The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
Improving the patient experience of care (including quality and satisfaction);Improving the health of populations; andReducing the per capita cost of health care.
What is the triple aim for health care?
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.
What is the triple vs quadruple aim of healthcare?
Definition: Quadruple Aim is the expansion of the Triple Aim (enhancing patient experience, improving population health, and reducing costs) to include an additional goal of improving the work life of health care providers.1 Organizations view this expansion in different ways, but the Institute for Healthcare Improvement calls this new aim “Joy in Work.” 1 Many health care organizations have adopted the framework of the Triple Aim, but the stressful work life of clinicians and staff has proven to play a large role in the ability to achieve and maintain the 3 aims.
In primary care, the adoption of the Triple Aim has enhanced the patient experience, but resources are lacking to help providers and staff maintain these overarching goals. Professional burnout and reduced job satisfaction have hindered the ability of providers and staff to provide quality care.2 Therefore, a fourth aim focusing on the improvement in work life of clinicians and staff has been proposed to create a more symbiotic relationship between patients and health care providers.
How it relates to ACO/PCMH: The Triple Aim is focused on improving patient care, and practices within PCMH and ACOs must continue pursuing the original 3 aims while expanding their focus to the Quadruple Aim.1 Expansion of pharmacists’ roles can help support many aspects of the Quadruple Aim.
Pharmacists can, under various collaborative care models, assume responsibility of chronic disease state management and preventive care in order to increase the efficiency of the care team, support value-based care, and have a clinical impact.3 Pharmacists can also play a role in quality-focused initiatives to support the system and providers’ efforts to improving the provided quality of care.
The expansion of pharmacist roles within the care team can increase access to care while allowing pharmacists to practice at the top of their training. Involved organizations/oversight: The expansion of the Triple Aim to the Quadruple Aim has been proposed to improve the work life of health care providers.
Feeley D. The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement website.28 Nov 2017. Available at: www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy, Accessed October 9, 2019. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med,2014 Nov;12(6):573-576. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4226781/ Stefanacci RG. Targeting the quadruple aim through clinical pathways. J Clin Pathways,2018;4(2):33-35. Available at: www.journalofclinicalpathways.com/article/targeting-quadruple-aim-through-clinical-pathways
Contributing authors: Ashley Huntsberry, PharmD, BCACP Sara Wettergreen, PharmD, BCACP University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Last Updated 11/25/2019
What is the quintuple aim?
The Quintuple Aim of health care adds health equity to the existing Quadruple Aim of improving the individual experience of care for patients, improving the health of populations, reducing the per capita cost of care, and improving the experience of health care professionals.
What is the meaning of patient centered care?
Abstract – Patient-centered care focuses on the patient and the individual’s particular health care needs. The goal of patient-centered health care is to empower patients to become active participants in their care. This requires that physicians, radiologic technologists and other health care providers develop good communication skills and address patient needs effectively.
- Patient-centered care also requires that the health care provider become a patient advocate and strive to provide care that not only is effective but also safe.
- For radiologic technologists, patient-centered care encompasses principles such as the as low as reasonably achievable (ALARA) concept and contrast media safety.
Patient-centered care is associated with a higher rate of patient satisfaction, adherence to suggested lifestyle changes and prescribed treatment, better outcomes and more cost-effective care. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your area of interest.
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- According to one theory, most patients judge the quality of their healthcare much like they rate an airplane flight.
- They assume that the airplane is technically viable and is being piloted by competent people.
- Criteria for judging a particular airline are personal and include aspects like comfort, friendly service and on-time schedules.
Similarly, patients judge the standard of their healthcare on nontechnical aspects, such as a healthcare practitioner’s communication and “soft skills.” Most are unable to evaluate a practitioner’s level of technical skill or training, so the qualities they can assess become of the utmost importance in satisfying patients and providing patient-centered care.(1).
What are social determinants of health?
What are Social Determinants of Health? – Social determinants of health are the conditions in which people are born, grow, live, work and age.1 They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care (Figure 1). Figure 1: Social Determinants of Health Addressing social determinants of health is important for improving health and reducing health disparities.2 Though health care is essential to health, it is a relatively weak health determinant.3 Research shows that health outcomes are driven by an array of factors, including underlying genetics, health behaviors, social and environmental factors, and health care.
While there is currently no consensus in the research on the magnitude of the relative contributions of each of these factors to health, studies suggest that health behaviors, such as smoking, diet, and exercise, and social and economic factors are the primary drivers of health outcomes, and social and economic factors can shape individuals’ health behaviors.
For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have access to sidewalks, parks or playgrounds, recreation centers, or a library.4 Further, evidence shows that stress negatively affects health across the lifespan 5 and that environmental factors may have multi-generational impacts.6 Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.
Who created the triple aim?
While IHI President Emeritus and Senior Fellow Don Berwick may not be the originator of the Triple Aim, he has been its most visible proponent for over a decade. In the following interview, he describes the societal role of the Triple Aim, comments on the so-called quadruple aim, and describes how the Triple Aim continues to surprise him.
