Quadruple Aim Research Articles

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge

Many physicians care for patients who remain in the hospital for prolonged periods despite being “medically ready” or stable for discharge. However, this phenomenon is not well-defined, and optimal strategies to address the problem are not known. A prolonged hospitalization past the point of medical necessity can harm patients, frustrate care teams, and is costly for the health care system. In this perspective, we describe opportunities to improve value of care for these patients through the lens of the Quadruple Aim, a common framework used to guide health care transformation efforts. We then offer recommendations, including some employed by our hospitals, for clinicians, researchers, and health care systems to improve the care for patients who are “stuck” in the hospital.

Achieving the Quadruple Aim Through Bidirectional Care.

This chapter discusses the notion of 'bidirectional health literacy' between the patient/care partner and the care team, and its impact on the quadruple aim: the care experience, population health, engagement, and the cost of care. It provides a brief historical perspective of the quadruple aim along with its relationships to value and health literacy. It overviews the responsibilities of health care organizations and highlights best practices, such as bidirectional care opportunities in patient-centered medical homes, with a focus on improving provider and care team communication. The chapter's aim is to provide a new bidirectional perspective on health literacy. It illuminates for readers that the focus of health literacy should not just be about patients' understanding of and engagement in their own health and health care, but instead, a partnership where care teams become equally 'literate' about the patient/care partner, by learning what they value, the contextual and social determinants that impact their ability to engage in self-care, and by demonstrating cultural humility in all of their care efforts. Various models that support bidirectional literacy and care are provided.

Transition Requirements from Problem List to an Overarching Care Plan for the Support of Person-Centered Care.

To keep healthcare effective, accessible and affordable to all we need a fundamental paradigm shift. Self-management for prevention and care with the help of healthcare professionals, having a shared view of the state of well-being, will play a significant role in this transition. The problem list is widely adopted as centerpiece of electronic health records and is although often patient oriented, but mostly limited to the institutional level. The requirements for this paradigm shift has been discussed in a series of workshops. Truly person-centered care requires to move towards a holistic problem list with an assessment and planning process resulting in an overarching care plan. The change process towards a real person-centered problem list, integrated in an overarching care plan, should be focused on the transition of health services delivery and requires a transition based on the "Quadruple Aim" principles.

How Health Literacy Develops the 'Four Aims' of Better Health Care.

The chapter's audience and purpose are twofold. First, the chapter introduces the 'Quadruple Aim' to policy makers and provides a general overview of health literacy strategies and tools to meet the Quadruple Aim to enhance care delivery while reducing costs. Second, the chapter identifies gaps in health literacy related research and encourages a research agenda to further the evidence base of health literacy to reduce cost, enhance quality, increase access, improve satisfaction, and achieve health equity.

An autoethnography of death and dying in Northern Ireland

PurposeIn Northern Ireland, access to good quality palliative care is an accepted and expected part of modern cancer care. The “Transforming Your Palliative and End of Life Care” programme “supports the design and delivery of coordinated services to enable people with palliative and end of life care needs to have choice in their place of care, greater access to services and improved outcomes at the end of their lives”. The purpose of this autoethnography is to share the author’s lived experience so that it might be used to improve services.Design/methodology/approachAutoethnography is employed as the research method. The author describes her experience of caring for father over the last six months of his life. She explores the tensions between the different players involved in the care of her father and the family and the internal conflict that developed within her as daughter, carer, care coordinator and doctor. Using multiple data sources, selected data entries were explored through reflexive, dyadic interviews to explore the experience and meaning in each story.FindingsThe author found that autoethnography was a powerful tool to give voice to the carer experience. Narration can be a powerful tool for capturing the authentic lived experiences of individuals and families and is a tool seldom utilised in integrated care. This account provides an insight into the author's expectations of integrated palliative care, as a designer and implementer and now an academic in integrated care and concludes with some reflections about the gap between policy and practice in palliative care services in Northern Ireland.Originality/valueAutoethnography can be a powerful tool for capturing the authentic lived experiences of individuals and families and is an essential component of the quadruple aim.

