Evidence-Based Practice And The Quadruple Aim Essay.

Evidence-Based Practice And The Quadruple Aim Essay.

Evidence-Based Practice And The Quadruple Aim Essay.


Experts express concern that attaining of the Triple Aim of reducing health care costs, improving patient experiences and ultimately population health, may be compromised by high levels of burnout among physicians. Some have called for a fourth aim of improving the work environment for care providers.Evidence-Based Practice And The Quadruple Aim Essay.


Burnout has been linked to poor outcomes in many occupational settings. This study’s aim was to investigate linkages between physician burnout and patient outcomes through a systematic review of the literature.

Systematic search of 3 databases using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. In total, 1201 articles were reviewed, and 28 were included in the final analysis. Studies needed to be empirical, measure physician burnout as a predictor, and include patient outcome measures.Evidence-Based Practice And The Quadruple Aim Essay.

The majority of studies were cross-sectional and measured patient outcomes via physician perception self-reports (n=14). Five studies reported clinical measures (quality, errors), and 9 included patient ratings of their care.Evidence-Based Practice And The Quadruple Aim Essay.

Studies using self-reports of suboptimal quality and errors found that physicians higher in burnout consistently reported worse quality, yet studies linking burnout to independent clinical outcomes found no relationships. Similarly, burnout was related to lower patient ratings of care, but when specific behaviors were rated there was no relationship.

Although the interest in burnout’s effects is strong, the lack of rigorous empirical studies examining patient outcomes is problematic. Future research should develop and test causal models to better understand which domains of patient care are influenced by physician burnout.Evidence-Based Practice And The Quadruple Aim Essay.

Evidence-based practice (EBP) is defined by Duke University Medical Center as the integration of clinical expertise, patient values and the best research evidence into the decision-making process for patient care.

EBP strategies allow NPs and other health care providers to translate research findings into clinical practice. With efficient literature-searching skills and the application of formal rules of evidence in evaluating research findings, providers can apply existing scientific knowledge in their clinical practice for each individual patient.Evidence-Based Practice And The Quadruple Aim Essay.

“The Institute for Healthcare Improvement said we should target the triple aim in health care: improving the patient experience, improving population health outcomes and decreasing health care costs,” says Melnyk. “Some years after the triple aim goal came out, a fourth aim was added: improving the work life of clinicians and their well-being. EBP is the secret sauce to enable us to get to that quadruple aim.”Evidence-Based Practice And The Quadruple Aim Essay.

In a time when NPs and many other providers experience symptoms of burn out, EBP can be empowering. While it may require a different skillset, research has shown that when providers deliver evidence-based care, patient outcomes are markedly improved.Evidence-Based Practice And The Quadruple Aim Essay.

Unfortunately, even when health care providers hold positive opinions about EBP, many do not actively implement EBP strategies due to a lack of time, lack of leadership buy-in and investment or lack of understanding.

“We conducted a study of 276 chief nurse executives from across the U.S. and found that, although they believe in value of EBP, they didn’t invest in it for their clinicians. Although they identified quality and safety as key priorities, EBP was at the bottom,” says Melnyk.Evidence-Based Practice And The Quadruple Aim Essay.

“This tells us they don’t understand EBP is the direct pathway to getting to health care quality and safety. EBP is all about using the best evidence to make the best clinical decisions to achieve the best clinical outcomes.”

Learn the seven steps of the EBP process from renowned experts in the field in Foundations of Evidence-based Practice in Health Care. This free, massive open online course (MOOC) will guide you through current trends, provide strategies to overcome barriers and help you create system change in your practice setting.Evidence-Based Practice And The Quadruple Aim Essay.

Don’t wait—the next course ends April 22, 2019. Enroll today!

Additional Resources:

AANP-accredited CE: Search for EBP education on a variety of topics, including adolescent mental health, depression and anxiety in primary care, prescribing psychotropic drugs and neuropathic pain.Evidence-Based Practice And The Quadruple Aim Essay.
The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare: Gain an immersive experience, online learning and research from this national hub for all things EBP. Plus, the Accreditation Board for Specialty Nursing Certification (ABSNC) has approved the institute’s EBP Certification program—coming fall 2019!
“Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice:” Written by Bernadette Melnyk, the newly released fourth edition delivers real-world examples and meaningful strategies to help you meet today’s clinical challenges and ensure positive patient outcomes.Evidence-Based Practice And The Quadruple Aim Essay.

Have you ever wondered why the United States spends more money on healthcare than any western country, yet it ranks 37th in world health outcomes? Have you ever questioned why patients are awakened every 2 to 4 hours for vital signs in th​e hospital when they are stable and in desperate need of sleep? Or wondered why nurses work 12-hour shifts when research shows the multiple adverse outcomes of working lengthy hours for both clinicians and patients? Have you ever thought about the millions of healthcare dollars that could be saved if all primary care providers would follow the evidence-based recommendations of the U.S. Preventive Services Task Force? Have you ever questioned why it often takes decades for the evidence that is generated from research to be translated into the real world to improve healthcare quality and patient outcomes?