What were the origins of the Triple Aim? The Triple Aim was the brainchild of two of IHI’s faculty, John Whittington and Tom Nolan, who came up with it in about 2006. It was a real breakthrough. The goal they had in mind was to articulate, in a very cogent way, the aims of health care from the viewpoint of the society it serves.
You can’t define or pursue quality if you don’t know your aims. The proper way to think about goals is that they’re external to the organization, external to the industry. They lie in the world of the people we help, the customer, the patient, the consumer.
Safety — Don’t hurt me; Effectiveness — Promise me science; Patient-centeredness — Honor me as an individual; Timeliness — Let’s have no delays that aren’t instrumental; Equity — Close racial and socioeconomic gaps in health; and Efficiency — Don’t waste money, space, or any other resources.
Whittington and Nolan said, “No, wait a minute. Those aims apply when you need or use the care. Those properties should be there in the individual experience of care when we care for your heart attack, your broken arm, your depression, or you get your checkup.” They identified another component they called the health of the population.
Why do you have your heart attack? Why did you break your arm? Why are you depressed? The causes of these health burdens don’t lie in health care. The cause of illness isn’t the absence of health care; health care’s a repair shop. Whittington and Nolan asserted that, “Society also needs us to help you stay healthy.” They included that second component.
The first aim is the better experience of care. The second aim is better health for the population. The third aim they included, which I think was particularly brilliant, is while reducing per capita cost. That is because the needs of the people we serve go beyond health care.
People may need to pay a college tuition. A corporation maybe want to be more competitive and pay its workers more. Government may need to put money into roads or schools. Whittington and Nolan posited this system of aims — better care for individuals, better health for populations, and lower per capita cost — as a more complete statement of the social need here to fill.
It’s like a compass that helps us define success. Their framing became known as the Triple Aim. I got to co-author the paper about it, but it’s always embarrassed me that people often think I came up with it. I didn’t think of the Triple Aim. That was John Whittington and Tom Nolan.
LEARN MORE: IHI Summit on Improving Patient Care, April 11–13 in San Francisco, CA Why did so many people think the Triple Aim was a radical idea when it was first proposed? A lot of people thought — and possibly many of them still do — that the Triple Aim is a very radical idea for a couple of reasons.
One, it forces health care delivery out of its own box. The first component of the Triple Aim — better care of individuals — that’s our sweet spot. That’s why we’re here. We give care for you when you get sick. It’s disruptive to tell a hospital or even the health care enterprise as a whole, “You’ve got a second job,” which is to address the health of populations.
Is that really my job? We know that bad housing causes poor health. We know that good health depends on good transportation. We know that racism is the enemy of health. Does that mean I’m supposed to work on housing and transport and racism? Whittington and Nolan said, “Yes.” Hospitals don’t have a plan, mostly, to work on the causes of heart attacks; they work on the heart attacks.
Adopting the Triple Aim implies a major shift in process. The second real disruption is the lower per capita cost part of the Triple Aim. People in systems that are struggling the way ours are always feels like they don’t have enough money. The natural response to the challenge is, “What do you mean, ‘lower costs?’ I need more money.
I must take care of more people. People are sicker, they’re older.” Whittington and Nolan said, “No, we can lower costs by working on waste and activities that aren’t value-added.” That’s the premise. All modern quality theorists think that there’s a wide terrain of opportunity to improve quality, the experience of the person you’re helping, and reduce cost at the same time.
Every mature company in the competitive world globally is trying to do that. Health care needs to do that, but that’s not our mentality. It’s always, “We need more.” Health care is 16 percent, 17 percent, 18 percent of the gross domestic product, and there appears to be no limit yet to our claim on the economy.
With the Triple Aim, Whittington and Nolan tried to put an end to that claim. They said, “No, no, no. Lowering per capital cost is also your duty. If we work on better care for individuals and better health for populations, we can lower per capita cost effectively.” I believe that but think of all the health care lobbyists that are on Capitol Hill arguing for more money.
Think about the health care system that wants to build the next building and expand its work. To say we don’t need more is disruptive, to say the least. Nonetheless, I go to countries around the world that I’ve never been in before — that may not even know that IHI exists — but they’re using the Triple Aim.
- We see it at all levels.
- We see it at a hospital level, clinics, individuals, all the way up to ministries of health.
- There are ministries of health in the world that are setting their goals as nations by using the Triple Aim as the compass.
- It’s interesting that the framework has gotten that much traction.
Does the Triple Aim represent health care taking responsibility for its role in society? Health care is a big part of society. Economically, we’re a sixth of the economy in our country and similar proportions in other countries. People care about it. I may not be in health care very much, but I’m in my own health all the time.
It matters if my knee hurts or if I’m feeling ill or depressed all the time, not just when I’m in health care. On the cost side, the question is, “How much do we think we’re entitled to?” Do we really think that health care is entitled to everything it can possibly get? I don’t think that’s so, because health care is taking resources from other places.
