The Quadruple Aim Model

Dr. Teri Pipe is dean of the College of Nursing & Health Innovation at Arizona State University (ASU). She joined ASU in 2011. In 2016 Dr. Pipe was appointed Chief Wellbeing Officer for Arizona State University. Before coming to ASU, Dr. Pipe served as director of Nursing Research and Innovation at Mayo Clinic Arizona. In 2014 she was selected as a Robert Wood Johnson Foundation Executive Nurse Fellow. Below is a blog she wrote for us on the Quadruple Aim model of care.

In 2008, Donald Berwick and colleagues provided a framework for understanding value in health care. The framework, which includes three overarching goals, has become widely known as the Triple Aim: optimizing the experience of care for individuals and families, improving the health of populations, and reducing health care’s per capita costs.

Recently, a fourth aim has been proposed, which recognizes that achieving the Triple Aim requires an engaged and highly effective workforce. The Quadruple Aim adds the component of improving the experience of those directly providing care. More explicitly, the expanded aim acknowledges the importance of physicians, nurses, and all employees in finding joy and meaning in their work.

The proponents caution that joy and meaning are not necessarily synonymous with happiness. Rather, joy and meaning reflect a deeply-rooted understanding that daily work is important and often linked to a larger purpose, allowing the health team to derive a sense of accomplishment and contribution. As with most worthwhile aims, however, there are significant challenges that must be overcome in order to address the goal of joy and meaning in the health workplace.

The current situation is not particularly encouraging. In a 2012 survey it was reported that US physicians suffer more burnout than other American workers. Likewise, in a 2013 survey of Registered Nurses, 51% of RN’s were concerned that their work was affecting their health, and 35% felt like resigning from their current job.

While stress and burnout are not new problems in the health workforce, the additional pressures of information overload, changes in reimbursement strategies, and time sensitivities are pressuring health professionals in newly demanding ways. Add to this the psychological and physical threats of harm– dysfunctional communication, lack of respect, poor workflow design, and non-value added task burden, and we have a scenario that does not promote patient care and safety.  

A refreshed approach is needed, and the framework provided by the Quadruple Aim provides a platform for positive dialogue and solution design.

From my vantage point as a health leader and health professions educator, the Quadruple Aim inspires me to explore how to engage my colleagues in designing learning environments that encourage their students to seek new ways to create joy and meaning for themselves as they go about gaining the other competencies required for their profession. Faculty would also benefit by deriving joy and meaning from their important work.

We are bridging the academic-practice cultures in more streamlined and effective ways, helping students transition from their academic programs into work environments where the Quadruple Aim is valued and supported. An example of this is a recent Day of Dialogue convened in Washington, DC between leaders from the American Organization of Nurse Executives and the American Association of Colleges of Nursing to discuss challenges that could be better solved if we work together rather than in our familiar silos.

With an eye on improved effectiveness, productivity and joy in the workplace, in conjunction with improved outcomes for patients, my colleagues at Brigham and Women’s Hospital, Dana-Farber Cancer Institute, and Arizona State University, launched the Workforce Outcomes Research and Leadership Development Institute—otherwise known as the WORLD-Institute.

As academic organizations strive to provide interprofessional education, the forth aim is a natural place where students could potentially learn from, with and about each other in the service of better health care. The Quadruple Aim also provides a challenge for health leadership. How will we continue to focus on patient experience, population health and cost while simultaneously co-creating environments that foster and reward joy and meaning for the health provider team? This is a question that will benefit greatly from innovation, collaboration, and much deeper conversation.


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