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:
- 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.
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