And when you’re conscious of waste, of non-value-added activities, overuse, failures of coordination, administrative nonsense, pricing games, and the costs of defects, it’s hard to justify taking dollars from the public schools or from a government that needs to fix roads or from a corporation that wants to be more globally competitive.
- If we’re wasting money, we’re not entitled to more of it.
- Our costs are in part confiscation, and we need to stop it.
- Health care costs can seem so abstract.
- How do you connect it to everyday realities? As I learned from Tom Nolan and John Whittington, health care is ground zero for all sorts of conflict.
It is, for example, a central issue in labor negotiations. Nolan and Whittington ask, “Where does the money come from? This $3 trillion in health care costs, this 18 percent of the economy, this money we want more of, where’s it coming from?” In the end, it’s coming from only one source: wages.
The only source of money for health care in any country, including the United States, is wages for the hard work of people. They go to work, they get paid, and that money leaves their hands through taxes, through out-of-pocket payments, through employer’s putting money into a health insurance plan instead of giving it to workers because it’s their contribution to premiums.
Every dollar that health care spends came from a worker, so we ought to think very hard about whether health care is entitled to take that money. Of course, if everything we did worked, if every dollar we spent contributed to health and well-being and peace of mind and longevity, then, yes, it’s important and maybe we can claim, “Well, we need that money and we should get it.” But not when we have the defect rates and the waste rates that we have.
- When I first got into the arena of health care quality 40 years ago, people often said, “Don’t talk about money.
- The doctors and the nurses don’t want to hear you talk about the money.” I guess that’s still true, but it’s not a mature attitude.
- It’s not owning our responsibility.
- Every patient’s the only patient.
We need to do everything we can for everybody, but we must also turn our eyes toward the idea that the money is not ours. It’s someone else’s, and we shouldn’t waste it. What have we learned about what it takes to successfully pursue the Triple Aim?
You must be a systems thinker. No lone individual can achieve the Triple Aim. Even just better care for individuals — with the burdens of chronic illness and the enormous technologies we can bring to bear in health care — demands extraordinary, unprecedented levels of cooperative work. The Triple Aim makes it clear that we’re a team and we’ve got to act like one. Properties of communities make us sick, or help us stay well, and we must work as communities on those properties to successfully pursue population health. We need to make sure every kid is ready for school, birthing is safe, work is supportive of morale and physical health and safety, elders have the respect and the nurturing they need, communities are resilient, we’re fair, and that equity exists. Reducing costs must be cooperative. I may need to spend money to help you save money. We must be systems thinkers, and I believe that payment systems should respect that way of thinking. Habits run deep. For example, the habit of asking for more is hard to break. Part of the Triple Aim is lowering per capita cost. One of the 10 health care redesign principles proposed by IHI’s Leadership Alliance is to “return the money.” Lower prices, lower costs, and give the money back. This is hard because the habits of retention are well-enforced by the payment systems. The roles of leaders and boards are more apparent with the Triple Aim. You must help the workforce organize itself across these boundaries to deliver what the Triple Aim contemplates. It’s very tough. I can see places that are approximating pursuit of the Triple Aim, but no one’s really got it yet.
What do you think about the so-called “quadruple aim”? People sometimes now talk about the quadruple aim with joy in work as the fourth part. You can’t get to better care for individuals, better health for populations, and lower costs with a demoralized workforce.
It won’t work. We must have the energy to work together and confidence that we can succeed. It’s too hard in a stressed environment with burnout and people losing confidence. As President Emerita and Senior Fellow Maureen Bisognano says, “You can’t give what you don’t have.” We can’t have the Triple Aim without joy in work, but I’ve resisted the label “quadruple aim” for a technical reason: the original idea of the Triple Aim is to define what society wants from us, which is external.
Joy in work is internal. It’s important, but it’s not quite on the same playing field as the social need, though I recognize that it’s essential for meeting the social need. The Triple Aim isn’t biblical. It’s not chiseled in tablets and people are certainly entitled to do anything they want with the term.
But sometimes people say, “The Triple Aim is better care, better satisfaction, and lower cost.” No, the satisfaction of patients is part of the first aim. I’ve heard people talk about it as quality, safety, and service. Anyone can list three aims and go ahead and do it. I’m not saying there’s one right definition, but if you want to go back to the origins, it’s very clear: It’s better care for individuals, better health for populations, and lower per capita cost while maintaining the first two.
What has surprised you most since the Triple Aim idea was first proposed? One is the stickiness of the concept. I had no idea it would take off the way it has. It’s almost magical. It would be interesting to figure out why. Why is this framing so helpful? Partly, it’s helpful because it is so simple.
It’s an elegant way to name why we’re here: better care for individuals, better health for populations, and let’s not waste. That sounds just about right. But I remain surprised by how many people have embraced it, top to bottom, in organizations. My second surprise is a little more negative. Waste is everywhere.
