Nurs Forum. 2020;55:54–64.wileyonlinelibrary.com/journal/nuf54 | © 2019 Wiley Periodicals, Inc.

DOI: 10.1111/nuf.12382

OR I G I NA L AR T I C L E

Implications for policy: The Triple Aim, Quadruple Aim, and interprofessional collaboration

Natalie Bachynsky PhD

East Texas Medical Center Crockett, Crockett

Medical Center Clinic, Crockett, Texas

Correspondence

Natalie Bachynsky, PhD, East Texas Medical

Center Crockett, Crockett Medical Center

Clinic, 1050 E. Loop 304, suite 200, Crockett,

TX.

Email: [email protected]

com

Abstract

Healthcare delivery in the Unites States stimulates policy change at a rapid pace. The

Patient Protection and Affordable Care Act of 2010 (ACA) is intended to expand

access to care and ultimately improve the health of Americans. The Triple Aim,

created by The Institute for Healthcare Improvement, delineates policy implications

for improving population health, the healthcare experience, and per capita cost. The

Quadruple Aim adds a fourth policy implication, for example, addressing the needs of

the healthcare provider. Advanced practice registered nurses are key in carrying out

the goals of the ACA and achieving the Triple and Quadruple Aims, via the formation

of interprofessional teams. This article offers insight into these policy implications

and identifies filters through which related nursing policy will be developed.

K E YWORD S

advanced practice, interprofessional education, policy/politics, quality improvement, social

determinants of care

1 | INTRODUCTION

Advanced practice registered nurses (APRNs) play an integral role in

the development of health policy for our nation. Fortunately, the

number of APRNs is growing rapidly and will continue to grow as the

demand for health promotion policy and interprofessional healthcare

services increases. In 2012, the Bureau of Labor Statistics (BLS)

estimated that employment of APRNs would increase 31% by the

year 2022. By comparison, the average growth rate for all employ-

ment groups was only projected to be 11% by 2022.1 APRNs must be

prepared to develop policy that considers the implications of the

patient’s health care needs and psychosocial, environmental, and

financial resources. When APRNs have access to advanced treat-

ments and therapies for patients but high costs prevents them from

obtaining the most effective treatments, both the APRN and the

patient suffer negative outcomes.

The Institute for Healthcare Improvement (IHI) was founded in

1991 in Cambridge, Massachusetts, by a team of forward‐thinking healthcare professionals focused on cultivating healthcare policy.

Policy implications demanded improved care for patients while

enhancing interprofessional processes that included APRNs, while

providing health care in a seamless manner. The initial IHI team, led

by Dr. Don Berwick, was committed to redesign the healthcare

system. Policy implications demanded that this system be free of

errors, waste, delay, and unsustainable costs.2 The IHI has evolved

from a small, grant‐funded organization focused on researching and

disseminating evidence‐based practices, to a self‐sustaining enter-

prise committed to leading policy initiatives on major factors that

transform healthcare delivery, that is, incorporate the patient’s

experience and cost of care.

2 | THE TRIPLE AIM

In 2008, The Institute for Healthcare Improvement (IHI) created The

Triple Aim:

A framework for optimizing health system performance

by simultaneously focusing on the health of a popula-

tion, the experience of care for individuals within that

population, and the per capita cost of providing that

care.2

The mission of the IHI is to “improve health and health care

worldwide”.2 The Triple Aim model delineates the key elements

and policy implications that are necessary to achieve this mission

Figure 1, Figure 2, and Box 1, Box 2.

Although the United States delivers some of the best, most

advanced clinical care in the world, the healthcare system fails to

address the policy implications related to obtaining the quality, cost‐ effective healthcare services needed by vulnerable populations.4

APRNs often provide care to patients who face barriers such as

poverty and insufficient health literacy, preventing the underserved

from achieving the best health outcomes. Although the Patient

Protection and Affordable Care Act of 2010 has provided insurance

coverage for many individuals and families that could not afford

insurance in the past, these patients continue to be burdened by the

same barriers that existed before the time they obtained healthcare

coverage. One of the major policy implications that APRNs face is

providing health care that is available and that can be maintained for

long‐term health. The team at IHI realized:

the successful health and healthcare systems of the future

will be those that can simultaneously delivery excellent

quality of care, at optimized costs, while improving the

health of the population and believes that that is the

ultimate destination for the high‐performing hospitals and

health systems of the future.2

The Triple Aim provides a structure for APRNs to advocate and

develop policy for healthcare delivery that addresses patients’ needs

and enhances their ability to achieve optimal health with the

resources available. The IHI provides free materials and resources

for organizations and facilities interested in implementing the Triple

Aim. The IHI online site also provides exemplars from real

organizations have implemented the Triple Aim framework, high-

lighting policy implications of common barriers to achieving optimal

health care.

