Cooperating for better care.

Triple Aim

Tag Archives

Should systems buy or build?

An NEJM Catalyst article looks at whether health systems should buy or build to expand. Among the comments:

“As in many industries, health care has experienced waves of consolidation in the name of growth. Hospitals have bought physician practices, doctors are opening ambulatory surgical centers, and there is a buy free-for-all across all parts of the continuum of care (and new forms of payment) as never before. Such vertical integration purportedly drives financial efficiencies with scale, improves clinical quality by reducing problems of care transitions, encourages teamwork, and calibrates scope of practice to services provided. Yet the jury is still out. Costs continue to rise as the market power of health systems grow (with lots of finger pointing), readmissions and problems in patient handoffs persist, anticompetitive practices emerge, and quality remains highly variable.

“Perhaps this lack of progress toward the Triple Aim suggests that we should reconsider our assumptions that vertically integrated systems will achieve productivity, patient-centeredness, and will deliver on a scalable version of Kaiser Permanente. Perhaps we should revisit the so-called rules of health care.”

To read the article, please hit this link.

Berwick: Push for the Triple Aim will continue under Trump


Ilene MacDonald, of FierceHealthcare, writes about the views of former CMS Administrator Don Berwick, M.D., on health policy under the Trump administration.

She writes:

“Trump’s pre-election healthcare platform called for complete price transparency, and elements of the Affordable Care Act also call for transparency to help make the healthcare system easier to understand, creating a more competitive market. That meant CMS had more authority and responsibility to make data more available to the public. That was a difficult journey, Berwick says, because historically CMS kept the data guarded and tightly controlled for research. Over time data has become more available but he’s unsure what the future holds with the new administration.”

Tom Price, M.D. [Trump’s pick for the new head of the Department of Health and Human Services] is a fan of doctors and doctor practices. And doctors are uncomfortable with transparency so I’m not sure which way he will call this,’ Berwick says.”

“Although Berwick isn’t sure what will happen to the star ratings system under the new administration, he says he is certain quality improvement in healthcare and the goal of the Triple Aim to improve individual care, boost the health of patient populations and reduce overall costs, will continue.”

To read all of Ms. MacDonald’s piece, please hit this link.

Could outpatient birth centers support ‘the Triple Aim’?


Two midwives assist a woman in labor on a birth chair in the 16th Century, from a work by Eucharius Rößlin.

Might hospital-affiliated outpatient  birth centers  be a way of achieving the “Institute for Healthcare Improvement’s’ “Triple Aim” as applied t0 obstetrics?

“Improving the patient experience of care (including quality and satisfaction); improving the health of populations, and reducing the per- capita cost of healthcare.”

To read a JAMA article about this idea, please hit this link.

Unconscious biases against healthcare innovation


A HealthAffairs piece looks at why healthcare innovation in the U.S. is so slow.

Jaan Sidorov, the author, notes that “many health system executives struggle with reconciling innovation with the downsides of abandoning existing business models and disrupting long-standing culture and workflows.”

“Advocates for innovation also note that responsibility for fostering innovation also includes health care organizations’ boards of directors. Yet, boards are grappling their own governance challenges and, since many directors may not have experience in the healthcare sector, they may also be unfamiliar with the underlying market drivers and specialized technologies that often underlie innovation.”

The article notes some things that could help:

  1. “Addressing downside risks. For example, an initial rollout can be restricted to a limited number of enrollees who are mostly likely to benefit, followed by expansion of the program only if measurable mileposts are achieved.
  2. “Including measures of early leading indicators of impact.
  3. “Recognizing that there often non-financial and non-clinical impacts, including the prospect of improving the Triple Aim experience of care and enhancing the organization’s reputation in a competitive marketplace.
  4. “Citing examples of the success of similar technology in other settings.
  5. “Avoiding subtle program descriptors (such as “research”) that could prompt unwarranted skepticism.
  6. “Reviewing all the just-published or Web-based information on the status of similar initiatives.”

The article sums up:

“One reason for the slow pace of innovation in U.S. healthcare may be the unconscious biases that have been described in behavioral economics. As innovators work with understandably reluctant executives and boards, it’s wise to not only describe a compelling business and clinical case, but to be prepared to address the mental errors that can otherwise undermine a good idea. ”

To read the HealthAffairs piece, please his this link.

AMA moves further to address physician-burnout issue


MedPage Today reports that the “American Medical Association wants physician work-life balance added to provider-experience measures for evaluating how well alternative payment models function” address what is seen as the growing  incidence of physician burnout under the stress of ever more complicated work, including vast quantities of red tape and record-keeping.
The new AMA policy, approved following the annual meeting of its House of Delegates, also changed  its support of the “Triple Aim” to  support of the “Quadruple Aim”. As originally conceived in the development of healthcare reform in recent years, the Triple Aim seeks to improve patient experience and the health of populations and to cut per-capita costs.

The AMA will ask the Centers for Medicare & Medicaid Services to use the Quadruple Aim when evaluating Accountable Care Organizations and other practice

New IHI head talks about his Scottish experience



The “Old Course” at St. Andrews. Mr. Feeley, like many Scots, is an enthusiastic golfer.

Derek Feeley is the new  chief executive of the Institute for Healthcare Improvement. Mr.  Feeley is  from Scotland, where he was head of the national healthcare system before becoming executive vice president of the IHI in 2013.