You can watch the non-value-added work. You just put on what the Japanese call “Muda glasses” — or waste glasses — and you can see it every day. It drives me nuts. It’s bad for patients. When Whittington and Nolan proposed the lower per capita cost component of the Triple Aim, I thought it would be embraced and people would say, “Yeah, let’s stop wasting.” And you know what? It really hasn’t happened.
Maybe people don’t see it, maybe they’re worried: “Your waste is my job and you’re telling me this activity isn’t needed?” It’s been hard to get organizations and individuals oriented around stopping non-value-added stuff. People think that changing the payment system toward value-based payment may do that.
I don’t know. All I know is that returning the money is the hardest part. The other more recent surprise for me is the second part of the Triple Aim, better health for populations. I knew about social determinants of health. I knew the words. I’m a pediatrician.
- I’ve been a faculty member in a school of public health.
- But in the past year or two, I’ve really dug in and begun to understand the power of these community determinants of health.
- And you know what? These determinants are monsters.
- This isn’t a nice little thing to do while we do our real work of treating the heart attacks.
We should treat the heart attacks and we should do our organ transplants and we should do our coronary surgery and our chemotherapy, absolutely, but when you say we’re on earth to help people stay healthy, the leverage is in community determinants of health.
There’s more rhetoric about that now. There are some good programs. Some countries have programs and approaches that we need to copy, but we are taking baby steps so far on the health of populations and giant progress is available if we want to go for it. Editor’s note: This interview has been edited for length and clarity.
Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow, Institute for Healthcare Improvement. You may also be interested in: The Triple Aim: Care, health, and cost (This is the original Health Affairs article that first proposed the Triple Aim.) Don Berwick’s 2018 IHI Forum keynote “Start Here: Getting Real About Social Determinants of Health”
Why is there now a quadruple aim?
Introduction – In 2014, the Quadruple Aim—adapted from the widely-accepted Triple Aim —was suggested as a framework to optimize healthcare system performance. The framework encompasses reducing costs, improving population health and patient experience, with a new fourth domain: healthcare team well-being,
- These performance dimensions can be applied to far-reaching, crucial healthcare challenges, such as reducing the massive rates of burnout present in healthcare workers and combating rising healthcare costs,
- These foci are crucial for healthcare quality, yet healthcare systems must also consider other factors.
Reimbursement for care provided in the United States is based on productivity, i.e., work relative value units (wRVU), despite a shift towards value-based care by the Centers for Medicare and Medicaid Services, Most private insurers mimic this productivity-based reimbursement strategy,
Thus, healthcare systems are facing 2 daunting yet seemingly opposed challenges: striving to achieve the goals proposed in the Quadruple Aim while increasing productivity, There are an increasing number of forces that create demands on providers’ performance and cognitive load. These include expectations of physicians to generate wRVU by seeing more patients, suboptimal design of the EHR (electronic health record), shifting patient/consumer expectations of the provider-patient relationship, and a rapidly increasing alternative primary care sector, e.g., walk-in clinics, urgent care, concierge medicine, and online offerings.
Many physicians spend hours of overtime completing EHR and other administrative tasks, Despite these pressures, physicians are also dedicated to providing quality care to their patients, These burdens trickle down within teams, creating a stressful environment wherein team members must work with administrative tasks instead of focusing on patient care,
- These competing demands contribute to the burden that healthcare professionals are experiencing today, likely encouraging moral distress and burnout and creating a cycle that makes it even harder to provide high-quality care.
- Despite this, interventions tend to target one specific problem rather than comprehensively targeting the challenges experienced in primary care.
For example, interventions such as mindfulness and stress management are often used to improve the well-being of the healthcare team. While these intervention strategies can foster improvement related to the targeted issue, they often fail to address the root causes of stress and burnout, and may be a temporary fix for organizational problems that will eventually return.
- Practice change, and the incorporation of research evidence into routine clinical practice can be extremely challenging for healthcare workers.
- Considering the many time-related demands and pressures that healthcare team members face in their daily work, the added responsibility of changing routine care practice or workflow can seem tedious and unimportant.
Yet, obtaining buy-in from clinic staff is crucial for implementation success, The relative advantage of the intervention and its compatibility with perceived needs likely enhance buy-in, so interventions that simplify work processes and reduce work stress may be more effectively implemented.
- An intervention is needed that comprehensively targets the numerous demands faced in primary care delivery.
- Using theory informed by prior research, we posit that enhancing healthcare efficiency can simultaneously address these demands without requiring additional resources (Fig.1 ).
- To our knowledge, no previous intervention has primarily targeted efficiency for quality improvement.
Optimal clinic efficiency is achieved when appropriate resource use creates an environment that promotes teamwork and skills development while protecting against work stress, burnout, and dissatisfaction. This enables team members to provide high-quality care and a positive patient experience,
- While a productivity focus requires outcomes and puts pressure on individual providers to create results, an efficiency focus is related to process changes and requires organizational change.