3 | THE QUADRUPLE AIM

The US healthcare system today often lacks the capacity to link

medical information over multiple admissions, let alone over multiple

sites. Our healthcare expenditures are higher than those of other

developed countries–nearly double–but the outcomes are no better.

The National Academy of Medicine (formerly IOM) identified six

areas to which “care improvement efforts” should be directed to

provide quality of care, including safety, effectiveness, patient‐ centeredness, timeliness, efficiency, and equity.5 Berwick, Nolan,

and Whittington6 encouraged a broader system of linked goals,

known as the Triple Aim, a three‐pronged focus on improving the

healthcare system by improving care, improving the health of the

population, and reducing per capita costs. These three aims were

interdependent goals, for pursuit of one affected the other two either

positively or negatively.

The addition of a fourth aim, known as the Quadruple Aim, added

a fourth prong, which focuses on care of the provider in optimizing

the performance of the healthcare system. The rationale for the

fourth prong is the product of the high incidence of provider burnout,

a factor that often leads to lower patient satisfaction, reduced health

outcomes, and increased patient care costs. The Quadruple Aim is

designed to enhance and improve provider work life and ultimately

patient outcomes.7 The primary concern in maintaining Quadruple

Aim balance is social justice, ensuring equitable gains in health care in

all populations of stakeholders, including the provider.6(p760‐761)

The implications of the Quadruple Aim requires an exercise in

balance for policymakers, for each aim may be subject to constraints,

for example, how to spend resources, what coverage to provide, to

whom to provide it, and how to improve the work life of the provider.

Policy implications related to one or two aims may be seen as

strategic, but the third may not be viewed by stakeholders as being in

the public’s best interest, and the fourth aim as beyond the scope of

health care. For example, a congestive heart failure patient may

receive quality inpatient care resulting in improved health on

discharge; but repeated, long‐term readmissions of this insured

individual are not perceived as cost‐effective by the insurer and

frustrating to the provider.

Berwick et al6(p761) refer to “a tragedy of the commons,” which is a

conflict between common healthcare interests of the individual and the

community. These authors theorize that the Quadruple Aim may only

F IGURE 1 The Triple Aim2 [Color figure can be viewed at wileyonlinelibrary.com]

F IGURE 2 The Quadruple Aim

BACHYNSKY | 55

be achieved by considering the policy implication of overriding common

self‐interests of both groups. Promising innovations, such as medical

homes, retail clinics, telehealth, and medical tourism, have been

developed that challenge traditional healthcare models.

Tools are being developed for measuring healthcare quality,

based upon the Quadruple Aim. The policy implications of measuring

costs and health status are more of a challenge, for knowledge of

actual costs is required from a system that typically hides them. But

gathering of both types of data is facilitated with system‐wide

electronic medical records.6(p761‐762)

3.1 | Preconditions of the quadruple aim

Policy in pursuit of the Quadruple Aim is the exception in

the American healthcare system. To pursue the Quadruple

Box 1 The SBAR Tool*

Situation

Background

Assessment

Recommendation

*Adapted from http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

Box 2 Healthy People 2020: Leading Health Priority Topics and Indicators*

1. Increase the proportion of persons with healthcare insurance and a usual primary care provider.

2. Increase the proportion of persons receiving clinical preventative services, such as routine disease screenings (e.g., colorectal

cancer, hypertension, and diabetes) and immunizations.

3. Improve environmental quality to decrease illness caused by poor air and water quality and specifically decrease children’s

exposure to secondhand smoke.

4. Prevent unintentional injury and violence that that causes negative physical and emotional consequences for the victim and

others impacted by the incidents.

5. Improve maternal, infant, and child health by decreasing the number of preterm births and infant deaths during the first year of

life.

6. Address mental health by reducing the suicide rate and reducing the proportion of adolescents (12‐17 years old) who experience

major depressive episodes.

7. Improve nutrition and physical activity and decrease obesity in adults, children, and adolescents by increasing the number of

adults that meet physical activity guidelines and increase the proportion of children and adults that consume the adequate

amount of vegetables.

8. Improve oral health by increasing the proportion of children, adolescents, and adults who use the oral healthcare system within

the past year.

9. Address sexual and reproductive health by increasing the proportion of 15‐ to 44‐year‐old sexually experienced females receiving

reproductive health services within the past year and increasing the proportion of persons with HIV that are aware of their

serostatus.

10. Address social determinants (personal, social, economic, and environmental factors) that impact health, specifically increasing the

proportion of students that graduate with a regular diploma four years after starting the ninth grade.