Advancing evidence-based healthcare facility design: a systematic literature review.

Healthcare facility design is a complex process that brings together diverse stakeholders and ideally aligns operational, environmental, experiential, clinical, and organizational objectives. The challenges inherent in facility design arise from the dynamic and complex nature of healthcare itself, and the growing accountability to the quadruple aims of enhancing patient experience, improving population health, reducing costs, and improving staff work life. Many healthcare systems and design practitioners are adopting an evidence-based approach to facility design, defined broadly as basing decisions about the built environment on credible and rigorous research and linking facility design to quality outcomes. Studies focused on architectural options and concepts in the evidence-based design literature have largely employed observation, surveys, post-occupancy study, space syntax analysis, or have been retrospective in nature. Fewer studies have explored layout optimization frameworks, healthcare layout modeling, applications of artificial intelligence, and layout robustness. These operations research/operations management approaches are highly valuable methods to inform healthcare facility design process in its earliest stages and measure performance in quantitative terms, yet they are currently underutilized. A primary objective of this paper is to begin to bridge this gap. This systematic review summarizes 65 evidence-based research studies related to facility layout and planning concepts published from 2008 through 2018, and categorizes them by methodology, area of focus, typology, and metrics of interest. The review identifies gaps in the existing literature and proposes solutions to advance evidence-based healthcare facility design. This work is the first of its kind to review the facility design literature across the disciplines of evidence-based healthcare design research, healthcare systems engineering, and operations research/operations management. The review suggests areas for future study that will enhance evidence-based healthcare facility designs through the integration of operations research and management science methods.

Creating Healthful Work Environments to Deliver on the Quadruple Aim: A Call to Action.

Nurses face workplace stressors that contribute to job dissatisfaction, burnout, and turnover, impacting not only patient safety but the nurses' physical and emotional well-being. At the 2018 American Academy of Nursing conference, a policy dialogue "Creating Healthy Work Environments to Address the Quadruple Aim" was convened focusing on creating healthy work environments by addressing stressors such as violence and bullying. That discussion is encapsulated in this article, providing proven and practical strategies for reducing risk.

Communication of Medication Nonmedical Switching Policies and Procedures by Insurance Companies: Results of an E-Survey

PurposeNonmedical switching is defined as a change in a stable patient's prescribed medication to a clinically distinct, nongeneric alternative for reasons other than lack of clinical response, adverse effects, or poor adherence. Nonmedical switching often results from formulary changes implemented by insurers to lower medication costs. We sought to survey randomly sampled physicians to elicit their opinions regarding insurers' communication about nonmedical switching. MethodsWe performed an online, cross-sectional survey of licensed, practicing physicians who were >2 years but <30 years out of residency and/or fellowship, who practiced in an internal medicine, family medicine, or specialist setting, spent ≥10% of their work time providing direct patient care, and had received at least 1 request for a nonmedical switch for ≥1 patient in the prior 12 months. The survey was fielded from November to December 2018. We report weighted percent responses categorized from 5- or 7-point Likert scale questions. FindingsE-mail invitations were sent to 13,117 randomly sampled physicians, and 1818 opened the e-mail and followed the embedded survey link to participate. Of these, 1010 total physicians (55.5%), 606 primary care and 404 specialists, who treated patients experiencing nonmedical switching in the prior 12 months completed the survey. A few physicians were notified about nonmedical switches by insurers; more frequently physicians learned about them from pharmacies serving their patients. Notification frequently occurred at or after a refill came due. Notification via electronic medical record or insurer letter was less frequent. Few thought that insurers clearly communicated information about alternative medications when a nonmedical switch was required, and most disagreed that insurers provided clear procedures, timelines, and methods to track challenges. Nearly all agreed that insurers should provide supporting documentation or rationale for nonmedical switches and specifics on alternatives. Respondents overwhelmingly agreed that steps to improve communication and physicians' and patients’ ability to navigate nonmedical switches or challenge procedures should be implemented. ImplicationsThis survey of primary care and speciality physicians suggests that physicians believe that insurers’ current level of communication regarding nonmedical switching is suboptimal. Respondents suggested that insurers did not optimally communicate information about alternative medications when a nonmedical switch was required and did not provide clear procedures, timelines, and methods to track challenges. A preponderance of physicians agreed that steps to improve physician-insurer communication to aid in the navigation of nonmedical switch and to challenge procedures should be implemented. If not addressed, these identified nonmedical switch communication issues may have a negative effect on achieving the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care practitioners and their staff.

