The Evolving Aims of Healthcare Evaluation

Welcome to the first entry in Verto’s new three-part blog series on the importance of equity in improving health system performance. The series begins with an exploration of the history of health system evaluation and the progression of the Triple Aim to the Quadruple Aim, and ultimately, the Quintuple Aim. 

2008 was a year of firsts and innovation. The U.S. elected its first African-American President, Barack Obama.The pioneering president would go on to introduce the largest expansion of public healthcare in the industrialized world since President Johnson’s creation of Medicaid and Medicare with the passage of the Affordable Care Act. And on the frontlines of care delivery, scientists used genome editing for the first time to achieve a significant breakthrough in the battle against HIV. 

While it may not have shared the spotlight with these high-profile headlines, something else was brewing at the time that would change how we view healthcare reform today. A formative research paper by the Institute for Healthcare Improvement (IHI) titled “The Triple Aim: Care, Health, And Cost” was published in the May/June 2008 edition of HealthAffairs

Simply complex

The Triple Aim proposed that improvement of the healthcare system depended on three interrelated elements: 

  • Improving the experience of care 
  • Improving the health of populations; and
  • Reducing per the per capita costs of care

Despite consisting of only three goals, there is inherent complexity in this framework. A 2012 IHI blog post details the IHI Triple Aim Initiative pilot program which started in 2007 with just 15 organizations in three participating countries. Eventually, the pilot expanded to over 150 organizations in nine countries. The reach and scale of the prototyping initiative alone speaks to just how complex and ambitious the Triple Aim was.  

It wasn’t until 2012 that there was enough data from the pilot to meaningfully evaluate how countries, regions, and organizations could measure success against the framework. Matthew Stiefel and Kevin Nolan (also of the IHI) published a white paper which was designed as a “menu of suggested measures for the three dimensions of the Triple Aim.” 

A fourth dimension: providers left behind

Now that there were means to measure the pursuit of the Triple Aim, the question then became: how did we do? It turns out not so well. In 2014, amid high provider burnout, a recommendation was made to expand the Triple Aim to include a focus on healthcare provider experience. The authors behind the recommendation, Thomas Bodenheimer and Christine Sinsky, cited “stressful work life” as a recurring theme among healthcare providers. Both clinicians and administrative staff felt this was negatively impacting the goals of the Triple Aim. 

And so, the concept of the Quadruple Aim was proposed. The reasoning was simple enough, if we improved the experience for providers and staff, there was a better chance of achieving the goals of the Triple Aim.

But how did the authors of the original Triple Aim paper feel about the proposition of a fourth aim? In a 2017 interview with co-author Don Berwick, he suggested that while the Triple Aim framework wasn’t set in stone, the intent was to focus externally on what society expected of the healthcare system. He felt that job satisfaction of healthcare workers was more of an internal input. However, there was more to the story. 

On equal ground

In that same interview, Berwick discussed a growing realization of his. As time passed, he began to “understand the power of community determinants of health.” Indeed, many socioeconomic factors contribute to improving the overall health of a population. Today we understand the importance of social determinants of health and one key interrelated concept: equity.

Stay tuned for the next entry in our three-part series where we will explore the the inclusion of equity in the most recent iteration of the IHI’s evaluation framework: the Quintuple Aim.

September 11, 2023
Eric Phillipson
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