- Thus, theoretically, a focus on efficiency should allow personnel to achieve performance measures while improving workplace well-being since resources and processes are more effective, and team members are working at the top of their license (using the most advanced skills they were trained/educated for).
Below, we present results from a 2 week pilot test of an efficiency-focused intervention in a single primary care clinic. Theoretical modeling linking all Quadruple Aims to organizational efficiency and productivity
What is the NHS quadruple aim?
What Is the Quadruple Aim & How Is It Maturing? – Put simply, the Quadruple Aim encourages system leaders to ask themselves the following questions:
“Is the health of the population improving?”,
- “When people require, or access services, is their experience of care good?”,
- “When we deliver care, are we doing so efficiently, or in such a way that reduces the overall cost / increases the value for money?”,
- “Is the staff who is supporting and providing care and services finding fulfilment in their work?”.
The Quadruple Aim is the natural development of the Triple Aim, which started out as a means of optimising health system performance by suggesting that organisations working in healthcare pursue 3 key objectives: improving the health of the population, enhancing the patient experience of care, and reducing the overall cost of healthcare. The pandemic led many organisations to turn to innovation for help. Perhaps the biggest change was the rapid up-take and widespread adoption of technologies that facilitated new ways of working (e.g. video consultations ). Although organisations improved efficiencies and brought in new ways of working, staff had to learn to adapt to them — an effort that’s seen variable levels of success,
Healthcare is a sector that relies heavily on the care, attention, and skills of those delivering the service. Rightly, therefore, we should include the staff experience within the measurements of value. The introduction of a fourth pillar — “joy at work” often measured in terms of staff satisfaction is a really important addition.
The last two or so years of the pandemic proved that even when money was poured into systems and even with the unparalleled commitment of staff, health systems struggled to cope, because there is only so much that people can do within the systems they find themselves. Figure 3. Digital technologies in the public health response to COVID-19 However, we need to continually refresh our thinking. At Objectivity, we’re proud to be able to call upon our expert Healthcare Advisory Board, which meets quarterly to discuss emerging trends and ideas in the health and care sector. Figure 4. Healthcare Advisory Board expert panel discussion.
What is the quadruple aim in the ICU?
Introduction – Coronavirus disease 2019 (COVID-19) has uniquely stressed health care systems, policy makers, and health care workers throughout the world as they face the worst health and economic crises of our lifetimes. Administrators are rapidly navigating their institutions through uncertain times, providing leadership and strategic plans to manage numerous evolving systems threats.
Many of these plans run counter to the accepted mantra in modern times, including intentional cancelations of profitable elective procedures and layoffs or furloughs of dedicated medical staff during the pandemic.1 The Triple Aim of health system reform addresses ongoing and future challenges faced by the health care sector, 2 with recent calls for expansion to a Quadruple Aim 3 to include considerations and protection for staff.
These 4 interdependent goals consist of (1) enhancing patient experience and safety, (2) improving population health, (3) reducing costs and preventing loss of revenue, and (4) improving wellness and satisfaction of health care workers. The fourth Aim incorporates the increasing understanding that excellent health care is not possible without a physically and psychologically safe and healthy workforce.
Is the quadruple aim a framework?
Quadruple AIM – Interprofessional Education The Triple Aim was developed by the Institute for Healthcare Improvement in October of 2007. Building upon this, our office has now adopted the Quadruple Aim. The Quadruple Aim framework was designed to help health care organizations:
Improve the patient experience of care (including quality and satisfaction); Improve the health of populations; and Reduce the per capita cost of health care Improve provider satisfaction (professional wellness)
To contribute to UAMS’ success in reaching the Quadruple Aim; the Office of Interprofessional Education has developed a strategic goal framework that supports a horizontal organizational structure that bridges across UAMS’ six- health professions (colleges), clinical delivery system and our research enterprise. : Quadruple AIM – Interprofessional Education
Who proposed the quadruple aim?
“We can and must take care of ourselves to best take care of those we took an oath to serve.” – C. Michael Valentine, MD, FACC, president of the American College of Cardiology. Nearly 450 ACC members joined together on Capitol Hill from Sept.30 – Oct.2 to advocate for patients at ACC’s 2018 Legislative Conference. In the days leading up to the Congressional visits, members of the entire cardiovascular team passionately advocated for each other, making it clear that better patient outcomes can best be achieved in an environment that combats burnout and fosters engagement and satisfaction.
The Quadruple Aim, a term coined by Thomas Bodenheimer, MD, in a 2014 Annals of Family Medicine paper, is the concept that the three dimensions of Institute for Healthcare Improvement’s Triple Aim by Donald M. Berwick, MD – improving the care of individual patients, promoting the health of populations and lowering health care costs – must take into account the wellbeing of health care providers in order to be effective.
Over the past decade, health care organizations have faced increasing pressure due to declining reimbursements, increasing burden of quality reporting, electronic health record requirements, prior authorization and a national shortage of nurses and physicians.