Leading Innovative Practice: Leadership Attributes in LEAP Practices.

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Addressing quadruple aims through primary care and public health collaboration: ten Canadian case studies

BackgroundHealth systems in Canada and elsewhere are at a crossroads of reform in response to rising economic and societal pressures. The Quadruple Aim advocates for: improving patient experience, reducing cost, advancing population health and improving the provider experience. It is at the forefront of Canadian reform debates aimed to improve a complex and often-fragmented health care system. Concurrently, collaboration between primary care and public health has been the focus of current research, looking for integrated community-based primary health care models that best suit the health needs of communities and address health equity. This study aimed to explore the nature of Canadian primary care - public health collaborations, their aims, motivations, activities, collaboration barriers and enablers, and perceived outcomes.MethodsTen case studies were conducted in three provinces (Nova Scotia, Ontario, and British Columbia) to elucidate experiences of primary care and public health collaboration in different settings, contexts, populations and forms. Data sources included a survey using the Partnership Self-Assessment Tool, focus groups, and document analysis. This provided an opportunity to explore how primary care and public health collaboration could serve in transforming community-based primary health care with the potential to address the Quadruple Aims.ResultsAims of collaborations included: provider capacity building, regional vaccine/immunization management, community-based health promotion programming, and, outreach to increase access to care. Common precipitators were having a shared vision and/or community concern. Barriers and enablers differed among cases. Perceived barriers included ineffective communication processes, inadequate time for collaboration, geographic challenges, lack of resources, and varying organizational goals and mandates. Enablers included clear goals, trusting and inclusive relationships, role clarity, strong leadership, strong coordination and communication, and optimal use of resources. Cases achieved outcomes addressing the Q-Aims such as improving access to services, addressing population health through outreach to at-risk populations, reducing costs through efficiencies, and improving provider experience through capacity building.ConclusionsPrimary care and public health collaborations can strengthen community-based primary health care while addressing the Quadruple Aims with an emphasis on reducing health inequities but requires attention to collaboration barriers and enablers.

Reflecting Art in Nursing Practice: Developing Visual Arts Programs to Transform and Strengthen Practice.

Despite evidence of its positive impact on observation, description, empathy, and self-care, few arts-related professional development opportunities exist for nurses in practice settings. This academic medical center launched a 4-part visual arts-humanities professional development workshop for RNs to enhance their clinical skills through reflective activities and guided conversations of art. Participating RNs provided written feedback of their impressions and reflections on course content and potential personal growth. Participants reported profound changes in their self-awareness in multiple areas, and 3 consistent themes emerged: 1) seeing as enhanced observation; 2) attunement, and 3) thinking shifts. The workshop also provided respite from patient care demands for professional development and opportunities to cultivate collegial relationships among nurses from different areas and units. These findings underscore the value of the Quadruple Aim, which focuses on workplace practices that promote a sense of well-being and meaning at work. Consistent support from the chief nursing officer and nursing leadership was essential to the success of the program.

