Should the Triple Aim become the Quadruple Aim?

There's something crucial missing from the healthcare industry's oft-cited Triple Aim, according to a new report from the Annals of Family Medicine (AFM).

The industry can't achieve the Triple Aim's core ideals--providing better care, improving population health and lowering costs--without first improving the work life of healthcare providers, write study authors Thomas Bodenheimer, M.D., and Christine Sinsky, M.D.

The researchers observed "widespread burnout and dissatisfaction" while visiting primary care practices around the country, with complaints about a stressful work environment a common refrain among physicians, according to the report.

"These sentiments made us wonder, might there be a fourth aim--improving the work life of healthcare clinicians and staff[?]" write Bodenheimer and Sinsky.

Healthcare provider stress is a serious threat to patient safety and a contributing factor to the physician shortage, FiercePracticeManagement previously reported. One study found that nearly one in two American doctors has experienced symptoms of professional burnout.

"We have had many family physicians respond thanking us for the article," Bodenheimer told the American Academy of Family Physicians. "Dr. Sinsky and I have rarely had so many emails expressing that an article reflects what they (physicians) are feeling."

So what's to blame for all the stress? The AFM report found a seemingly innocuous factor--paperwork--may be a leading culprit, citing a 2011 study in which 87 percent of physicians named administrative tasks the main cause of burnout. This is likely compounded by the rise of electronic health records, with another study finding that even when in the exam room with patients, primary care physicians spend from 25 to 50 percent of the time attending to the computer.

Doctors aren't the only healthcare workers afflicted with burnout, either, the report notes. Nurses report high incidences of workplace stress, often feeling overburdened by work and unsupported by managementFierceHealthcare reported. Receptionists struggle with trying to meet both patient and doctors' demands, with one report finding 68 percent reported being verbally abused by patients.

Healthcare organizations striving to meet the Triple Aim without addressing the needs of clinicians may actually hurt their ability to achieve the three ideals, the AFM researchers write. So to address the critical "fourth aim," the report offers the following suggestions:

  • Employ "team documentation" to reduce the burden associated with paperwork, with nurses, medical assistants and other staff assisting with data entry during a patient's visit
  • Have physicians and their staff work in the same space to increase overall efficiency
  • Allow nurses and medical assistants to handle preventive care and chronic care coaching using physician-written directions
  • Use pre-visit planning and pre-appointment laboratory testing to lessen time wasted on reviewing lab results
  • Standardize prescription refill workflows to save time and provide better care
  • Make sure all staff are well-trained and focused on providing quality patient care

In the study's conclusion, Bodenheimer and Sinsky emphasize the interdependency of all the Triple Aims with their proposed fourth aim.

"Healthcare 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," they write.

To learn more:
- check out the study
- read the article