- Reacting to these external challenges, organizations have reflexively increased productivity expectations for physicians.
- Additional demands on physicians frequently come without an increase in time or resources, and often, though perhaps unintentionally, at the expense of what physicians cite as the most meaningful aspect of medicine: the doctor-patient relationship.
A recent Medscape survey of 14,000 physicians, researchers found that more than 50 percent of physicians report burnout, described as exhaustion, cynicism and depersonalization. Burnout contributes to dysfunctional relationships, depression, substance abuse and even suicide.
- Cardiologists are among the least satisfied and least likely to seek help.
- Widespread efforts to promote physician resilience (though well-intentioned) skirt the crux of the problem, which is that burnout is fundamentally a system problem.
- Although the ethical obligation to physicians is obvious, there is also a business case to be made for organizational commitment to physician engagement.
Studies show that burnout increases medical error, patient dissatisfaction and physician turnover. Moreover, burnout is not limited to physicians. All members of the health care team are affected. The Quadruple Aim is directed at the wellbeing of nurses, advanced practice providers, medical assistants, staff and anyone else involved in caring for patients.
There is no easy fix. There needs to be intentional, comprehensive and sustained efforts to give physicians the skills to cope within the system while simultaneously addressing the systemic issues that contribute to burnout. The solution begins with acknowledgement and a commitment to culture change, particularly at a higher level of leadership.
The College is our professional home and we are fortunate that our president has taken on the challenge of promoting the Quadruple Aim on an organizational, state and national level. This year’s Legislative Conference once again reminded us that the College is one of the most empowering platforms for us to come together, share ideas and act as our own champions.
What are the 7 principles of care?
(A principle is a particular approach to doing something.) The principles of care include choice, dignity, independence, partnership, privacy, respect, rights, safety, equality and inclusion, and confidentiality.
What are the 7 principles of person-centred care?
These are the guiding principles that help to put the interests of the individual receiving care or support at the centre of everything we do. Examples include: individuality, independence, privacy, partnership, choice, dignity, respect and rights.
What are the 4 principles of person-centred care?
Any example of person-centred care, within any health care experience, will involve a combination of these principles. there is likely to be more emphasis on the principles of dignity, compassion and respect, coordination and personalisation.
What are the 4 major determinants of health?
Frequently Asked Questions Health equity can be defined in several ways. One commonly used definition of health equity is when all people have “the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance'”.1 The U.S.
- Department of Health and Human Services defines health equity as attainment of the highest level of health for all people.
- Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.2 Achieving health equity, eliminating disparities, and improving the health of all groups is an overarching goal for Healthy People 2020 and a top priority for the Centers for Disease Control and Prevention (CDC).3 Health is influenced by many factors, which may generally be organized into five broad categories known as determinants of health: genetics, behavior, environmental and physical influences, medical care and social factors.
These five categories are interconnected. The fifth category (social determinants of health) encompasses economic and social conditions that influence the health of people and communities.4 These conditions are shaped by socioeconomic position, which is the amount of money, power, and resources that people have, all of which are influenced by socioeconomic and political factors (e.g., policies, culture, and societal values).5,6 An individual’s socioeconomic position can be shaped by various factors such as their education, occupation, or income.
- How a person develops during the first few years of life (early childhood development)
- How much education a person obtains and the quality of that education
- Being able to get and keep a job
- What kind of work a person does
- Having food or being able to get food (food security)
- Having access to health services and the quality of those services
- Living conditions such as housing status, public safety, clean water and pollution
- How much money a person earns (individual income and household income)
- Social norms and attitudes (discrimination, racism and distrust of government)
- Residential segregation (physical separation of races/ethnicities into different neighborhoods)
- Social support
- Language and literacy
- Culture (general customs and beliefs of a particular group of people)
- Access to mass media and emerging technologies (cell phones, internet, and social media)
All of these factors are influenced by social circumstances. Of course, many of the factors in this list are also influenced by the other four determinants of health. Addressing social determinants of health is a primary approach to achieving health equity.
Health equity is “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance'”.7 Health equity has also been defined as “the absence of systematic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages—that is, different positions in a social hierarchy”.8 Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities.
The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people’s lives by reducing health inequities. Health organizations, institutions, and education programs are encouraged to look beyond behavioral factors and address underlying factors related to social determinants of health.
A growing body of research highlights the importance of upstream factors that influence health and the need for policy interventions to address those factors—in addition to clinical approaches and interventions aimed at modifying behavior.9 The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people’s lives by reducing health inequities.
Health organizations, institutions, and education programs are encouraged to look beyond behavioral factors and address underlying factors related to social determinants of health. The created the to address social determinants of health.4 The Commission uses the following three principles to guide its work in eliminating health inequities for local communities and nations and throughout the world: Figure 1. World Health Organization’s Social Determinants of Health Conceptual Framework 4
- Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and age.
- Tackle the inequitable distribution of power, money, and resources—the structural drivers of those conditions of daily life—globally, nationally, and locally.
- Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.4
The commission created the conceptual framework below that describes relationships among individual and structural variables. The framework represents relationships among variables that are based on scientific studies or substantial evidence. The framework provides a point from which researchers can take action, such as creating targeted interventions, on social determinants of health.
- More information is available from a variety of sources, including the following publications and web sites.
- . Editors Erik Blas and Anand Sivasankara Kurup.2010, World Health Organization: Geneva.
- Commission on Social Determinants of Health (CSDH),,2008, World Health Organization: Geneva.
- Hillemeier, M., Lynch, J., Harper, S., Casper, M.,,2004, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services: Atlanta.
- Brennan Ramirez LK, Baker EA, Metzler M., Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.
- Hofrichter, R., Bhatia, R. (Eds.) Tackling Health Inequities through Public Health Practice: Theory to Action.2010, Oxford University Press.
- Raphael, D., ed. Social determinants of health: Canadian perspectives,2004, Canadian Scholars’ Press Toronto.
- Marmot, M.G. and R.G. Wilkinson, Social determinants of health,2nd ed.2006, Oxford ; New York: Oxford University Press. x, 366 p.
You can e-mail the Office of Health Equity at,
- Braveman, P.A., Monitoring equity in health and healthcare: a conceptual framework, Journal of health, population, and nutrition, 2003.21(3): p.181.
- U.S. Department of Health and Human Services,,2018.
- CDC, ; ODPHP,,
- Commission on Social Determinants of Health (CSDH), Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health,2008, World Health Organization: Geneva.
- U.S. Department of Health and Human Services., Social Determinants of Health.
- Commission on Social Determinants of Health (CSDH). A Conceptual Framework for Action on the Social Determinants of Health. Discussion Paper for the Commission on Social Determinants of Health DRAFT.2007, World Health Organization: Geneva.
- Brennan Ramirez LK, B.E., Metzler M., Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, Centers for Disease Control and Prevention, Editor.2008, Department of Health and Human Services: Atlanta, GA.
- Braveman, P. and S. Gruskin, Defining equity in health. Journal of Epidemiology and Community Health, 2003.57(4): p.254-258.
- Health Policy Brief: “The Relative Contribution of Multiple Determinants to Health Outcomes,” Health Affairs, August 21, 2014.
Why is it difficult to achieve the triple aim?
Bright Spots – Despite the absence of overall significant improvement, we found bright spots (10% or greater improvement from baseline to year 3) for all measures except hospital readmissions and specialty referrals. All bright spots practices in care quality measures participated in the collaborative’s quality thread.
- Two-thirds of bright spots for cost and patient experience measures participated in those threads (Table 3).
- Two practices were noted as bright spots for at least one measure in each element of the Triple Aim.
- Both programs had stable EHRs and registry use and both reported faculty involvement with the data management.
They also had engaged I3 champions who were able to create and sustain a culture of improvement in their programs. When examining the relationship between practice characteristics and improvement, practices that had a higher number of annual patient visits were more likely to improve in triple aim measures above the collaborative median (OR 10.8, 95% CI: 0.68–172.2, P =0.03, Table 4).
- There were nonstatistically significant trends for having PCMH recognition with improvement (OR 5.50, P =0.08).
- When examining survey responses, a total of 18 programs provided feedback on the I3 collaborative.
- Ey facilitators for the programs included having engaged departmental leadership support, aligning I3 work with ongoing system goals, and having a multidisciplinary team approach to getting the work done.
Challenges included disruptions with a nationally-certified EHR conversion, data collection that required off site collection, multiple competing demands of teaching practices, and disseminating information to those not directly involved in I3. When asked what aspects of the triple aim the practice found easiest to address, responses were mixed and seemed to correlate with ease of data access.
Matching outcomes with interventions was difficult, as practices may have been working in one area of the triple aim, but the outcome measure failed to capture the work that they were doing (eg, collecting outcomes of patient continuity and time to third available visit, but working on a different aspect of patient experience).
When asked what aspects were most beneficial to their practice, several programs noted learning from each other, increasing resident awareness of and enthusiasm for population health, and having time set aside for face-to-face meetings to grapple with these issues. In our study of residency teaching practices attempting to work on triple aim goals, 24% made improvements in all three aims. All practices that were able to pull and report data improved on at least one measure. However, there were no statistically significant improvements in the collaborative as a whole.
This is likely due to an array of factors, including wide variation in triple aim baseline measures across practices. The specific approaches to improving care may be more local than hypothesized, as some sites were able to make significant improvement. Additionally, allowing participants to select the measures they wanted to improve, while enhancing their engagement, may have missed an important assessment of their capacity to engage in practice improvement activities.
The triple aim, often thought of as an iron triangle, 15 where cost, experience, and quality goals are in constant competition with each other, is also difficult; working on more than one of these areas at a time may mean that individual measures are tougher to move within a short time period.
- Many practices experienced substantial difficulty obtaining data, even those that were part of large health systems.
