In 2014, the Triple Aim proposed by IHI in 2007 became the Quadruple Aim. This transition occurred because the objectives of the Triple Aim – better patient experiences, better population health, and lower costs – had been pursued mainly with what may have been an ill-conceived and dangerous assumption. Specifically, the dedication of clinicians and providers was assumed to be an inexhaustible resource of human initiative, technical expertise, and plain old labor.
This assumption was dangerous because significant driving forces in healthcare, such as administrators, investors, regulators, and vendors within the industry, held this assumption to be true. This view led to initiatives, compliance requirements, and work demands that frequently did not align strongly with those dedicated healthcare professionals’ motivations and goals yet asked more and more of them.
Finally, healthcare team well-being was added to create the vital concept of the Quadruple Aim. How much progress has been made in the eight years since?
Many have reported real progress on parts of the Quadruple Aim. Still, several things stand out. First, gains in one of the Aims sometimes come at a cost, even to the point of backsliding, in others. If the true goal is to optimize for all four Aims, why is this acceptable? Second, some efforts become parochial and limited in focus as though they are driven by more competitive or “better” thinking than the unified way of thinking that is required to serve the four aims. Third, some analysts consider operational efficiency a frequent enabler of competing goals, but honestly, efficiency has never been a core strength or serious pursuit in healthcare. While efficiency is usually the key to serving these competing goals, it may address the fourth Aim, the team’s well-being, the most. And that is why it becomes such a breakthrough for the Quadruple Aim because, with significant weakness in the fourth Aim, the other three are rarely, if ever, met.
Here is a simple but essential chain of thought. Performance Improvement, as the critical path toward the Quadruple Aim, needs to be deftly integrated into all the processes used to manage clinical care. Endless speeches, white papers, classes, and slogans are not enough to accomplish this. Instead, genuinely re-engineering the workflows and tools used is required. Contrary to this requirement, the typical approach to PI is to approach it as a distinct function governed by conceptual methodologies, which are only blueprints for manual human work. Any means of technical facilitation is usually homegrown, lacking standardization and any real efficiency, and so are pinpoint solutions serving only separate tasks in the process chain without real integration or collective advantage. In Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study published in BMC Research Notes, Bengt B. Arnetz et al. said, “To our knowledge, no previous intervention has primarily targeted efficiency for quality improvement.”
An advanced PI software workbench designed with the real goals in mind, not just the separate objectives’ tasks, and strong UI/UX (user interface and user experience) that is directly connected to the processes for tracking, analyzing, and investigating quality metrics and safety event reports, represents a significant and vital innovation that can have tremendous impacts on efficiency for the overall effort. It is certainly worth an exploratory look and, frankly, serious consideration, but many will not take that next step because it is very different from what they have “always done.” So maybe it’s time for a real break out to get to the Quadruple Aim.
