From the Triple Aim to the Quadruple Aim

Cristina Roure

Readers of the blog Advances in Clinical Management will be familiar with the term Triple Aim coined by Donald Berwick from the Institute for Healthcare Improvement of the United States(1) which recognizes those clinical projects that simultaneously achieve the triple objective to:

1. Improve the patient experience (satisfaction and quality)
2. Improve clinical outcomes in the population
3. Reduce health care per capita costs

We can increase the quality at the expense of increasing the cost or reduce costs at the expense of quality of care to patients or at the expense of clinical outcomes, but according to Berwick, only by focusing on achieving the objectives in all three dimensions simultaneously in a balanced manner we can improve the health care of the population. The concept is attractive but it’s easier to understand than it is to implement.

Recently there have been critics who say the Triple Aim remains limited and should consider, if I may, a "fourth leg" or objective: the satisfaction of health professionals.

Thomas Bodenheimer and Christine Sinsky from the Department of Family and Community Medicine at UCSF (University of California San Francisco) said in a recent article that the growing burnout among health professionals that affects 46% of American physicians endangers the Triple AIM(2).

The professional burnout syndrome is characterized by a state of physical, emotional and mental exhaustion in professionals facing emotionally demanding situations with insufficient resources for long periods getting little or no results and leading to a "cynical" or distant attitude towards work (depersonalization) and a feeling of powerlessness and of not having performed adequately.

Bodenheimer and Sinsky said that the patients’ expectations and those of society in general regarding health care are constantly increasing and in exchange the reality of health professionals, increasingly stressful every day, negatively affects their ability to achieve the Triple Aim. Professionals’ dissatisfaction associated with decreased patient satisfaction regarding the received care contributes to overuse of unnecessary diagnostic tests and medication that may end up in worse health outcomes and cost increases.

To address the gap between the expectations of society and the professionals’ ability of achieving the three objectives of the Triple Aim adding a fourth goal and make it a Quadruple Aim is paramount. The fourth objective is to promote professionals’ emotional well-being and improve their working environment and their resilience.

Again the Mayo Clinic in Rochester, Minnesota has pioneered research and innovation in this field and in 2007 created the Program for Physician Well-being. Led by the Department of Medicine, Psychiatry and Psychology, its main objective is to promote research on the spectrum of personal, professional and organizational factors that influence well-being, satisfaction and productivity of professionals. They have even created an interactive tool to measure well-being of their doctors: the Mayo Clinic Physician Well-Being Index (MPBI)(2). In the following presentation, you can see briefly what’s this tool about and its validation by more than 7,000 American doctors:

The program also conducts clinical trials to evaluate their interventions. Thus, a controlled and randomized clinical trial conducted in a group of 74 doctors shows that a consistent intervention in 19 fortnightly meetings provided with certain content, in small groups, with a protected hour and paid for by the organization for nine months can improve some elements in the medical welfare and reduce burnout in its dimension of depersonalization, regarding their baseline and compared to a control group and that this result persists after the 12 months from the intervention(3).

A study conducted in Spain in 2010 already showed a 39.3% of burnout in primary care(4). Perhaps the lack of attention to this "fourth leg" partly explains the paradoxical difficulty of implementing programs like Triple Aim when their benefits on paper are so obvious to everyone.

Bibliography:

1. Berwick D, Nolan T, Whittington J. The Triple Aim: Care, Health, And Cost. Health Affairs 2008; 27(3):759-769.
2. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to Promote Physician Well‐being, Job Satisfaction. JAMA Intern Med. 2014;174(4):527-533.
3. Shanafelt T, Kaups K, Nelson H, et al. An Interactive Individualized Intervention to Promote Behavioral Change to Increase Personal Well-Being in US Surgeons. Ann Surg 2013;00:1–7.
4. D. Navarro-González, A. Ayechu-Díaz, I. Huarte-Labiano. Prevalencia del síndrome del burnout y factores asociados a dicho síndrome en los profesionales sanitarios de Atención Primaria. SEMERGEN Atención Primaria 2014; 22 de mayo de 2014.