Achieving the Quadruple Aim

May 28, 2015
Dr. Bill O’Connor CMIO and VP, AdvisoryServices,
Orion Health

It was lunchtime.

I don’t recall the exact date of this meal or what I managed to scrounge up to eat from a leftover patient meal tray, but I was sitting in the nurses’ station, poking away at a computer, entering orders on a couple of unruly patients I had seen on call the night before.

My first case was cancelled that morning, due to the patient having a bacon, egg, and cheese sandwich on the way to the hospital. Someone forgot to tell him not to eat anything after midnight. I found that more annoying than normal as I continued pecking away at the computer while eating my “lunch.”

My second case that day was delayed because we couldn’t find some of the required pre-op testing the patient had already completed.

As I was continuing my job as a data entry clerk (err … physician), I was tapped on the shoulder by one of the nurses who wanted me to go in and talk with a patient that I had rounded on that morning. I abruptly snapped back, telling her I had already seen that patient today and didn’t have time for any more of her irritating and long-winded questions. Not only did that particular patient have a lot of questions, but I had to waste 30 minutes of my time arguing with her insurance company over a pre-authorization that she needed.

As I was thinking to myself, ‘Why am I so unlucky to have a slate of unhappy patients?’ it finally dawned on me: It wasn’t the patients who were miserable. It was me. And I wasn’t alone. It varies by specialty, but many physicians would choose a different specialty if they were able to do it all over again. More than 70 percent of internists – a critical cog in our healthcare machine – would choose a different specialty. Almost half of all physicians said they would choose another career entirely.


And physicians aren’t alone in their misery; nurses, technicians, and receptionists have widely reported significant job dissatisfaction. But why? Healthcare jobs are good, generally stable, and most of them pay well.

Many authors and clinicians have described the most common issues: forced use of poorly implemented EHRs, too many alerts with no clinical significance, missing patient information, burdensome administrative tasks, lawsuits and defensive medicine, and difficulty working with payers. The list of administrative and non-clinical tasks that clinicians universally dislike seemingly grows longer each year.

I don’t remember the first time I heard the Triple Aim discussed, but you can’t go many places in healthcare today without hearing discussions around its lofty goals of improving the health of our population, improving the patient experience, and reducing costs. It is possible to do these three things, and we’ve witnessed some success, but we will never achieve the true vision of the Triple Aim unless we expand that vision to include the people responsible for its delivery: healthcare workers.

As I learned during my mystery-meat epiphany, miserable clinicians create miserable patients. How can we possibly achieve an improved patient experience if patients are being treated by grumpy, unhappy clinicians?

Furthermore, it is clear that a stressed and unhappy healthcare worker makes more mistakes, is more likely to have non-compliant patients, and is more likely to leave practice – all of which lead to increased costs.

How can we possibly achieve the Triple Aim in this environment?

Talk to almost any physician or nurse and ask them why they went into healthcare and what they like about their job. Most of them will tell you they just want to provide high-quality care, and they like most when they’re able to do exactly that.

It’s time that we expand the Triple Aim to include healthcare providers and enable these professionals to do what they do best. A “Quadruple Aim” that expands the Triple Aim by adding physician engagement will allow the industry to focus on improving the way our clinicians work and deliver care. This is a necessary element to help reduce costs and significantly improve the health of our population.

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