Quadruple Aim: Putting the Nurse into the Equation

By Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPHQ, FNAP, FACHE, vice president and associate chief nursing officer, University Health System, and president, South Central Texas Organization of Nurse Executives

More than a decade ago, Triple Aim appeared in the literature through the work of three healthcare leaders whose focus on healthcare improvement centered around three areas: improved care, improved health of populations and reduced healthcare cost (Berwick, Nolan, & Whittington, 2008). Healthcare organizations have adopted these aims to develop strategies for efficient, effective and sustainable delivery of healthcare services (Mery, Majumder, Brown, & Dobrow, 2017; Obucina et al., 2018). The impetus for the drive toward healthcare improvement resulted from the displeasure and frustrations with poor health outcomes and the spiraling costs of healthcare. Leaders from the provider side, consumers, regulators, policymakers and academicians responded to the call to action of triple aim. In 2010, the framework of triple aim was interwoven into the fabric of the U.S. healthcare delivery system in response to the enactment of the Patient Protection and Affordable Care Act (ACA). Curricula for educating health professionals adopted the triple aim framework to keep pace with the rapid changes in healthcare (Paterson, Fair, Cashman, Evans, & Garr, 2015). As the largest group of healthcare professionals, nurses have become key players in the delivery of safe, effective, efficient and patient-centered care.

Triple Aim: Did It Hit the Mark?
Proponents of triple aim continue to advance the concepts of care, health and cost and its alignment to achieving integrated health (Block, 2014; Whittington, Nolan, Lewis, & Torres, 2015). However, there are sentiments that although triple aim can be used to transform the U.S. healthcare system and can lead to a positive cultural change in the way care is delivered, there are threats that must be overcome. These threats include health disparities that overwhelm the healthcare system, the continued pressure to produce revenues and the ever-increasing politics in healthcare (Slavitt, 2018). Questions have been raised on whether the triple aim initiative was effective or successful as a framework to improve the care experience of patients, improve the health of the populations and reduce the per capita costs of healthcare. Opinions and views regarding the adequacy and sufficiency of triple aim have arisen, in part because of the missing focus and attention on the providers and healthcare workers (Bodenheimer & Sinsky, 2014; Lacagnina, 2018; O’Connor, 2015; Till, 2017). Spinelli (2013) equates the lack of attention to the healthcare workforce as the phantom limb of triple aim. These authors have suggested that another aim should be added to the triple aim — the providers and healthcare workers. Quadruple aim advances the view that caring for the caregivers and the providers is as critical as the three components of the triple aim. Sikka, Morath and Leape (2015) have suggested that improving the experience of providing care should be the fourth aim.

Is It Time to Shift Gears?
In a thought-provoking and controversial book by Spiegelman and Berrett (2013), the idea of patients coming second — and employees first — underscores the shift in paradigm about patients and healthcare workers. The thesis of the argument lies in the notion that an engaged workforce is likely to result in better patient care outcomes. As an antithesis, Viggiano, Pawlina, Lindor, Olsen and Cortese (2007) have argued that the needs of the patient come first. The writer of this article submits that the truth is somewhere in the middle. As a synthesis, the quadruple aim provides a conciliation of these two seemingly polarized and diverged notions. The debate is not whether one chooses the healthcare workers over the patients, or vice versa. The resolution is to meet the needs of the patients while addressing the needs of the healthcare workers.

Nurses in the Limelight: Time to Reflect and Act
The high-profile stories about nurses in recent times give nurse leaders pause. Whether the news is about the nurse who was prosecuted for a fatal medication error (Gordon, 2019) or about a nurse who was killed by a patient (Brusie, 2019), one could not help but reflect on the current workplace environment. The complex issues surrounding nursing errors (Mohsenpour, Hosseini, Abbaszadeh, Shahboulaghi, & Khankeh, 2017), the hazardous and adverse outcomes from workplace violence (Nowrouzi-Kia, Isidro, Chai, Usuba, & Chen, 2019; Zolnierek, 2015), or the negative and wearisome effects of stress, fatigue or burnout (Waddil-Goad, 2018) mandate a thoughtful and thorough examination of the fourth element of quadruple aim — the provider and the healthcare worker. Bowles, Batcheller, Adams, Zimmermann and Pappas (2019) have asserted that nursing leaders must advance professional practice and work environments as critical elements of quadruple aim.