- Barriers included limited capabilities of the nationally certified EHR to pull needed measures; policy limits internal to the health system or length of reporting queue; and insufficient training or skill of staff to obtain needed EHR data.
Barriers to improvement will continue if these supports are not addressed. The structure of the I3 POP Collaborative, which varied in design from its earlier two counterpart programs, may have also contributed to inability to demonstrate significance of outcomes overall.
- Managing three different thematic areas simultaneously contributed to insufficient focus on targeted aims for improvement.
- Allowing practices to have freedom choosing measures without limits and not providing incentives or tangible support for the work involved, beyond educational sessions, may have contributed to the collaborative taking on a more diffused or lesser priority within the teaching practices.
Finally, the variables measured were compared using traditional statistical methods that may not account for clinical significance or ability to surpass a clinically significant threshold. Furthermore, the rate for several measures already exceeded national benchmarks 16,17 at baseline.
However, this experience provides insight into the challenges and strains that primary care microsystems are experiencing within health systems. When reflecting on the facilitators of improvement, having departmental leadership support, aligning I3 work with local health system goals, and having a multidisciplinary team approach to getting the work done were described as key facilitators.
Having a vision and commitment for systemic change is important for success.18 Future work needs to focus on cultivating leadership and systems supports in large-scale improvement. Limited literature describes specific curricular activities or experiences that incorporate QI principles and methodologies into graduate medical education.19-31 Several of these studies have shown an improvement in patient care as measured by specific quality indicators.
The I 3 POP takes a broader approach and incorporates the triple aim for both learners and faculty development. There are several limitations to the I3 POP evaluation. I3 POP is a decentralized, regional collaborative, with most data obtained through EHR. Although these results are subject to the limitations of data pulls, these are the same data that our health care systems are evaluated upon, making it paramount that data are as accurate as possible.
Additionally, many of these residency programs are working on QI initiatives in chronic disease, prevention and utilization independent of this collaborative. It is not possible to tease out the effects of the I3 collaborative from those of other practice- and system-based improvement efforts.
What is the role of the IHI?
IHI works closely with hospitals to implement proven interventions for avoiding preventable deaths. IHI works to improve service delivery efficiencies to save more lives, provide better care, and improve patient safety.
Which of the IOM aims has this hospital most clearly met?
Safe care means avoiding injuries to patients from the care that is intended to help them. Michael contracted an infection because his care was not as safe as it could have been. Which of the IOM aims has this hospital most clearly met? Timely.
Why is it important to address diversity biases prior to providing patient care?
Communication Breakdown – Be it the result of a language barrier, differences in philosophy, differences in cultural norms (& expectations), or even cultural bias, a lack of diversity can lead to a communication breakdown with patients. And when patients cannot fully communicate or express their needs, dangerous mistakes can occur.
How do I cite the Institute of healthcare Improvement?
IHI.org is an Internet system that provides resources, at low or no cost, to people all over the world to help them take effective action to improve health care. It will be helpful to people in many different roles in the health care system — including (but not limited to) physicians, nurses, other clinicians, managers, executives, policy-makers, educators, students, and interested members of the lay public.
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How is health care funded in Canada?
The provincial and territorial governments – The provinces and territories administer and deliver most of Canada’s health care services, with all provincial and territorial health insurance plans expected to meet national principles set out under the Canada Health Act,
Each provincial and territorial health insurance plan covers medically necessary hospital and doctors’ services that are provided on a pre-paid basis, without direct charges at the point of service. The provincial and territorial governments fund these services with assistance from federal cash and tax transfers.
Medically necessary services are not defined in the Canada Health Act, It is up to the provincial and territorial health insurance plans, in consultation with their respective physician colleges or groups, to determine which services are medically necessary for health insurance purposes.
- If it is determined that a service is medically necessary, the full cost of the service must be covered by the public health insurance plan to be in compliance with the Act.
- If a service is not considered to be medically required, the province or territory need not cover it through its health insurance plan.
The roles of the provincial and territorial governments in health care include:
administration of their health insurance plans; planning and funding of care in hospitals and other health facilities; services provided by doctors and other health professionals; planning and implementation of health promotion and public health initiatives; and negotiation of fee schedules with health professionals.
Most provincial and territorial governments offer and fund supplementary benefits for certain groups (e.g., low-income residents and seniors), such as drugs prescribed outside hospitals, ambulance costs, and hearing, vision and dental care, that are not covered under the Canada Health Act,
Although the provinces and territories provide these additional benefits for certain groups of people, supplementary health services are largely financed privately. Individuals and families who do not qualify for publicly funded coverage may pay these costs directly (out-of-pocket), be covered under an employment-based group insurance plan or buy private insurance.
Under most provincial and territorial laws, private insurers are restricted from offering coverage that duplicates that of the publicly funded plans, but they can compete in the supplementary coverage market. As well, each province and territory has an independent workers’ compensation agency, funded by employers, which funds services for workers who are injured on the job.