The quadruple quest for the Holy Grail of healthcare

18 minute read

We’ve always been taught that the patient comes first, but if we don’t look after healthcare workers, we won’t get very far

The observations of Australian otolaryngologist, Dr Eric Levi, will have struck a chord with many members of the medical profession. First published on his blog, and republished by The Medical Republic, Dr Levi has raised an issue often overlooked in the quest to deliver high quality healthcare. In a series of frequently candid posts, Dr Levi detailed the stresses and strains of working in healthcare and its impact on the people it is supposed to help.

Using words including hardened, depressed, anxious, disillusioned and even suicidal, the Melbourne-trained doctor described the raw, negative emotions experienced by his colleagues. These emotions have been created, or at least exacerbated, in doctors and other healthcare workers by an overwhelming workload, further hampered by onerous bureaucratic and administrative tasks, he says.

Dr Levi wrote, “They won’t be playing their best game. Their morale suffers, the hospital suffers and ultimately, patients suffer.”  He suggested a series of measures, many of them simple, to alleviate this despondency, to raise flagging morale and restore a semblance of joy and meaning to the workplace.

“Can we … think about simple creative things to make our work more enjoyable and meaningful? Can we agree that we all want to come to work to enjoy caring for patients?” he asked. “Investing in the well-being and morale of staff members will reap long-term benefits.”

This call to improve the well-being of the healthcare provider has, in recent times, become known as the “fourth pillar” of the Quadruple Aim, and sits on top of what’s referred to as the Triple Aim.

The addition of this fourth pillar to improve healthcare builds on a framework first discussed a decade ago by Donald Berwick, one of the leading lights of the US-based Institute for Healthcare Improvement (IHI) who served under former US president Barack Obama as administrator of the Centers for Medicare and Medicaid Services.

In a paper written in 2008, Berwick and two colleagues, Thomas Nolan and John Whittington, set out three core objectives of health, labelled the Triple Aim: improving the individual experience of care, improving the health of populations and reducing the per capita costs of care. This triumvirate was not a short-term fix – as the lofty ambitions may indicate – but a call, instead, for systemic change that would shape and guide healthcare policy and involve, among other things, the pursuit of integrated care, the bridging of the divide between primary, secondary and acute care, and the elimination of inefficient, ineffective and unnecessary treatments.

While established primarily with the creaking and inequitable US health system in mind, Berwick told The Medical Republic via email that the framework was just as relevant in Australia. “The idea of the Triple Aim has been well received in many nations across the whole range of national wealth and development stages, and I do believe that the notion is relevant to Australia,” he said.

“The lower cost component does benefit from mature public dialogue about the fact that ‘more care’ does not always mean ‘better care’.

“I do recall being very impressed some years ago by an effort, helped by the federal government I believe, to better educate citizens about that distinction between ‘more’ and ‘better’.

“It included, for example, a short public service TV spot showing two people walking and talking about the choice between back surgery and more conservative approaches that have excellent outcomes.

“So, in that sense, there is at least some history in Australia of taking a really useful, thoughtful, and mature approach to avoiding overuse of needless or ineffective care.”

The addition of the fourth dimension came later, having been identified by Thomas Bodenheimer and Christine Sinsky as a critical component in achieving the Triple Aim. After all, they argued, how could you optimise the performance of a healthcare system when the workforce providing that care was weary, disenchanted, or worse?

It is an argument shared by Dr Levi.

Having determined widespread burnout as a cause of lower patient satisfaction, poorer health outcomes and potentially higher costs – precisely the opposite of the Triple Aim’s objectives – Bodenheimer and Sinsky concluded: “The Triple Aim has provided society with a compass, pointing the way forward for our healthcare system. The positive engagement, rather than the negative frustration of the healthcare workforce is of paramount importance in achieving the primary goal of the Triple Aim – improving population health.

Leaders and providers of healthcare 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.”

Berwick told The Medical Republic he accepted the addition of the fourth pillar as pivotal in aspiring to the goals of the original Triple Aim.

