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The Quadruple Aim — A Framework for Success & Measuring Value

Business

May 31, 2022 - 8 minute read

2061 Blog Healthcare Tech Trends 416X300
Andrew Smith Director of Healthcare Services at Objectivity

Andrew started his career on the Financial Management Training Scheme of the NHS, at the Royal Liverpool and Broadgreen University Hospitals. He later spent 10 years at the Department of Health, where he led several national programmes, working at the interface of the NHS and the commercial sector. 

For the last few years, Andrew has focussed on Population Health projects and advised governments in the EU and Middle East, and supported health tech companies within the UK.  

Part of Population Health is about lifestyle and wellness, as such, Andrew enjoys running with his twin boys and, alongside his wife, supporting their daughter with her Rhythmic Gymnastics ambitions. 

See all Andrew's posts

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Table of contents

  1. What Is the Quadruple Aim & How Is It Maturing? 
  2. Applying the Quadruple Aim to Encourage and Measure Success 
  3. Conclusion 

At Objectivity, we have a core set of values that we work to — this is embedded throughout everything we do. We’re privileged to be able to work with amazing, innovative clients that share our values and strive to do good. Of course, we need to deliver results — therefore, it’s tremendously important to not only share values with our clients, but to ensure that we communicate and agree on common goals. It’s fair to say that (elsewhere) some technology solutions have attracted attention for being implemented without fully understanding the system-level problem they seek to address.  

The Quadruple Aim of Healthcare is a major source of inspiration for us at Objectivity when working with our healthcare clients. Whether a client asks us to develop a software solution for them to improve efficiencies, or an application to better support patients receiving care at home, we’re willing and able to help. However, at Objectivity, we want the project to not only be successfully delivered, but for it to add value 

Part of the rationale for setting up Objectivity into a divisional structure is to ensure we bring expert sector understanding to our projects and continually learn about how the work we do contributes within the context of the project itself. Before designing or implementing a service, we ask many questions at the “Consulting” stage of our projects (see diagram below) — questions such as “What are you trying to achieve? What value will this bring? What do your end users want to see?”. Understanding this — and sharing these goals — ensures success. 

Figure 1. Product lifecycle stages. 

Figure 1. Product lifecycle stages. 

Measuring value, however, is notoriously subjective — a Finance Director might describe value in terms of bottom-line savings or increased efficiencies, an Operational Manager might see value as achieving results (successful surgery), and a Customer Services Director will view this in terms of patient/customer satisfaction (Patient Reported Experience Measures). Of course, they are all right, as their CEO might demand that all three objectives are achieved. After all, patients/customers will choose another provider if their experience is poor, profitability will suffer if costs outstrip income, and, if the outcomes of the service do not deliver what is promised, the reputation of the organisation will be damaged. 

Therefore, in this context, it’s no surprise that the impact of Don Berwick’s succinct and beautifully described Triple Aim of healthcare has been so strong. It was first introduced by the Institute of Healthcare Improvement (of which Don was founder and CEO) and published in Health Affairs in 2008. The Triple Aim was originally described as: 

Figure 2. Don Berwick's Triple Aim of Healthcare.

  1. Improving the patient experience of care (including quality and satisfaction), 
  2. Improving the health of populations,  
  3. Reducing the per capita cost of healthcare. 

Although the Triple Aim was developed with a population focus in mind, I personally believe that population health is something that should permeate all parts of the system – it’s how the community, education, housing, local government and, of course, health come together that determines its success.  

What Is the Quadruple Aim & How Is It Maturing? 

Put simply, the Quadruple Aim encourages system leaders to ask themselves the following questions: 

  • “Is the health of the population improving?”, 
  • “When people require, or access services, is their experience of care good?”, 
  • “When we deliver care, are we doing so efficiently, or in such a way that reduces the overall cost / increases the value for money?”, 
  • “Is the staff who is supporting and providing care and services finding fulfilment in their work?”.  

The Quadruple Aim is the natural development of the Triple Aim, which started out as a means of optimising health system performance by suggesting that organisations working in healthcare pursue 3 key objectives: improving the health of the population, enhancing the patient experience of care, and reducing the overall cost of healthcare. A fourth aim (joy at work) was added in 2014 — in response perhaps at the concerning figures coming from staff satisfaction surveys.   

The pandemic led many organisations to turn to innovation for help. Perhaps the biggest change was the rapid up-take and widespread adoption of technologies that facilitated new ways of working (e.g. video consultations). Although organisations improved efficiencies and brought in new ways of working, staff had to learn to adapt to them — an effort that’s seen variable levels of success. Healthcare is a sector that relies heavily on the care, attention, and skills of those delivering the service. Rightly, therefore, we should include the staff experience within the measurements of value.

The introduction of a fourth pillar — “joy at work” often measured in terms of staff satisfaction is a really important addition. The last two or so years of the pandemic proved that even when money was poured into systems and even with the unparalleled commitment of staff, health systems struggled to cope, because there is only so much that people can do within the systems they find themselves. 

