The Quadruple Aim
Jan 26, 2023
What keeps you awake at night?
I am deeply saddened and troubled by the cultural shift that has occurred in healthcare over the past decade. It is almost inconceivable how healthcare professionals went from being highly respected, pillars of our community to being subjected to such oppressive demands that the latest statistics show over 60% of them are burned out!
I became one of those statistical data points, even before COVID hit! I never saw it coming, but I can attest to the fact that the stress of fighting unhealthy authority gradients can lead to physical ailments, not just emotional ones. We are four-dimensional beings as I discussed earlier.
I knew I wasn’t the only one facing burnout, but NO ONE talked about it openly, until recently … and NOW it is everywhere! People are sharing their pain on social media, and most of the burnout and moral injury discussions have to do with autocratic leaders reducing our profession to a game of numbers; profits (mostly for them) and losses (mostly for us).
Some C-suites seem to care more about their spreadsheet’s bottom line than patient care, quality, or safety. Yes, we understand that we need to be cost-conscious and run a business, but don't forget about the human beings involved in this business:
- the front line - those generating the revenue and
- the endpoints – the patients benefitting from the care being provided in this business!
It is shocking to see how this type of transactional, business mindset gets translated down to the physicians (revenue producers) via dehumanizing conversations about “the numbers, ie: your performance.” These discussions don’t tend to go well from a clinician’s point of view because our clinical expertise and contributions to the care of the patient are so much more valuable than what the CFO interprets from his spreadsheet.
Many would like to say, “I’m not here to worry about the flippin’ numbers, I’m here to take darn good care of the patient, and I need more time and staff to do that well!” Some will say it, but the fear of retribution for speaking up has resulted in institutional silence, moral injury, and crushed spirits for so many professionals.
Stories of retaliation are being shared as well and though I can’t repeat them all here, what I can safely say is, some Healthcare Executives are not nice, others are just plain mean and inappropriate!
“They treat physicians and staff more like an ATM or 'cash cow' than human beings.” They might even refer to you as “dispensable;” you are just a data point on their spreadsheet.
“They forget your name shortly after you sign the contract, and you may never see them again,” unless, of course, you suffer some sort of disciplinary action, which is often accompanied by unfair retribution!
“Some need to be reminded that their “RVU-producing provider” is a mother, father, daughter, son, brother, sister, friend, or partner to someone who loves them and needs them to be happy and healthy.”
The COVID crisis magnified the already strained conditions, some of which are now being described as “toxic workplace environments.” This precipitated a mass exodus of physicians and nurses who just aren’t going to take it anymore! And unfortunately, those that didn’t leave are left picking up the slack; STILL with too little support, so they continue to suffer, long after the acute crisis has passed.
We are seeing the development of unprecedented secondary health effects due to these extremely stressful working conditions and underperforming leaders. The effects range from negative, self-limiting beliefs to addictions, to a two-fold rise in suicidality.
Statements such as “I am not good enough, I don’t make a difference, I am expendable, and I can't do this anymore” are all too commonplace. Not only does this mindset contribute further to the healthcare worker shortage but is extremely damaging to the long-term health of the healthcare worker’s heart, mind, body, and SOUL.
WHY? – because of POOR LEADERSHIP!
Many will never return to healthcare – but it doesn’t end with single individuals! It creates a bleak outlook for the future of healthcare. What the heck is this world coming to and what do we do NOW!?
We can sum all of this up in one simple concept - Adopt The Quadruple Aim!
CMS introduced the Triple Aim in 2008 (white pieces of pie in the image). The Goal was to address challenges like chronic disease management and care coordination in ways that could be replicated and measured across the US.
- Improve patient/population health outcomes, based on “their needs/assets of the population.”
- Improving the patient experience – quality, safety, equitable, timely, efficient, patient-centered.
- While reducing per capita costs!
The problem is, the Triple Aim created unintended consequences of hostility, as healthcare workers were left out of the equation. The reforms that many of us experienced led to an overloaded, overwhelmed, burned out culture, with the opposite effect of quality reductions and increased costs. By 2014, 46% of physicians reported feeling burned out and recommendations to consider the Quadruple Aim (blue piece of the pie) were made!
U.S. Surgeon General Vivek Murthy, MD stated in 2016, “If health care providers aren’t well, it’s hard for them to heal the people for whom they are caring.” He apologized and recommended the Quadruple Aim as the #1 priority for health system performance.
The 2017 Physician & Advanced Practitioner Well-Being Solutions Survey Report stated that both providers & leaders are burned out. Physician Burnout was recognized as being at a CRITICAL STAGE!
Most organizations had not adopted the Quadruple Aim before COVID hit, when burnout rates were near 50%. We all know what happened after that. Some organizations responded by developing wellness programs, but still not enough has been done.
Healthcare cannot continue to focus on the Triple Aim - patient experience, population health, and lowering costs (white pieces of pie in the image), while ignoring the clinicians. Now it is imperative that we concentrate on taking care of the healthcare team, or there won’t be much of a team to focus on!
It is simple, straightforward, and basic leadership! Take care of the stakeholders - your revenue producers and the entire support staff, so they can take excellent care of the patients. We can’t just get by with the bare minimum (or less). This is not RETAIL, we are not selling widgets! This is about patient’s lives and healthcare worker's livelihoods!
It's no different than a professional athletic team - you must develop and take care of your players in every way possible to win. Team owners have demonstrated it for decades - if the team is not winning, you may need to upgrade by bringing in a few key players, but the ultimate bottom line is – get a coach who knows what being a Level 4 Leader is all about!
We need to do the same thing in healthcare; focus on Physician Wellness to have a successful team = the Quadruple Aim! If you don’t, the strain on the system will continue, and the results of neglectful administrative choices will be reflected in the bottom line!
Checklist to Evaluate your System:
A. Does my organization understand the fundamental nature of burnout and the need for duo, parallel strategies to manage it?
- Individual Burnout Management Strategies
Individual Strategies are necessary, however, it's so much bigger than that; an individual will never be resilient enough to compensate for this complex work environment. Throwing money at “Personal Strategies” such as yoga, mindfulness training or counseling is never going to be enough to prevent or manage burnout. It takes two strategies operating simultaneously and in parallel to do that well!
- System Strategies are the key to managing the complexities of healthcare today. Making a paradigm shift to the Quadruple Aim (adding the blue piece to the pie in the image) is a visual representation of that. The key is to realize that both sides of the organization are burned out, so the medical and leadership teams must collaborate to mitigate all the issues causing burnout for everyone. Triage the concerns based on severity and tackle them a few at a time.
B. Is there a formal Wellness Committee? If not, it must be created to keep the teams healthy, vibrant, and engaged. That committee needs its own budget, influence, and leveraging power. Because administrators are burned out too; larger organizations may need to consider breaking it into two parts - a Physician Subcommittee and an Administrative Subcommittee; each to work on their side of the equation. Then both sides need to convene on a regular basis to stay involved, engaged, and working together to benefit the entire organization.
An administrative person should be assigned to the committee to:
- organize meeting times and places,
- keep and distribute the minutes,
- communicate with the wellness champions, and
- help to communicate the messaging in whatever ways the committee deems best to,
- keep the conversation productive and activities moving forward.
C. Are physicians feeling efficient? Becoming a highly reliable organization should be a strategic goal for all organizations because efficiency helps get the work done quicker, so we can all have better work-life balance. AND it helps the bottom line of the organization – a win/win!
Still not sure about all this? Consider the fact that this is becoming a recruitment and retention point of CONTENTION! See my next Blog - The Business Case for a Physician Wellness Program.