“The Quadruple Aim is an effort to emphasise the importance of working toward joy and pride in the healthcare workforce as a precondition to excellence in care,” he said.

“In recent times, in some nations, burnout has been all too common among doctors, nurses and others. I don’t have an opinion about changing from Triple to Quadruple but, either way, reducing such burnout is essential for progress.”

It is hard to pinpoint a moment in time when Australia adopted – formally or otherwise – Berwick’s Triple Aim vision, or framework, as the IHI prefers to call it. But over the years it has seeped into the Australian healthcare lexicon, and now underpins the way many healthcare organisations now aim to function.

Carrie Marr, chief executive of the Clinical Excellence Commission, which has worked with the IHI for a decade, said the Triple Aim had become “embedded” in the Australian health system over the past 18 months. She detailed the work being carried out by the South East Sydney Local Health District (SESLHD) as an example of a collaborative approach to drive improvement in population health.

“South East Sydney LHD has moved away from the traditional hospital based model of activity and growth in the hospital sector,” Marr said.

“Using Triple Aim we know that improving population health is about working with partners and the community. Health, alone, can only add so much to improve health and life. Much is influenced by social determinants, active communities and effective education.

“We have signed collaborative agreements with our council to advance this work and have targeted diabetes in Maroubra and Botany Bay where the variation in care is stark.”

To enhance the approach, Marr said SESLHD had developed an “equity strategy” which she said was “radical in its construction”.

The new strategy was, Marr said, based on the “concept of coproduction, which is supported by strong evidence in the literature on well-being and is much about engaged, active and involved communities”.

“Citizens feel they have much more control over their lives and the intervention from multiple statutory agencies,” she explained. “The general practice community is vital in promoting self-management, anticipatory care and risk stratification, which are all designed to decrease avoidable admissions for patients with comorbidity.”

By way of example, Marr claimed it was clear that social isolation was among the key reasons for the admission of the elderly to hospital, alongside overprescribing in this group. She said a study conducted in her native Scotland substantiated the latter, with 17% of admissions of frail elderly people caused by “excessive medication”.

According to Walter Kmet, chief executive of WentWest, the Western Sydney Primary Health Network, the Quadruple Aim has been “picked up” by several PHNs in their approach to primary healthcare, and is an integral element to the creation of the much-debated Health Care Homes set to roll out in 200 trial sites across 10 Primary Health Networks from October 1.

On its web page exploring the “Patient-Centred Medical Home”, WentWest explains the 10 “building blocks” established by Thomas Bodenheimer designed to lay the foundations for the Quadruple Aim.

“The model plays a pivotal role in achieving improved health of populations, enhanced patient experiences, healthcare cost reductions and better support for health professionals – also known as the Quadruple Aim,” WentWest spells out on its website.

In defining the four pillars, WentWest lists reduced waiting times, improved access to care, and meeting the needs of patients and their families as goals for patient experience of care, while improved health outcomes, equity of access and “reduced disease burden” are aims outlined in driving quality and population health.

Meanwhile, sustainable cost will be achieved through actions including the reduction of avoidable and unnecessary hospital admissions, and a return on the investment of innovation costs. The fourth pillar, which WentWest described as “improved provider satisfaction”, will be derived through sustainability and meaning of work, increased clinician and staff satisfaction, and teamwork.

“Our remit is unashamedly to improve the capacity and capability of primary care and we are applying this construct to that environment,” Kmet told The Medical Republic. “But when we go and talk to the hospital district or specialist providers, it is something they have also adopted.”

Kmet highlighted the work conducted by the Western Sydney Integrated Care program, where hospital clinicians work with Western Sydney PHN and other agencies to develop integrated care for patients with four chronic conditions: congestive cardiac failure, coronary disease, chronic obstructive pulmonary disease and diabetes.

“We are talking the same language, these are the sorts of things we want to achieve,” Kmet said of the pursuit of integrated care.

“Clearly if we look at the Australian system, it’s fragmented, it’s disconnected and lacks integration. Part of the picture here is that, without a doubt, we are going to achieve more if we work in partnership than if we work separately.” He added: “It’s about ensuring the system is there for the patient rather than the patient being there for the system.”