Figure 3. Digital technologies in the public health response to COVID-19

Figure 3. Digital technologies in the public health response to COVID-19

However, we need to continually refresh our thinking. At Objectivity, we’re proud to be able to call upon our expert Healthcare Advisory Board, which meets quarterly to discuss emerging trends and ideas in the health and care sector. At our last meeting at Alder Hey Innovation Centre, we focussed on how we can tackle and reduce inequalities within the work we do — whether this be digital exclusion, access to services due to distance, or socio-economic factors. So, perhaps we should consider adding a “fifth element” of the Quadruple Aim — Equity? Furthermore, how about sustainability? At Objectivity, we’ll certainly be looking at incorporating these important measures of success and adding value into our toolkit.  

Figure 4. Healthcare Advisory Board expert panel discussion.

Figure 4. Healthcare Advisory Board expert panel discussion. 

Applying the Quadruple Aim to Encourage and Measure Success 

I was first introduced to the Triple / Quadruple Aim of healthcare whilst visiting Gesundes Kinzigtal (“Healthy Kinzigtal”) in southwest Germany in 2013. Gesundes Kinzigtal serves as an amazing example of commissioners (the insurance company) and providers (the physicians) co-owning and co-developing a system and working together through a management company (OptiMedis AG) to improve the health of the population.  

Gesundes Kinzigtal is responsible for organising care and improving the health of nearly half of Kinzigtal’s 71,000 inhabitants. Their results are fantastic: better health outcomes, fewer emergency admissions than other areas, better patient satisfaction and financial savings of 17% compared to comparison groups. You can read more about it in this article by the King’s Fund. 

While working alongside colleagues from OptiMedis in Kinzigtal, what struck me was the transparency and shared ownership of goals. Furthermore, these goals acknowledged a long-term commitment and the re-investment of system savings with and for local people to enable better health outcomes in the future. For me, coming from a career as a trained NHS Accountant and after having worked in the UK Department of Health for 12 years, this was a refreshing approach.  

The Quadruple Aim allows for the structure of overall goals, metrics, and incentives to be aligned and shared. When working in this way, organisations don’t need the finance department to worry exclusively about finances, or an Operations Manager to focus only on operations and so on. Each element is important and, crucially — interoperable. Instead, all the elements depend on each other.  

In Kinzigtal, a shared and co-developed programme of work was set out that described how these goals could be achieved and ensured that the Quadruple Aim permeated throughout their system — the success of one supported the success of the others. Similar to a suspension bridge, where each part works together, some in horizontal tension and some in vertical compression, it’s the balance of all of them that supports the whole. Yet, the bridge is flexible enough to withstand external pressures — e.g. varying loads and high crosswinds in the case of a suspension bridge, or perhaps a pandemic in the case of healthcare systems. As we saw earlier, the CEO might demand all elements are present and accounted for: patient experience, outcomes, value for money, and staff experience. Each of these aspects working well brings harmony and overall success.  

We’re pleased to see the NHS is using a similar version of the Quadruple Aim, which is described as a  “common duty” for healthcare systems to use when planning and delivering services.  

At Objectivity, we use a matrix to measure the value goals the client has against each pillar of the Quadruple Aim, and we identify indicators to show whether/how well these goals are being met.

Figure 4. The Quadruple Aim of Healthcare

Figure 5. The Quadruple Aim of Healthcare 

Figure 5. Our process of implementing the Quadruple Aim of Healthcare in projects.

Figure 6. Our process of implementing the Quadruple Aim of Healthcare in projects. 

Conclusion 

Earlier in this article, we mentioned that we always take great care to understand the context of the work we do with clients to make sure we deliver value. Whatever the request, given our breadth of experience and with 800+ (and growing) business and technology experts on board, it’s likely we can help, but please be patient with us when we ask many questions about what a successful project means to you.  

When we say that a project has been “successful”, we mean that it has delivered value; not just that it was delivered excellently. We know that each project is different and will have specific aims and objectives, and that certain metrics will initially be identified as more important than others. For instance, certain clients may have a greater focus on one element (e.g. patient experience), or for some services, at certain times (e.g. COVID-19 pandemic), it will more important to deliver quickly and effectively.  

As such, it’s crucial for us to understand your goals and what you’re trying to achieve — while being guided by the Quadruple Aim and our values — so, please bear with us as we consider how the project that we work on together will address the framework’s key pillars: 

  1. Better health outcomes, 
  2. Improved patient experience, 
  3. Improved staff satisfaction, 
  4. Lower cost of care. 

When partnering with healthcare organisations, we strive to address all of these aspects while also providing you with a service that is value-for-money. Taking the time to understand your needs and expectations while considering the Quadruple Aim’s key pillars gives us satisfaction and, as our previous experiences have demonstrated, leads to a successful assignment — success in the context of what it is you are trying to achieve.  

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Andrew Smith Director of Healthcare Services at Objectivity

Andrew started his career on the Financial Management Training Scheme of the NHS, at the Royal Liverpool and Broadgreen University Hospitals. He later spent 10 years at the Department of Health, where he led several national programmes, working at the interface of the NHS and the commercial sector. 

For the last few years, Andrew has focussed on Population Health projects and advised governments in the EU and Middle East, and supported health tech companies within the UK.  

Part of Population Health is about lifestyle and wellness, as such, Andrew enjoys running with his twin boys and, alongside his wife, supporting their daughter with her Rhythmic Gymnastics ambitions. 

See all Andrew's posts

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