11. Decrease the rate of substance abuse by decreasing the proportion of adolescents using alcohol or illicit drugs during the past 30

days and decreasing the proportion of adults engaging in binge drinking during the past 30 days.

12. Address the use of tobacco by reducing cigarette smoking in adults and reducing the use of cigarettes by adolescents during the

past month.

*Adapted from U.S. Department of Health and Human Services.3 Leading health indicators. Retrieved from http://www.healthypeople.gov/

2020/Leading‐Health‐Indicators

56 | BACHYNSKY

Aim, consideration of the following policy implications are

necessary:

1. the population must be recognized as the point of concern;

2. policy constraints must be overcome; and,

3. an integrator, the key facilitator to services in all four aims, must

exist.

3.1.1 | The population and policy constraints

The first policy implication is to specify a population that is a point of

concern. In this instance, population is defined as persons enrolled in

a registry that will track the Quadruple Aims over time, that is, access

to care, health status, and costs of care. The second policy implication

is policy constraints, which occur within the processes of decision‐ making, politics, and social contracting of the population involved,

that is, implementation of, access to, and cost of health care under

the Patient Protection and Affordable Care Act of 2010.6(p762‐763)

3.1.2 | The integrator

The integrator function is the third policy implication, which is the

entity, often the insurer, responsible for all aspects of policy

development for the Quadruple Aim, especially for a specified

population. An effective integrator links healthcare organizations for

working as one system within the policy implications of overlapping

boundaries, providing coordinated care for a defined population. The

integrator is responsible for five basic functions in facilitating policy

development supporting the Quadruple Aim.

3.1.3 | Integrator function #1

First, the integrator is responsible for involving individuals and

families, to ensure the patient population is informed about the

policy implications of health status and the benefits and limitations of

individual healthcare policies and specific practices and procedures.

Integrators work with individuals and groups through policy

development designed for providing a plan of care, guiding patients

through acute care, and providing advocacy and interpretation within

the complex healthcare system.6(p763‐764)

3.1.4 | Integrator function #2

Second, integrators work for “redesign of primary care services and

structures,” to strengthen the infrastructure for primary care within

the population. Primary care providers are expanded, for example,

through the medical home. The expanded role of providers allows for

development of policy focused on the implications of long‐term relationships between the patient and care team, shared care plans,

coordinated care, providing access to subspecialties, and innovative

scheduling and access to care facilitated by the electronic medical

record.6(p764)

3.1.5 | Integrator function #3

The third policy function of the integrator is “population health

management,” through policy development deploying resources or

specifying how resources will be deployed. Internet information may

assist segments of the population to identify options for treatment

and management through self‐care. Integrator facilitated policies also

analyze the implications of the value and resources necessary for

preventive self‐care management of high risk behaviors such as

smoking, violence, physical inactivity, poor nutrition, and other

unsafe healthcare practices.6(p764)

3.1.6 | Integrator function #4

The fourth function involves analysis of the policy implications of

financial management, thtat is, the integrator allocates payments and

resources supporting the Quadruple Aim. The first implication of

financial management is focused on policy implications of “…cost

control…defining, measuring, and making transparent the per capita

cost of care for a defined population.”6(p764) A second implication

would be to reduce and control costs and eliminate valueless

services. A third implication, and the most powerful, would be to

match supply and resources to underlying needs and to eliminate

unnecessary duplication of providers, equipment, and facilities. The

fourth implication and final component would be to “…cap total annual

spending, with strictly limited year‐on‐year growth targets.”6(p765)

3.1.7 | Integrator function #5

Fifth, the integrator’s policy implications must also focus on “system

integration at the macro level,” to produce individual and population‐ based care and interventions that are evidence‐based. Providing the

best interventions and outcomes would imply access to state‐of‐the‐ art knowledge; standardized definitions of, for example, quality and

cost; and trustworthy measurement of evidence.6(p765) In summary,

Porter and Teisberg8 indicated analysis of the policy implications of

health care would result in the best healthcare outcomes at the

lowest costs and would provide the greatest value within the

healthcare system.