One example cited by Kmet of GPs and specialists working in tandem is in Western Sydney, where endocrinologists and diabetic educators visit the general practice to see patients with complex issues rather than the patient being shunted across town to the diabetes clinic at Blacktown Hospital.

It was a simple, yet effective, measure in creating an improved patient experience, he said. In addition, it created more of a team environment, with the GP forming a personal relationship with the endocrinologist.

“It’s convenient for the patient, they get a better experience, and can have their care better managed at the practice,” Kmet said. “The GP also improves their knowledge of diabetes so they can be more proactive and more capable of managing those conditions.”

Despite such examples, Kmet admitted WentWest was only “scratching the surface” of an integrated approach.

Nevertheless, primary care on its own could go some way to delivering on the goals of the Quadruple Aim, he said.

“General practices can do a lot by understanding their patients’ experience,” he said. “We have introduced something novel called ‘happy or not?’” where patients can rate the experience of care with their practice on completion of their visit.

Kmet said it was offered to general practices to assess their engagement with patients, with about 16 installing the console. Options were also available for patients to write down feedback about their experience.

“Obviously, general practices took this up voluntarily, and the results from any one practice were for their use only and only known to their practice and ourselves for quality improvement purposes,” he explained.

“Clearly we are not linking this by way of any other ramifications, as the purpose is to assist practices to improve their patients’ experience of care. Secondly, we can also do a lot around quality and population health. How well does a general practice know its patients? How well does it know about their conditions? How responsive is it to those conditions and problems? How proactive can it be? What are the things we can do, for example, to know more about the data of the practice and of the patients so we can improve quality and population health?

“And in terms of sustainable cost, there are things that general practice can do to lower costs in the system. If, as we have done in western Sydney, you introduce pharmacists to the general practice team, medications can be better managed and we can de-prescribe a lot of medication.

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Patients also have a critical role to play in the bid to improve the healthcare system

“So the Quadruple Aim is not just about the system. Although the system will obviously benefit from an integrated care approach, general practice can equally adopt this framework.”

But Kmet stressed that every general practice, health district and PHN would have its own ideas of how best to adopt the Quadruple Aim. While the aims themselves might be identical, the methods might differ, he said.

“This is not a one-size-fits-all. The Quadruple Aim is not a one-booklet program,” Kmet said. “It’s rather a construct to say ‘how can we do these things and how can we do them better’. And it applies to each individual practice as well as across the system.”

One of the champions of the Health Care Homes experiment, Dr Steve Hambleton, who was chairman of the Primary Health Care Advisory Group which recommended the model to the federal government, said one of the “specific intentions” of the new approach would be to “tick the boxes” of the Quadruple Aim.

Hambleton outlined a range of ideas to pursue the aims, among them far greater discipline over the collection, dissemination and examination of data that has the capacity to assist population health at a local, regional and ultimately national level.

“Many [general practices] already operate in the manner of Health Care Homes in Australia. We are formalising that, and the Quadruple Aim is part of the reason we are formalising it so we do get better population health,” Hambleton said.

“I said at a recent meeting that if we can demonstrate the benefit we are having on our patients, we can use that data to go to government and ask for investment in primary care.”

One of the straightforward rationales of reducing the per capita cost of healthcare was to stop preventable hospitalisation, and that means improving primary care, he added.

“I don’t want to criticise primary care, because we are doing a good job, but we have got to do a better job because the expensive care is in the acute sector.”

Yet while the overarching pursuit of the Triple or Quadruple Aim is, naturally, in the hands of government policy and the healthcare system itself, it is clear the patient has an instrumental role to play.

In Donald Berwick’s seminal 2008 paper, he spoke of the “tragedy of the commons”, an economic theory where people take more than their fair share. He argued the “great task in policy is not to claim stakeholders are acting irrationally, but rather to change what is rational for them to do”.

“The stakes are high,” Berwick wrote. “Indeed, the Holy Grail for universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs.”

