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Dr. Joshua Tepper

The Next Step for Better Quality Care

Often when we talk about improving health care, we turn to the Triple Aim.

Developed in 2007 by the Institute for Healthcare Improvement (IHI) in the United States, the Triple Aim captures three objectives for a better quality health system: Improving a patient’s experience of care, improving population health and doing this at a reasonable cost. It has become a way of thinking embraced by many health care systems around the world.

The Triple Aim takes a big-picture, system-wide approach that can be applied to any part of the health care system, as well as across all levels of an organization. The ultimate endgame is a sustainable health care system that patients trust and that contributes to healthier populations.

As is the case so often though, all great ideas get improved upon over time. Recently, attention has been drawn to what people are calling a “forgotten” aim: Improving the work life of health care providers, including clinicians and staff. Or more simply put, caring for those who provide care.

Drs. Thomas Bodenheimer and Christine Sinsky introduced the concept of the Quadruple Aim in a paper in the Annals of Family Medicine, where they argued that in order to fully realize the objectives of the Triple Aim we need to improve the experience and work life of providers.

The paper reinforces what I’ve heard from many providers about personal workplace stress, fatigue and burnout. Many of those same people have expressed feelings of guilt, disappointment and failure from working in environments that aren’t always conducive to fostering the joy of caring or the vital patient-provider relationships that drew many of them into the field in the first place.

But it’s not only established health care professionals who are feeling such pressure and anxiety. These feelings can start early, as a recent editorial in the Canadian Medical Association Journal recently pointed out. It pegged the rate of burnout among medical residents as high as 50 percent. The impact of burnout can lead to errors, reduced empathy, exits from the professions – all of which impact the quality of patient care. Tragically, it can also lead to suicide, as discussed in this recent story from a Toronto-based pediatrics resident.

There are other workplace risks that can contribute to burnout. A study published in The New England Journal of Medicine looked at workplace violence against health care workers in the U.S. and showed that it can also contribute to “increased rates of missed workdays, burnout, and job dissatisfaction along with decreased productivity.” I thought about these risks again recently when I read the data that shows between 2008 and 2013 there were more than 4,000 reported incidents of workplace violence against Canadian registered nurses and licensed practical nurses that were serious enough to prevent them from going to work. “That surpasses the number reported by police officers and firefighters put together,” according to a recent story in the Toronto Star.

When I read these statistics and stories, and hear clinicians increasingly describing their job as a “firehose coming at me,” I know that any meaningful discussion of quality and hopes for quality improvement must include providers and their welfare.

The system has been rightly criticized in the past for being provider-focused. It is important to note that adding one more aim to the traditional Triple Aim would not diminish our efforts to achieve the first three – especially with regard to improving patient experience. The Quadruple Aim commits to improving the work life of providers, without compromising patient needs. In this way, it adds balance to our view of the system – one that still prioritizes patients without negating professionals either. I appreciate its promise of co-designing environments where health care professionals and caregivers can flourish so that they can provide even higher quality care to patients.

Incorporating a fourth aim would serve to complement, enhance and ultimately realize the delivery of the first three aims. “There’s ample evidence” reports IHI “that creating a happier, healthier and more resilient workforce is more productive, delivers better outcomes for patients and saves health care organizations from significant waste and cost.”

Health Quality Ontario speaks to this in Quality Matters, our framework for achieving a high quality, patient-centred health care system that also sets out key enablers, one of which is helping professionals and caregivers thrive. Quality Matters talks about “re-imagining” the health care system as a partnership between patients, families, and providers. This approach embraces the Quadruple Aim to ideally create more positive experiences for patients and providers alike.

The need to care for providers, helping them to not just cope but thrive, has not been “forgotten” – however it has not always been a key focus. Our hope is that Quality Matters will help bring some of the focus needed to achieve this fourth aim.


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