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From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider Thomas Bodenheimer and Christine Sinsky The Annals of Family Medicine November 2014, 12 (6) 573-576; DOI: https://doi.org/10.1370/afm.1713
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Abstract
The Triple Aim—enhancing patient experience, improving population health,
and reducing costs—is widely accepted as a compass to optimize health
system performance. Yet physicians and other members of the health care
workforce report widespread burnout and dissatisfaction. Burnout is
associated with lower patient satisfaction, reduced health outcomes, and it
may increase costs. Burnout thus imperils the Triple Aim. This article
recommends that the Triple Aim be expanded to a Quadruple Aim, adding the
goal of improving the work life of health care providers, including clinicians
and staff.
In this issue
The Annals of Family Medicine: 12 (6) Vol. 12, Issue 6 November/December 2014 Table of Contents Index by author Back Matter (PDF) Front Matter (PDF) The Issue in Brief
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primary health care patient-centered care health care workforce
INTRODUCTION
Since Don Berwick and colleagues introduced the Triple Aim into the health
care lexicon, this concept has spread to all corners of the health care system.
The Triple Aim is an approach to optimizing health system performance,
proposing that health care institutions simultaneously pursue 3 dimensions of
performance: improving the health of populations, enhancing the patient
experience of care, and reducing the per capita cost of health care. The
primary Triple Aim goal is to improve the health of the population, with 2
secondary goals—improving patient experience and reducing costs—
contributing to the achievement of the primary goal.
In visiting primary care practices around the country, the authors have
repeatedly heard statements such as, “We have adopted the Triple Aim as our
framework, but the stressful work life of our clinicians and staff impacts our
ability to achieve the 3 aims.” These sentiments made us wonder, might there
be a fourth aim—improving the work life of health care clinicians and staff—
that, like the patient experience and cost reduction aims, must be achieved in
order to succeed in improving population health? Should the Triple Aim
become the Quadruple Aim?
RISING EXPECTATIONS OF PHYSICIANS AND PRACTICES
Society expects more and more of physicians and practices, particularly in
primary care. Patients want their health to be better, to be seen in a timely
fashion with empathy, and to enjoy a continuous relationship with a high-
quality clinician whom they choose. A patient-centered practice has been
described as, “They give me exactly the help I need and want exactly when I
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Article
Abstract
INTRODUCTION
RISING EXPECTATIONS OF PHYSICIANS AND PRACTICES
PHYSICIAN BURNOUT
STAFF BURNOUT
CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE AIM
ADDRESSING THE FOURTH AIM
CONCLUSION
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need and want it.” Yet for primary care, society has not provided the
resources to meet these lofty benchmarks.
PHYSICIAN BURNOUT
The wide gap between societal expectations and professional reality has set
the stage for 46% of US physicians to experience symptoms of burnout.
Widespread across specialties, burnout is especially prevalent among
emergency department physicians, general internists, neurologists, and family
physicians. In a 2014 survey, 68% of family physicians and 73% of general
internists would not choose the same specialty if they could start their careers
anew. Professional burnout is characterized by loss of enthusiasm for work,
feelings of cynicism, and a low sense of personal accomplishment and is
associated with early retirement, alcohol use, and suicidal ideation.
According to a recent RAND Corporation survey, the principal driver of
physician satisfaction is the ability to provide quality care. Physician
dissatisfaction, therefore, is an early warning sign of a health care system
creating barriers to high-quality practice.
We have heard physicians making such statements as:
“The joy of practicing medicine is gone.”
“I hate being a doctor…I can’t wait to get out.”
“I can’t tell you how defeated I feel…The feeling of being
punished for delivering good care is nerve-racking.”
“I am no longer a physician but the data manager, data
entry clerk and steno girl… I became a doctor to take care
of patients. I have become the typist.”
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Subjects
Keywords
primary health care, patient-centered care, health care workforce
Other research types:
Health policy
Professional practice
Other topics:
Organizational / practice change
Mindfulness and reflection
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In a 2011 national survey, 87% of physicians named the leading cause of
work-related stress and burnout as paperwork and administration, with 63%
indicating that stress is increasing. Forty-three percent of physicians
surveyed in 2014 reported spending over 30% of their day on administrative
tasks. Physicians spend more time on non–face-to-face activities (eg, letters,
in-box management, and medication refills) than with patients. Even when
in the exam room with patients, primary care physicians spend from 25% to
50% of the time attending to the computer. Between 2009 and 2010,
primary care physicians at a Veterans Affairs facility spent 49 minutes per day
responding to inbox-type alerts in addition to documentation of care provided.
One-half of such alerts have little clinical significance or could be handled by
other team members; 80% of the text in the alerts is unnecessary. The volume
of alerts and texts overshadows important information that requires action.
Moreover, the alerts create interruptions known to adversely affect patient
care.
