Hospital Impact: How health systems can use professionalism to achieve the Quadruple Aim

Organizational professionalism might provide the holistic approach necessary to achieve the elusive Quadruple Aim. (Getty/monkeybusinessimages)

Most health systems aspire to achieve the Triple Aim: enhance patient experience, improve population health and reduce costs. Given how these all depend on an efficient workforce, Thomas Bodenheimer, M.D., and Christine Sinsky, M.D., proposed the idea of the Quadruple Aim, which would include the goal of improving the work life of healthcare providers.

Attempts to accomplish these goals typically target specific processes or performance metrics. However, the wide range of practices that would need to be individually revised in order to achieve the spectrum of results envisioned in these four aims is daunting. Aligning the multitude of tasks required to create a healthy population under a single ethos could have a simplifying and unifying impact on what might otherwise seem an impossible endeavor.

A diverse group of administrators, physicians, ethicists, nurses and patients think organizational professionalism might provide that more holistic approach. This concept translates the professional values, skills and competencies currently embodied by individuals into a comprehensive framework for healthcare organizations. Their recently published Charter on Professionalism for Health Care Organizations is a multidisciplinary effort to create an environment that promotes professional behavior throughout an organization. The charter can serve as a blueprint to guide health systems to improve the health of patients, staff and the population.

Here are its core principles:

The patient comes first. Traditional patient-centered efforts have involved shared decision-making about medical options and goals of care. However, institutions will find more success when they make patients partners in the full spectrum of hospital activities.

  • The charter calls on hospitals to measure what matters to patients, engage them in the processes of care and support the role of patients as members of teams.

But as Bodenheimer and Sinsky point out, an ailing workforce does not create a healthy environment for patients. Although attention is primarily given to physician burnout, nurses, physical therapists and switchboard operators burn out, too. If the same commitment to service and interpersonal communication skills that characterize patient interactions extended to all the interactions that occur in the course of healthcare delivery, a remarkable change in the environment might emerge.

A more vibrant, nurtured workforce would create a truly healing environment for patients. In a relational culture focused on the patient, everyone has a role, each job has meaning and every employee feels connected to the mission of the organization. Work thus enhances daily life, not just the bank account.

  • The charter calls for a commitment to ensuring the well-being of individuals, to teamwork, and to accountability for each individual and for leadership to maintain a healing culture.

Financial health follows organizational health. Hospitals that score higher on the metric of “teamness” known as relational coordination have higher quality outcomes, efficiency outcomes, patient trust and worker satisfaction, according to a paper published by the Oxford Handbook of Positive Organizational Scholarship (PDF).

Moreover, ethics pays, as an article published by Business Ethics Quarterly points out. Once a hospital bill reaches 5% of household income, the likelihood of that bill being paid decreases to zero, so it hardly makes sense to force families into bankruptcy. Yet medical bills are the chief cause of bankruptcy in America.

  • The charter calls upon hospitals to commit to transparently managing conflicts of interest, to aligning incentives with values and to providing fair access to healthcare.

Improving population health requires moving beyond the walls of the hospital. The healthcare system for the most part acts as if the determinants of health were entirely biologic. Yet we know that health is largely related to social conditions. Perhaps only 10% of premature death is addressed by the biologic systems that healthcare can touch, according to a policy brief (PDF) published by Health Affairs.

Until health systems start to interact with those entities that address the structure of the built environment—such as the places where people buy food and the resources for substance abuse treatment—the healthcare delivery system will continue to be frustrated by the minimal impact that its brief touches with patients have when something in their fragile social support system crashes. Yet no social structure is in a position to affect all the influences on these determinants. Alliances among government, healthcare systems and the communities they serve will be required.

  • The charter calls upon health systems to commit to partner with communities to address the social determinants of health and to invest strategically in the communities they serve.

No individual organization can embody all of the charter’s dimensions. Rather, the charter describes a model healthcare organization, a structure to which every hospital and health system can aspire. Many of its challenges are cultural and require both organizational leaders and employees to alter their historical views of their organizations and their roles within them.

The charter authors aim to stimulate dialogue and innovation. They anticipate that healthcare organizations will endorse the charter’s principles and be inspired to experiment with consonant practices. The charter is conceived as a living document that can and should be modified in response to what we learn from experience. It must adapt to the unknown future of healthcare as well as guide us toward it.

Barry Egener, M.D., is the chairman of the Organizational Professional Charter Project and the medical director of The Foundation for Medical Excellence.