In short, patients need re-educating that “more” does not mean “better”.

Moves are under way – particularly with the trials of Health Care Homes – to do that in Australia.  Under the current GP fee-for-service model, volume is rewarded above quality.

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But if properly funded, new payment structures, such as those for the HCH, will encourage a more innovative approach that will, it is hoped, see GPs work more in partnership with patients.

“If you are paying someone to work on the basis they get paid every time they see a patient, well, that’s what they are going to do,” Walter Kmet from Went West said. “The question is, does a GP need to see everyone to provide good care and properly manage their condition? The answer is no.

“Patients’ experience of care is going to improve if they are more engaged in their own care. The more we can improve patient’s role in their own care, the more we can improve patient literacy and patient understanding about the options they have, and how they might make decisions about their care.”

Hambleton, a GP in the Brisbane suburb of Kedron, said doctors would be able to innovate without the restrictions of only face-to-face patient contact. That could extend to video conferencing or a telephone consultation or by delegating tasks to other members of the health care team. But he warned it would require cultural change from GPs and patients “that can’t be under-estimated”.

“All of our patients for the past 30 years have been trained to go to the doctor for everything and under the Health Care Homes we’re saying ‘you don’t need to come and see me,” he said. “The deal will be ‘As your GP, I’ll take responsibility and in return we’ll offer you enhanced access’.” That access will offer patients the ability to speak to nurses, to email the doctor and receive education on how to manage their condition without the need to trek to the clinic to see the GP.

“We want to give patients the tools to be engaged in their care and to activate them and their carers,” Hambleton said. “We are trying to improve the experience of care and to make it easier for the doctor to deal with a large number of people.”

The GP role under the Health Care Homes model would appear to mirror some of the tasks which, under Berwick’s model, would be carried out by “integrators” who would “work persistently to change the more-is-better culture”. That, Berwick said, would come through “transparency, systematic education, communication and shared decision-making with patients and communities” rather than “restricting access, shifting costs and erecting administrative hurdles to care”.

Empowering patients would also play a central role in the hospital sector as they, too, embraced the concepts of the Quadruple Aim, according to Alison Verhoeven, chief executive of the Australian Healthcare and Hospitals Association.

“The great task in policy is not to claim stakeholders are acting irrationally but rather to change what is rational for them to do.”

Discussions have already taken place in the context of clinical innovation and clinical excellence, with “substantial” work taking place on Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS). Such data is helping to shape and influence what “our future health system will look like as much as what we are doing at the moment”, she said.

“The data is being used in the design of services, or co-design of services but it’s also being used to identify variations of care. It’s part of a continuous quality improvement,” Verhoeven told The Medical Republic.

“I think you’d be hard pressed to find somebody in a health leadership position in Australia who isn’t working towards some part of the Triple Aim or the Quadruple Aim even if it wasn’t spelled out in their strategic plan.

“But everyone realises this is a journey and different parts of the sector and different organisations will be at different stages along this journey.”

At first glance, the Quadruple Aim, with its need for integrated care, a shift in deeply-engrained behaviours and culture and system overhauls, may appear a utopian vision.

But both Kmet and Hambleton insisted Berwick’s framework was an aspiration worth pursuing.

“The premise from a primary care perspective has to be that if we can implement some of the things we are talking about – such as the example around diabetes – and if we can provide an improved experience and have better quality engagement with patients, that will help provide greater satisfaction for healthcare staff,” Kmet said.

“Surely that is better than running the same race on a hamster wheel every day? It ultimately has to be better than what we are currently doing. We have got to aim for something and you may as well aim for something that makes sense and that will make a difference.”

As for Hambleton, it was important to aim for utopia, he said.

“If you aim high and miss your target you can still be pretty happy. If you aim for mediocre you’re going to hit it and no one is happy,” he said. “We have localised it, but we have shamelessly stolen Don Berwick’s idea. He is aiming for utopia and I say ‘good on yer, mate’. Let’s try for it.

“We won’t get there, but we’ll hit a lot better than mediocre.”

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