A 2013 survey of 30 physician practices found that electronic health record
(EHR) technology has worsened professional satisfaction through time-
consuming data entry and interference with patient care. Emergency
medicine physicians spend 44% of their day doing data entry, with 4,000 EHR
clicks per day; only 28% of the day is spent with patients. In a 2011 survey,
over three-quarters of physicians reported that the EHR increases the time it
takes to plan, review, order, and document care.
STAFF BURNOUT
Burnout affects not only physicians, but also other members of the health care
workforce. Thirty-four percent of hospital nurses and 37% of nursing home
nurses report burnout, compared with 22% of nurses working in other
settings. On the front lines of practice, receptionists have a stressful job,
with 68% experiencing verbal abuse from patients. Most receptionists feel
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that physicians fail to appreciate the complexity of their work. Sources of
stress include finding appointments for patients and feeling caught between
doctors’ and patients’ demands. A 2013 survey of 508 employees working
for 243 health care employers found that 60% reported job burnout and 34%
planned to look for a different job. Complaints included heavy patient loads,
small staffs, and high stress levels.
Physician and staff dissatisfaction feed on each other. “It’s really rough to be
around a burned-out doctor. They’re cynical, sarcastic, and wonder, ‘what’s
the use anymore?’” It can go the other way, too. A burned-out staff member
may not be doing his or her job, resulting in more stress for the already
overworked doctor. Adequate numbers of well-trained, trusted, and capable
support staff with low turnover predict greater physician satisfaction.
CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE AIM
Burnout among the health care workforce threatens patient-centeredness and
the Triple Aim. Dissatisfied physicians and nurses are associated with lower
patient satisfaction. Physician and care team burnout may contribute to
overuse of resources and thereby increased costs of care. Unhappy
physicians are more likely to leave their practice; the cost of family physician
turnover approaches $250,000 per physician. Dissatisfied physicians are
more likely to prescribe inappropriate medications which can result in
expensive complications.
Physician burnout is associated with reduced adherence to treatment plans,
resulting in negatively affected clinical outcomes. Burnout also leads to
lower levels of empathy, which is associated with worsened clinical outcomes
for patients with diabetes. Patient safety is threatened by nurse
dissatisfaction; many nurses report that their workload causes them to miss
important changes in their patients’ condition. Dissatisfied physicians are 2
to 3 times more likely to leave practice, thereby exacerbating the growing
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shortage of primary care physicians and complicating the achievement of a
healthy population.
Practices working toward the Triple Aim may increase physician burnout and
thereby reduce their chances of success. Higher scores on a patient-centered
medical home assessment may be associated with greater clinician burnout in
safety-net clinics. More EHR functionalities—email with patients, physician
order entry, alerts and reminders—intended to promote the Triple Aim are
associated with more burnout and intent to leave practice.
Group Health Cooperative implemented primary care reforms in the early
2000s aimed at improving Triple Aim performance. The unintended
consequence was increased physician burnout and resultant quality
reductions and cost increases. In 2006, Group Health changed direction,
focusing first on clinician work life by increasing visit length and reducing
panel size. Burnout dropped substantially with significant gains in clinical
quality, patient experience, and cost reduction. The Group Health story
demonstrates that without addressing the work life of those providing care,
Triple Aim measures are likely to worsen.
ADDRESSING THE FOURTH AIM
How can health care organizations work toward the fourth aim, improving the
work life of clinicians and staff? For primary care physicians the following list
suggests some practical steps:
Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.
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Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results
Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders
Standardize and synchronize workflows for prescription refills, an approach which can save physicians 5 hours per week while providing better care
Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day
To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice
In the longer run, to address the chasm between society’s expectations and
primary care’s capacity, more financial and personnel resources should be
dedicated to primary care. One study estimates that a 59% increase in
staffing, to 4.25 FTE staff per physician, is needed to achieve the patient-
centered medical home.
Patient-centeredness and the Fourth Aim
The barriers to achieving the Triple Aim include improving population health in
a society experiencing obesity and diabetes epidemics and growing income
disparities, rising health care costs, and a dispirited and disengaged health
care workforce. If the gap continues to widen between society’s expectations
for primary care and primary care’s available resources, the feelings of
betrayal and the wearing down from daily stress voiced by primary care
practitioners will grow. The negative impact on patient-centered care will be
deep and long lasting. On the other hand, if an emphasis on the workforce
comes at the expense of patients’ needs, this focus could have negative
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consequences. Health care is a relationship between those who provide care
and those who seek care, a relationship that can only thrive if it is symbiotic,
benefiting both parties.
CONCLUSION
The Triple Aim has provided society with a compass, pointing the way forward
for our health care system. The positive engagement, rather than the negative
frustration, of the health care workforce is of paramount importance in
achieving the primary goal of the Triple Aim—improving population health.
Leaders and providers of health care should consider adding a fourth
dimension—improving the work life of those who deliver care—to the
compass points of better care, better health, and lower costs.
Footnotes
Conflicts of interest: authors report none.
Received for publication May 10, 2014.
Revision received August 15, 2014.
Accepted for publication September 2, 2014.
© 2014 Annals of Family Medicine, Inc.
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