The Triple Aim is an initiative developed by the Institute of Healthcare Improvement to optimize health system performance.
The Triple Aim is a framework to help healthcare organizations improve healthcare delivery across three interconnected domains: patient experience, population health and care costs.
The framework has expanded to a Quadruple Aim, including improving the clinician and caregiver experience as another key component of improving healthcare delivery.
Developing the Triple Aim Framework
The IHI Triple Aim framework was developed by the Institute for Healthcare Improvement in Cambridge, Massachusetts in 2007 to help healthcare organizations improve the health of their patient population by providing high-quality care and lowering per capita care costs. By only focusing on decreasing costs, new initiatives to improve care could negatively impact quality or patient experience. IHI believed that focusing on all three aims at once allows healthcare organizations to identify and fix problems in care delivery, as well as focus attention and redirect resources to activities with the greatest impact on health.
After success in a series of collaboratives IHI led to study the Triple Aim in 141 healthcare sites around the world, the Triple Aim became part of the U.S. strategy for addressing healthcare issues, notably with the passage of the ACA. In 2011, the Agency for Healthcare Research and Quality incorporated the Triple Aim into the national strategy for quality improvement in healthcare under the leadership of Donald Berwick, President Emeritus and Senior Fellow of IHI.
Triple Aim Components
IHI defines the key domains of the Triple Aim as:
Improving patient experience of care (including quality and safety)
Improving the health of populations
Reducing per capita cost of health care
To make substantive change in improving the healthcare system, IHI believes that initiatives to improve healthcare must target each of these domains.
Triple Aim Success
Chinle Service Unit: The Chinle Service Unit is part of the Indian Health Services, serving 31 Navajo communities in the central region of Navajo Nation. With the Triple Aim framework the Chinle Service Unit was able to complete two projects that targeted all three domains of the Triple Aim. The first was to improve their patient care medical home to reduce emergency department and urgent care visits and to increase child immunization rates and primary care access. The second was to use the diabetes health coach model of care to decrease hospitalization rates, lower A1c levels and lower blood pressure. Both projects were successful in reducing expensive care visits, improving patient satisfaction with care and increasing population health.
CareOregon: CareOregon is a non-profit Medicaid health plan in Portland, Oregon that serves 128,000 low-income patients. With the Triple Aim initiative, they created a program, CareSupport, that provides centralized care coordination and case management to patients at high risk for poor health outcomes. The program has saved $400 per month per participant and maintained or slightly improved patients’ quality of life.
Critics of the Triple Aim framework note that it is impossible to meet each domain of the framework without acknowledging the importance of the clinician experience. Providers cannot practice high-quality care when experiencing stress and burnout. Practices trying to achieve the Triple Aim through EHR capabilities and PCMH requirements may be associated with greater clinician burnout in safety-net clinics. The Quadruple Aim is the answer to meeting the goals of the Triple Aim, while also addressing the clinician and caregiver experience.
The Quadruple Aim is vital to healthcare because professional burnout can lead to overuse of resources, increased costs of care and low quality care. Group Health Cooperative implemented primary care improvements in the early 2000s with the Triple Aim and unintentionally increased physician burnout, causing quality reductions and cost increases. In 2006, they focused first on clinician work life by increasing visit length and reducing panel size. Burnout dropped significantly, while also showing huge gains in clinical quality, patient experience and cost reduction.
Outside the Huddle
From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider | Annals of Family Medicine
The IHI Triple Aim | Institute for Healthcare Improvement