Impacting Quadruple Aim Through Sustainable Clinical-Community Partnerships: Best Practices From a Community-Based Organization Perspective

Health reform initiatives have caused disruptive change throughout the US health care system. A key driver of change is the adoption of alternative payment models that apply financial risk on physicians and hospital systems. Success in these value-based payment models requires health care provider and payor organizations to continue developing population-based approaches, including partnerships with community-based organizations that provide services within a community setting. Community-based organizations are positioned to serve as an extension of the care continuum because they provide desired access points to upstream services that address nonclinical factors. Yet many health care providers fail to enter into sustainable contracts with community organizations. This limits their ability to treat patients' social needs and widens the clinic-to-community gap, both of which must be addressed for success in value-based contracts. Future cross-sector collaboration will require stakeholders to abandon transactional partnership arrangements primarily concerned with referral systems in favor of transformational arrangements that better align partnership aims and more equally distribute ownership in solving for capacity building, evaluation, and sustainability. The following practices are based on the experience of local YMCAs and YMCA of the USA in establishing clinic-to-community partnerships throughout the country that can influence clinical cost and quality measures.

The impacts of accountable care organizations on patient experience, health outcomes and costs: a rapid review.

Objectives Accountable care organizations were implemented as a system-level approach to address quality differences and curb increasing healthcare costs in the United States of America, and have garnered the interest of policy makers in other countries to support better management of patients. The objectives of this paper are to: (1) identify the impacts of accountable care organizations on improving the quadruple aim goals of improving patient experience of care, enhancing population health outcomes, reducing the per capita cost of health care and ensuring positive provider experiences and (2) determine how and why such impacts have been achieved through accountable care organizations. Methods We used a rapid review approach, searching Health Systems Evidence (for systematic reviews) and PubMed (for reviews and studies). Results were reviewed for inclusion independently by two researchers. Data were extracted by one reviewer and checked for consistency by another. Results We identified one recent systematic review and 59 primary studies that addressed the first objective ( n = 54), the second objective ( n = 4) or both objectives ( n = 1). The reviewed studies suggest that accountable care organizations reduce costs without reducing quality. Key findings related to objective 1 include: (1) there are positive trends across the quadruple–aim outcomes for accountable care organizations as compared to Medicare fee-for-service or group physician fee-for-service models; (2) accountable care organizations produced modest cost savings, which are largely attributable to savings in outpatient expenses among the most medically complex patients and reductions in the delivery of low-value services; (3) accountable care organization models met the majority of quality measures and perform better than their fee-for-service counterparts and (4) there is relatively little evidence about the impact of accountable care organizations on provider experience. Qualitative studies related to objective 2 highlighted mechanisms that were important for enabling accountable care organizations, including supplemental staff to enhance coordination and accountable care organization-wide electronic health records. Conclusions General trends and increased adoption of models similar to accountable care organizations outside of the USA suggest that these models outperform traditional fee-for-service models across the quadruple aim goals, although with mixed evidence about health outcomes.

Working to Achieve the Quadruple Aim

Quality improvement activities are essential to achieving the Institute for Healthcare Improvement's Quadruple Aim of improving the health of our patients and members, enhancing members' care experiences, reducing costs, and attaining joy and meaning for our physicians and care teams in the workplace. These activities are also essential in creating a learning health care system.

Should Wellness Be a Core Competency for Physicians?

There has been a recent rise in calls for action around wellness and physician health. In medical education, wellness has been proposed as a physician competency. In this article, the authors review the history of the "wellness as a competency" concept within U.S. and Canadian residency programs and medical schools. Drawing from literature on the discourses of wellness and competence in medical education, they argue that operationalizing wellness as a physician competency holds profound implications for curricula, admissions, evaluation, and licensure. While many definitions of "wellness" and "competency" are used within medical training environments, the authors argue that the definitions institutions ultimately use will have significant impacts for trainees who are considered "unwell." In particular, medical learners with disabilities-including those with mental health, chronic health, learning, sensory, and mobility disabilities-may not conform to dominant conceptions of "wellness," and there is a risk they will become further stigmatized or even be considered unsuitable to practice in the profession. The authors conclude that framing wellness as a competency has the potential to legitimize support-seeking and prioritize physician health, yet it may also have the potential unintended effect of excluding certain learners from the profession. They propose a universal design approach to understand wellness at a systems level and to remove barriers to wellness for all medical learners.

Quality Improvement in Congenital Heart Surgery.

