The Quadruple Aim: care, health,cost and meaning in work

Rishi Sikka,1 Julianne M Morath,2 Lucian Leape3

1Advocate Health Care, DownersGrove, Illinois, USA2Hospital Quality Institute,Sacramento, California, USA3Harvard School of PublicHealth, Boston, Massachusetts,USA

Correspondence toDr Rishi Sikka, AdvocateHealth Care, 3075 HighlandAvenue, Suite 600, DownersGrove, Il 60515, USA;[email protected]

Received 5 March 2015Revised 6 May 2015Accepted 16 May 2015

To cite: Sikka R, Morath JM,Leape L. BMJ Qual Saf2015;24:608–610.

In 2008, Donald Berwick and colleaguesprovided a framework for the delivery ofhigh value care in the USA, the TripleAim, that is centred around three over-arching goals: improving the individualexperience of care; improving the healthof populations; and reducing the percapita cost of healthcare.1 The intent isthat the Triple Aim will guide the redesignof healthcare systems and the transition topopulation health. Health systems glo-bally grapple with these challenges ofimproving the health of populations whilesimultaneously lowering healthcare costs.As a result, the Triple Aim, although ori-ginally conceived within the USA, hasbeen adopted as a set of principles forhealth system reform within many organi-sations around the world.The successful achievement of the

Triple Aim requires highly effectivehealthcare organisations. The backbone ofany effective healthcare system is anengaged and productive workforce.2 Butthe Triple Aim does not explicitly acknow-ledge the critical role of the workforce inhealthcare transformation. We propose amodification of the Triple Aim to acknow-ledge the importance of physicians, nursesand all employees finding joy andmeaning in their work. This ‘QuadrupleAim’ would add a fourth aim: improvingthe experience of providing care.The core of workforce engagement is

the experience of joy and meaning in thework of healthcare. This is not synonym-ous with happiness, rather that allmembers of the workforce have a senseof accomplishment and meaning in theircontributions. By meaning, we refer tothe sense of importance of daily work.By joy, we refer to the feeling of successand fulfilment that results from meaning-ful work. In the UK, the National HealthService has captured this with the notionof an engaged staff that ‘think and act ina positive way about the work they do,the people they work with and the organ-isation that they work in’.3

The evidence that the healthcare work-force finds joy and meaning in work isnot encouraging. In a recent physiciansurvey in the USA, 60% of respondentsindicated they were considering leavingpractice; 70% of surveyed physiciansknew at least one colleague who left theirpractice due to poor morale.2 A 2015survey of British physicians reportedsimilar findings with approximately 44%of respondents reporting very low or lowmorale.4 These findings also extend tothe nursing profession. In a 2013 USsurvey of registered nurses, 51% ofnurses worried that their job was affect-ing their health; 35% felt like resigningfrom their current job.5 Similar findingshave been reported across Europe, withrates of nursing job dissatisfactionranging from 11% to 56%.6

This absence of joy and meaning experi-enced by a majority of the healthcareworkforce is in part due to the threats ofpsychological and physical harm that arecommon in the work environment.Workforce injuries are much more frequentin healthcare than in other industries. Forsome, such as nurses’ aides, orderlies andattendants, the rate is four times the indus-trial average.7 More days are lost due tooccupational illness and injury in health-care than in mining, machinery manufac-turing or construction.7

The risk of physical harm is dwarfedby the extent of psychological harm inthe complex environment of the health-care workplace. Egregious examplesinclude bullying, intimidation and phys-ical assault. Far more prevalent is the psy-chological harm due to lack of respect.This dysfunction is compounded by pro-duction pressure, poor design of workflow and the proportion of non-valueadded work.The current dysfunctional healthcare

work environment is in part a by-productof the gradual shift in healthcare from apublic service to a business model thatoccurred in the latter half of the 20th