In this Hospitals & Health Networks interview he talks his experience in Scotland. Among his remarks:

“{The Scottish system is}a single-payer system. It’s almost exclusively tax funded. There’s very little competition. The National Health Service is more or less a monopoly provider of health care, but part of my responsibilities in Scotland was extended to the health of the population, as well as to delivering effective health care, and I had to do that within a cash-limited financial allocation…. So what I had to do in leading that healthcare system is what we call the Triple Aim at IHI:”

  • “Improving the patient experience of care (including quality and satisfaction).
  • “Improving the health of populations.
  • “Reducing the per capita cost of healthcare.”

“I had to make sure that the quality of the healthcare experience we were delivering was as high as it could possibly be, and I had to make sure that we were delivering improvements in the health of the population. I had to make sure that we were getting maximum value for every dollar that we were spending.”

“The challenges that leaders are facing in healthcare are pretty similar right across the developed world, actually — economic factors, political change, demographic pressures, the growth of co-morbidities, shifting customer expectations, and the accelerating pace of change. The challenges that leaders are facing are actually very similar across the Developed World. There never has been such a challenging time to be a leader in healthcare, but the good news is, because we are all tackling the same kind of issues, the opportunities for us to collaborate and learn from each other are significant.”

Time to push the ‘Quadruple Aim’


This column by Yul Ejnes, M.D., an internist and a past chairman of the board of regents of the American College of Physicians, says medicine needs a “Quadruple Aim” instead of the “Triple Aim”.

The “Triple Aim” is a concept developed in 2007 by Donald Berwick, M.D., and the Institute for Healthcare Improvement (IHI). Its three dimensions are “Improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.”

Then in 2014, to Doctors and Christine Sinsky published a paper in the Annals of Family Medicine titled “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.”

Dr. Ejnes notes that “{T}hey very effectively made the case that our ability to achieve the triple aim is jeopardized by the burnout of physicians and other healthcare providers. They proposed adding a fourth dimension to the three in the triple aim: ‘the goal of improving the work life of healthcare providers, including clinicians and staff.”‘
“{E}fforts to achieve the triple aim have in many cases made things worse for providers. The added workload related to performance measurement, EHR use, greater documentation requirements, and increased access (expanded hours, e-mail, etc.) have had detrimental effects on the satisfaction and morale of members of the healthcare team.”

“It’s not about just physicians, either. All members of the healthcare team are at risk. The ‘Quadruple Aim’ bolsters the well-being of nurses, medical assistants, receptionists, and anyone else involved in providing care to patients.”

So here is Dr. Ejnes’s campaign platform:
“Healthcare leaders should discuss the quadruple aim when they would normally mention the triple aim, and explain to their audiences why that change is so important. (Also, when you hear a speaker refer to the triple aim, ask him/her about the quadruple aim in the Q&A.)
Changes designed to improve how we deliver care should also improve the work life of healthcare providers (and certainly not worsen it).”



IHI’s ‘new rules’ to push toward the Triple Aim



This Institute for Healthcare Improvement  (IHI) paper describes 10 “new rules” developed and being tested by members of the IHI Leadership Alliance as a set of guiding principles to help accelerate their progress toward delivering on the full promise of the Triple Aim. The authors  provide examples showing how IHI Leadership Alliance member organizations are enacting some of these rules.’

Forces battle to defeat Triple Aim



Joe Flower, in Hospitals & Health Networks, in a very provocative piece headlined ”Winning’ by Defeating the Triple Aim,” writes:

“We are near the end of the first act of whatever you want to call this vast change {in health care} we are going through.

“And where are we? Across America, the cry of the age is ‘Volume to value.’

“But in each market, some major players are throwing their muscle into winning against the competition by defeating the Triple Aim, by increasing their volume, raising their prices, doing more wasteful over-treatment, and taking on little or no risk for the health of populations. At least in the short term, the predatory strategies of these players are making it more difficult for the rest of us to survive and serve.”




3 tips on advancing population health



The National Institutes of Health, Bethesda, Md., in Montgomery County. The presence of the NIH and other big healthcare centers in the county have helped make it a healthcare-reform leader.

The Primary Care Coalition in Montgomery County, Md., discusses its lessons as it has pushed to improve population health.

  1. “Every project does not need to focus on all three dimensions of the Triple Aim (but your portfolio of projects does).”
    “Until this year, we tried to include a measure for population health, patient experience, and cost reduction for every project we had. Previously, we thought a Triple Aim portfolio was a collection of projects each of which should achieve all three aims simultaneously. We now understand that our portfolio of projects needs to achieve all three aims. ”
  2. “Be clear on the definition and identification of your population.
    “{A] lesson we learned from Kick-Start the Triple Aim was about the formal structure underlying the Triple Aim. First and foremost is to be clear on how we define and identify our population. For an organization like ours, that can get a little messy. Having complete clarity, however, drives how we operate going forward.”
  3. “Never underestimate the value of learning from patients.
    “The Triple Aim prototyping work we did with IHI {the Institute for Healthcare Improvement} focused on emergency department (ED) utilization and contributed to the success of our efforts to link ED patients to primary care (as described in a study published in Health Affairs in May 2015). During the prototyping, IHI promoted the concept of studying an “n of 1” [with “n” denoting sample size] and pushed us to see how much we could learn from talking to a single patient who went to the ED. We started small and ended up doing a number of interviews.”

Page 1 of 212

Contact Info

(617) 230-4965

Wellesley, Mass