Pioneering Quadruple Aim for Nursing
In recent years, interests in advancing the notion of quadruple aim in nursing have increased. Batcheller, Zimmerman, Pappas and Adams (2017) have highlighted the pioneering work of prominent nurse leaders on practice environment and triple aim. The Model of Interrelationship of Leadership, Environments, and Outcomes for Nurse Executives (MILE-ONE) will serve as a framework for further work in addressing the quadruple aim in nursing. To advance quadruple aim successfully and effectively, nurses as leaders and change agents should have competencies on advocacy, influence and innovation (Bowles, Adams, Batcheller, Zimmerman, & Pappas, 2018). It is imperative that nurse leaders create and promote healthy practice environments (Raso, 2015). To promote joy and meaning at work, nurse leaders must recognize and address the culprits that take the toll on nurses: overwhelming workloads, toxic work environment and safety concerns, among others (Laskowski-Jones, 2016).

Call to Action: Aim High(er) with Quadruple Aim
Whether one subscribes to the original work of Whittington and Nolan on triple aim (Berwick et al., 2008) or to the recent modification to quadruple aim (Bodenheim & Sinsky, 2014; Sikka et al., 2015), the nursing leadership imperative is clear: advocate for the nurses. To put nurses into the equation, nurse leaders should consider the following:

Promote a healthy work environment. Burns, Gonzalez, Hoffman and Fulginiti (2018) have outlined the elements of a healthy work environment (HWE) using the HWE framework by the American Association of Critical Care Nurses. Elements of the AACN HWE standards encompass skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (Burns et al., 2018; Wei, Sewell, Woody, & Rose, 2018). An HWE plan should include strategies to prevent nurse errors, promote a just culture and support second victims of errors. The American Nurses Association (ANA) has aligned healthy work environment with the Nurses Bill of Rights (ANA, n.d.).

Engage employees in well-being initiatives. Jacobs, McGovern, Heinmiller and Drenkard (2018) have described the inclusion of well-being as an organizational strategy. Using Rath and Harter’s (2010) work on well-being, Jacobs et al. (2018) explored the five essential elements of well-being: purpose, social, financial, physical and community well-being.

Participate in the Healthy Nurse, Healthy Nation initiative. The American Nurses Association has launched the Healthy Nurse, Healthy Nation grand challenge to promote health and wellness among nurses (“ANA enterprise launches Healthy Nurse, Health Nation grand challenge,” 2017). This initiative aims to improve nurses’ health in five areas: physical activity, rest, nutrition, quality of life and safety. Visit www.healthynursehealthynation.org for more details.

Advocate for and create a safe environment to protect nurses against bullying and violence in the workplace. Adopt a comprehensive safety plan that includes measures to address bullying and workplace violence. Laws (2016) wrote a comprehensive article on bullying in the workplace and highlighted the provisions in the Texas Board of Nursing (BON) regarding disruptive behaviors and their impact on communication and teamwork. Involve nurses in hospital safety committees that deal with workplace violence that includes prevention, staff education, monitoring and reporting (Nowrouzi-Kia et al., 2019). Collaborate with professional organizations that advocate for regulations and legislation that protect healthcare workers against violence (Zolnierek, 2015). Visit https://www.texasnurse.org/page/wkplace_violence_rpt to access the workplace violence report. Brennan (2018) recommended strategies to address the cracks in the foundation toward keeping nurses safe against violence in healthcare.

Final Words
The ultimate desired outcome resulting from quadruple aim is to promote meaning in work and help staff in finding joy at work. Derek Feeley (2017), president and CEO of the Institute for Healthcare Improvement (IHI), sums it up best: “Feel free to interpret the triple aim in a way that makes sense to you and your organization …. Whether you choose to work on the triple aim or the quadruple aim … you can’t ignore joy in work or equity and expect to secure the triple aim.”

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