss of autonomy, and administrative hassle, just to name several. Add to this the amplification of many of these burdens by the implementation of electronic health records (EHRs).

As Bodenheimer and Sinsky noted, efforts to achieve the triple aim have in many cases made things worse for providers. The added workload related to performance measurement, EHR use, greater documentation requirements, and increased access (expanded hours, e-mail, etc.) have had detrimental effects on the satisfaction and morale of members of the health care team.

It’s not about just physicians, either. All members of the health care team are at risk. The quadruple aim bolsters the wellbeing of nurses, medical assistants, receptionists, and anyone else involved in providing care to patients.

Also, it’s not all about paying physicians more. While it is true that the dysfunctional payment system, especially how primary care physicians are paid, contributes to the unhappiness, other factors include inadequate resources, inefficient workflows, ineffectual leadership, and inflated expectations.

So here is my campaign platform:

ADVERTISEMENT

  • Health care leaders should discuss the quadruple aim when they would normally mention the triple aim, and explain to their audiences why that change is so important. (Also, when you hear a speaker refer to the triple aim, ask him/her about the quadruple aim in the Q&A.)
  • Changes designed to improve how we deliver care should also improve the work life of health care providers (and certainly not worsen it).
  • Physician groups, hospitals, and insurers must measure the satisfaction of providers at all levels, make it public, and act on that information. (The Mini Z survey developed by Dr. Mark Linzer is one example of a way to measure provider experience.)
  • Insurers, including the government, must include provider experience as a metric for determining overall performance by ACOs and similar payment models.
  • The impact on provider satisfaction must be as important a factor in selecting or retaining EHRs as are other criteria, such as effect on profitability, and compliance with Meaningful Use.
  • Before adding “just one more thing” to a physician’s or other provider’s workload, organizations must identify tasks that can be eliminated or shifted to others (with the same requirement for those to whom the work is redirected).
  • Promote the use of resources such as the AMA STEPS Forward program, and the American College of Physicians’ Patients Before Paperwork initiative to help reduce burnout.

The provider experience can no longer be an afterthought or a “bonus” outcome. Otherwise, the ideals that Dr. Berwick and the IHI envisioned will never be achieved.

(The Campaign for the Quadruple Aim approves this message.)

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

Prev

The heartbreak of physician mommies. How this doctor learned to let it go.

January 24, 2016 Kevin 1
…
Next

The unintended consequences of the night float rotation

January 24, 2016 Kevin 7
…

Tagged as: Primary Care

Post navigation

< Previous Post
The heartbreak of physician mommies. How this doctor learned to let it go.
Next Post >
The unintended consequences of the night float rotation

ADVERTISEMENT

More by Yul Ejnes, MD

  • Different perspectives but the same goal: providing the best possible care to patients

    Yul Ejnes, MD
  • Rising premiums, high deductibles, and gaps in coverage before the ACA

    Yul Ejnes, MD
  • Improving physician satisfaction by eliminating unnecessary practice burdens

    Yul Ejnes, MD

Related Posts

  • Quality improvement: Helping boost everyone’s triple aim

    Michael A. Weiss, DO
  • Why health care replaced physician care

    Michael Weiss, MD
  • Care is no longer personal. Care is political.

    Eva Kittay, PhD
  • Health care workers need policy changes, not just applause

    Yuemei (Amy) Zhang, MD
  • How social media can help or hurt your health care career

    Health eCareers
  • Health care is not a service commodity

    Peter Spence, MD, MBA

More in Policy

  • Bundled payments in Medicare: Will fixed pricing reshape surgery costs?

    AMA Committee on Economics and Quality in Medicine, Medical Student Section
  • Who gets to be well in America: Immigrant health is on the line

    Joshua Vasquez, MD
  • Online eye exams spark legal battle over health care access

    Joshua Windham, JD and Daryl James
  • The One Big Beautiful Bill and the fragile heart of rural health care

    Holland Haynie, MD
  • Why health care leaders fail at execution—and how to fix it

    Dave Cummings, RN
  • Healing the doctor-patient relationship by attacking administrative inefficiencies

    Allen Fredrickson
  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Clinical ghosts and why they haunt our exam rooms

      Kara Wada, MD | Conditions
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 8 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • Addressing menstrual health inequities in adolescents

      Callia Georgoulis | Conditions
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
  • Recent Posts

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • Clinical ghosts and why they haunt our exam rooms

      Kara Wada, MD | Conditions
    • High blood pressure’s hidden impact on kidney health in older adults

      Edmond Kubi Appiah, MPH | Conditions
    • Deep transcranial magnetic stimulation for depression [PODCAST]

      The Podcast by KevinMD | Podcast
    • How declining MMR vaccination rates put future generations at risk

      Ambika Sharma, Onyi Oligbo, and Katrina Green, MD | Conditions
    • The physician who turned burnout into a mission for change

      Jessie Mahoney, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The triple aim must turn into the quadruple aim. Here’s why.
8 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...