Congenital heart disease is a major public health concern in the United States. Outcomes of surgery for children with congenital heart disease have dramatically improved over the last several decades with current aggregate operative mortality rates approximating 3%, inclusive of all ages and defects. However, there remains significant variability among institutions, especially for higher-risk and more complex patients. As health care moves toward the quadruple aim of improving patient experience, improving the health of populations, lowering costs, and increasing satisfaction among providers, congenital heart surgery programs must evolve to meet the growing scrutiny, demands, and expectations of numerous stakeholders. Improved outcomes and reduced interinstitutional variability are achieved through prioritization of quality assurance and improvement.

Strategies to use government-funded programme models to achieve the triple aim: A look at New York State’s DSRIP programme

New York State has become a leader in Medicaid reform and the Delivery System Reform Incentive Payments (DSRIP) programme has provided new opportunities for both providers and new healthcare market players to play a stronger role in transitioning to value-based payments (VBP). The lessons learned in New York will be adapted to help with widespread success across the country, particularly in shifting Medicaid to risk-based reimbursement. The DSRIP programme in New York promoted the development of new healthcare organisations to lead and manage the government funding in an effort to achieve cost and quality improvements across the state. These new healthcare organisations are creating long-term sustainable models to advance the programme goals. Sustainability of Medicaid and Medicare continues to be at the forefront of federal and state government health reform. With health reform now poised to be a major 2020 presidential election issue, VBP remains a leading strategy for reducing the total cost of care and meeting the Quadruple Aim of enhancing patient experience, improving population health, reducing costs and improving the work life of healthcare providers.

Value in Healthcare: Designing an Integrated Value-Based Healthcare System.

Value-based healthcare (VBHC) can be interpreted in many ways depending on one's jurisdiction. Often it is used synonymously with cost-effectiveness. In Alberta, VBHC might more appropriately be termed "values-based healthcare." This reflects our belief that a healthcare system should meet the needs and desires of its population and contribute to overall wellness. We therefore developed a framework based on the dimensions of quality, the Quadruple Aim and feasibility considerations, which enables us to assess and measure our system activities and initiatives to determine if they are in keeping with VBHC in the Alberta context.

Clinical and economic benefits of the Intellispace Portal applications CT TAVI and Spectral CT: Findings from a two-step Delphi panel

Background: IntelliSpace Portal (ISP) is an advanced visualization platform that offers a single integrated solution designed to help physicians work more efficiently. This study aimed to develop a consensus statement on the clinical and economic benefits of two Intellispace Portal (ISP) applications (computed tomography (CT) transcatheter aortic-valve implantation (TAVI) and Spectral CT) applications. Methods: A modified Delphi method of two rounds of queries was used in a panel of 17 experts (11 for Spectral CT and 8 for CT TAVI). The experts were identified via referral and selected to achieve a balanced representation of subject matter experts. The Delphi process was conducted online using the MESYDEL platform. Two rounds of Delphi queries were conducted between July 22 and October 14, 2019. All data was collected prospectively. Results: Areas of consensus represented contribution of ISP applications toward quadruple aim goals. Consensus was reached that the Spectral CT application led to more confident decision making, improved diagnosis capabilities leading to better treatment paths, and a better work experience. Panelists noted that they required fewer tests to make a diagnosis using Spectral CT. The majority of physicians (63%) agreed that CT TAVI led to time savings for ‘device sizing’ results, and 75% of physicians agreed that the tool resulted in a better work experience. Conclusions: The increased diagnostic confidence of spectral information could eliminate the need for many follow-up scans in patients, resulting in clinical benefit to the patient in terms of reduced exposure to radiation and economic benefit to healthcare systems in reducing the number of additional scans. The staff satisfaction goal of the quadruple aim is also satisfied by Spectral CT and CT TAVI leading to a better work experience in our panelist physicians. This may result in indirect benefits such as reduced rates of physician burnout and greater provider satisfaction.

Rethinking the electronic health record through the quadruple aim: time to align its value with the health system

Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The “quadruple aim” consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.