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century.8 Complex, intimate caregiving relationshipshave been reduced to a series of transactional demand-ing tasks, with a focus on productivity and efficiency,fuelled by the pressures of decreasing reimbursement.These forces have led to an environment with lack

of teamwork, disrespect between colleagues and lackof workforce engagement. The problems exist fromthe level of the front-line caregivers, doctors andnurses, who are burdened with non-caregiving work,to the healthcare leader with bottom-line worries anddisproportionate reporting requirements. Without joyand meaning in work, the workforce cannot performat its potential. Joy and meaning are generative andallow the best to be contributed by each individual,and the teams they comprise, towards the work of theTriple Aim every day.The precondition for restoring joy and meaning is

to ensure that the workforce has physical and psycho-logical freedom from harm, neglect and disrespect.For a health system aspiring to the Triple Aim, fulfill-ing this precondition must be a non-negotiable, endur-ing property of the system. It alone does notguarantee the achievement of joy and meaning,however the absence of a safe environment guaranteesrobbing people of joy and meaning in their work.Cultural freedom from physical and psychologicalharm is the right thing to do and it is smart economicsbecause toxic environments impose real costs on theorganisation, its employees, physicians, patients andultimately the entire population.An organisation focused on enabling joy and

meaning in work and pursuit of the Triple Aim needsto embody shared core values of mutual respect andcivility, transparency and truth telling and the safetyof the workforce. It recognises the work and accom-plishments of the workforce regularly and with highvisibility. For the individual, these notions of joy andmeaning in healthcare work are recognised in threecritical questions posed by Paul O’Neill, former chair-man and chief executive officer of Alcoa. This is aninternal gut-check, that needs to be answered affirma-tively by each worker each day:2

1. Am I treated with dignity and respect by everyone,everyday, by everyone I encounter, without regard torace, ethnicity, nationality, gender, religious belief, sexualorientation, title, pay grade or number of degrees?

2. Do I have the things I need: education, training, tools,financial support, encouragement, so I can make a con-tribution this organisation that gives meaning to my life?

3. Am I recognised and thanked for what I do?If each individual in the workforce cannot answer

affirmatively to these questions, the full potential toachieve patient safety, effective outcomes and lowercosts is compromised.The leadership and governance of our healthcare

systems currently have strong economic and outcomemotivations to focus on the Triple Aim. They alsoneed to feel a parallel moral obligation to the

workforce to create an environment that ensures joyand meaning in work. For this reason, we recommendadding a fourth essential aim: improving the experi-ence of providing care. The notion of changing theobjective to the Quadruple Aim recognises this focuswithin the context of the broader transformationrequired in our healthcare system towards high valuecare. While the first three aims provide a rationale forthe existence of a health system, the fourth aimbecomes a foundational element for the other goals tobe realised.Progress on this fourth goal in the Quadruple Aim

can be measured through metrics focusing on twobroad areas: workforce engagement and workforcesafety. Workforce engagement can be assessed throughannual surveys using established frameworks thatallow for benchmarking within industry and withnon-healthcare industries.9 Measures should also beextended to quantify the opposite of engagement,workforce burn-out. This could include select ques-tions from the Maslach Burnout Inventory, the goldstandard for measuring employee burn-out.10 In therealm of workforce safety, metrics should includequantifying work-related deaths or disability, lost timeinjuries, government mandated reported injuries andall injuries. Although these measures do not com-pletely quantify the experience of providing care, theyprovide a practical start that is familiar and allow foran initial baseline assessment and monitoring forimprovement.The rewards of the Quadruple Aim, achieved within

an inspirational workplace could be immense. Noother industry has more potential to free up resourcesfrom non-value added and inefficient productionpractices than healthcare; no other industry has morepotential to use its resources to save lives and reducehuman suffering; no other industry has the potentialto deliver the value envisioned by The Triple Aim onsuch an audacious scale. The key is the fourth aim:creating the conditions for the healthcare workforceto find joy and meaning in their work and in doingso, improving the experience of providing care.

Contributors All authors assisted in the drafting of thismanuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externallypeer reviewed.

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4 BMA Quarterly Tracker Survey. http://bma.org.uk/working-for-change/policy-and-lobbying/training-and-workforce/

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tracker-survey/omnibus-survey-january-2015 (accessed 4 May2015).

5 AMN Healthcare 2013 survey of registered nurses. http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey.pdf (accessed 4 May 2015).

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7 US Department of Labor Bureau of Labor Statistics.Occupational injuries and illnesses (annual) news release.

Workplace injuries and illnesses 2009. 21 October 2010.http://www.bls.gov/news.release/archives/osh_10212010.htm(accessed 4 May 2015).

8 Morath J. The quality advantage, a strategic guide for healthcare leaders. AHA Press, 1999:225.

9 Surveys on Patient Safety Culture. Agency for HealthcareResearch and Quality. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html (accessed 4 May2015).

10 Maslach C, Jackson S, Leiter M. Maslach burnout inventorymanual. 3rd edn. Palo Alto, CA: Consulting PsychologistsPress, 1996.

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