3.2 | Precedents and possibilities

Stakeholders addressing the policy implications of the Quadruple

Aim include the following entities:

1. government‐sponsored or owned healthcare systems with legally

defined duties to a specific population, that is, Veteran’s

Administration Medical Centers;

2. classic staff and group‐model health maintenance organizations

(HMOs), that is, Kaiser Permanente; and,

3. other national and governmental healthcare systems with global

budgets, for example, National Health Service of the United

Kingdom.6(p765‐766)

BACHYNSKY | 57

HMOs were designed to act as integrators in pursuit of the

Quadruple Aim. However, the HMO model often cannot overcome

the policy implications of barriers to care, for example, choice of

providers or specialists. Because of these barriers, managed care

actually managed money, not health care. But encouraging signs for

virtual integrated care, via electronic support systems and instant

communication capabilities, have emerged within HMOs.6(p766‐767)

Progress toward the goal of integrated care within the Quadruple

Aim depends upon the following policy implications:

1. political action and policy essentially focused on budget caps on

spending for specific populations;

2. measurement and fixed accountability for health status and needs

of specific populations;

3. improved, standardized measures of care, and per capita costs;

4. changes in payment models so that financial gains from cost

reduction are shared between those who pay and those who

invest; and,

5. evolving professional education accreditation, ensuring capable

and improving care processes and skills.6(p767‐768)

4 | INTERPROFESSIONAL HEALTHCARE DELIVERY

Interprofessional education is a key implication or consideration for

development of policies designed to resolve the complex problems of

the healthcare system. Patients often require care from multiple

health professionals, especially when managing a chronic condition

and the disjointed healthcare system of the past has been

detrimental at best. In 1999, the Institute of Medicine (IOM, now

the National Academy of Medicine) published the well‐known study,

To Err Is Human, which revealed the devastating number of

healthcare errors that harmed or killed patients. This study pointed

to the fragmented nature of healthcare delivery, especially in

instances where patients see multiple providers in different settings

that do not have access to complete information.9 When systems are

in place that do not safeguard patients from preventable healthcare

errors, patients, and families are harmed and may lose faith in the

healthcare community. By contrast, employing processes that

facilitate open and thorough communication between and among

team members decreases the number of mistakes by individual

healthcare providers because the plan of care is transparent and

actively monitored by every healthcare professional caring for the

patient.

In To Err Is Human, the IOM concluded that the majority of

healthcare errors do not result from individual recklessness but

instead are caused by faulty systems, processes, and conditions

that lead people to make mistakes or fail to prevent them.9 The

policy implications of interprofessional care, where two or more

individuals from different professions work together, has been

emphasized in health care since the IOM report. The primary

goal of interprofessional collaboration, improved quality of

healthcare delivery, is at the forefront of interprofessional policy

implications.10

The policy implications of the APRNs role in interprofessional

healthcare delivery, serve as the “connector” for the other profes-

sionals who comprise the healthcare team. In The Future of Nursing:

Leading Change, Advancing Health, nurses are called to collaborate

with other healthcare professionals, such as physicians, physical and

occupational therapists, social workers, and pharmacists to provide

quality care to patients with complex conditions.11 Policy promoting

the best interprofessional collaboration outcomes provides opportu-

nities for optimal use of the skills and knowledge of all health

professionals working together as a team to deliver comprehensive,

integrated care over which the patient ultimately maintains

control.10

Despite the evidence‐based policy supporting interprofessional

collaboration and care, human factors often hinder effective

implementation of this practice. The attitudes of the team members

are a significant policy implication in the outcomes of the team. The

concept of “interprofessionality” takes the mindset of the individuals

into account as a key implication impacting the functionality of the

team. Interprofessionality impacts interprofessional collaboration and

occurs when healthcare professionals “reflect on and develop ways of

practicing that provide an integrated and cohesive" approach to

meeting the needs of patients and families.12(p9)

Interprofessional collaboration is difficult for healthcare profes-

sionals when open communication, transparency, and shared‐ decision‐making are required. The paternalistic and hierarchical

system of the past was based upon the healthcare model in which

the physician diagnosed the patient, prescribed the treatment, and

evaluated the outcome, often without feedback from the other

members of the healthcare team or the patient. The policy

implications of interprofessional collaboration consider giving voice

to all team members and encouraging dialog based upon different

perspectives and viewpoints.

Following the IOM’s recommendation to implement interprofes-

sional care (IPC), healthcare systems transitioning to IPC had to

consider the policy implications embedded in barriers and resistance

arising from seasoned healthcare professionals. These policy implica-

tions encompassed the impracticalities in mandating team care for

healthcare professionals not trained in interprofessional collabora-

tion, that is, team working skills to foster communication and shared‐ decision‐making. The IOM further anticipated the policy implications

and challenges in actually implementing IPC in existing healthcare

systems, addressing the importance of integrating interprofessional

collaboration within continuing education courses and the didactic

and clinical curriculums of healthcare profession students.

4.1 | Interprofessional education

Interprofessional education (IPE) is defined as “‘members (or students)

of two or more professions associated with health or social care, to

be engaged in learning with, from and about each other”’ (p12).13 IPE

provides students with structured learning experiences for working

58 | BACHYNSKY

with other health profession students. In t

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