Tina Magers (nursing professional development and research coordinator at Mississippi Baptist Health Systems) and her team wondered why catheter-associated urinary tract infections (CAUTIs) affect as many as 25% of all hospitalized patients and questioned what evidence exists that could inform a practice change to reduce these infections in their hospital. (This is Step #0 in the seven-step evidence-based practice [EBP] process, which we describe in detail later in this chapter.) As a result, the team formed the following question in a format called PICOT (Patient population, Intervention or Interest area, Comparison intervention or group, Outcome, and Time; Step #1 in EBP) that facilitated them to conduct an expedited effective search for the best evidence (Magers, 2015):Evidence-Based Practice And The Quadruple Aim Essay.

In adult patients hospitalized in a long-term acute care hospital (P), how does the use of a nurse-driven protocol for evaluating the appropriateness of short-term urinary catheter continuation or removal (I) compared to no protocol (C) affect the number of catheter days and CAUTI rates (O) over a six-month post-intervention period (T)?Evidence-Based Practice And The Quadruple Aim Essay.

The team conducted an evidence search to answer this clinical question using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects (DARE), Ovid Clinical Queries, and PubMed (Step #2 in EBP), followed by rapid critical appraisal of 15 studies found in the search (Step #3 in EBP). A synthesis of the 15 studies led the team to conclude that early removal of urinary catheters would likely reduce catheter days and CAUTIs (the identified outcomes). Therefore, the team wrote a protocol based on the evidence, listing eight criteria for the continuation of a short-term urinary catheter (Step #4 in EBP).Evidence-Based Practice And The Quadruple Aim Essay.

After the protocol was presented to the medical executive committee at their hospital for approval, a process for the change was put into practice, including an education plan with an algorithm that was implemented in small group inservices for the nurses, posters, and written handouts for physicians. An outcomes evaluation (Step #5 in the EBP process) revealed a significant reduction in catheter days and a clinically significant reduction of 33% in CAUTIs. The team disseminated the outcomes of the project to internal audiences (e.g., their Nursing Quality Council, the EBP and Research Council, Nursing Leadership Council, Organization Infection Control Committee) and external venues (presentations at regional conferences and a publication in the American Journal of Nursing) (Magers, 2013). (Step #6 in the EBP process.)Evidence-Based Practice And The Quadruple Aim Essay.

This is a stellar exemplar of how a team with a spirit of inquiry and a commitment to improving healthcare quality can use the seven-step EBP process discussed in this chapter to improve patient outcomes and reduce hospital costs.

Evidence-based practice and the quadruple aim in healthcare
Findings from an extensive body of research support that EBP improves the quality and safety of healthcare, enhances health outcomes, decreases geographic variation in care, and reduces costs (McGinty & Anderson, 2008; Melnyk & Fineout-Overholt, 2015; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012a). In the United States, EBP has been recognized as a key factor in meeting the Triple Aim in healthcare, defined as (Berwick, Nolan, & Whittington, 2008):

Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of healthcare
The Triple Aim has now been expanded to the Quadruple Aim: the fourth goal being to improve work life and decrease burnout in clinicians (Bodenheimer & Sinsky, 2014).

Because EBP has been found to empower clinicians and result in higher levels of job satisfaction (Strout, 2005), it also can assist healthcare systems in achieving the Quadruple Aim. However, regardless of its tremendous positive outcomes, EBP is not standard of care in healthcare systems throughout the United States or the rest of the world due to multiple barriers that have continued to persist over the past decades. Some of these barriers include (Melnyk & Fineout-Overholt, 2015; Melnyk et al., 2012a; Melnyk et al., 2012b; Melnyk et al., 2016; Pravikoff, Pierce, & Tanner, 2005; Titler, 2009):Evidence-Based Practice And The Quadruple Aim Essay.

Inadequate knowledge and skills in EBP by nurses and other healthcare professionals
Lack of cultures and environments that support EBP
Misperceptions that EBP takes too much time
Outdated organizational politics and policies
Limited resources and tools available for point-of-care providers, including budgetary investment in EBP by chief nurse executives
Resistance from colleagues, nurse managers, and leaders
Inadequate numbers of EBP mentors in healthcare systems
Academic programs that continue to teach baccalaureat, master’s, and doctor of nursing practice students the rigorous process of how to conduct research instead of taking an evidence-based approach to care
Urgent action is needed to rapidly accelerate EBP in order to reduce the tremendously long lag between the generation of research findings and their implementation in clinical settings. Many interventions or treatments that have been found to improve outcomes through research are not standard of care throughout healthcare systems or have never been used in clinical settings. It took more than 20 years for neonatal and pediatric intensive care units to adopt the Creating Opportunities for Parent Empowerment (COPE) Program for parents of preterm infants and critically ill children even though multiple intervention studies supported that COPE reduced parent depression and anxiety, enhanced parental-infant interaction, and improved child outcomes (Melnyk & Fineout-Overholt, 2015). It was not until findings from a National Institute of Nursing Research funded randomized controlled trial supported that COPE reduced neonatal intensive care unit (NICU) length of stay in premature infants by 4 days (8 days in preterms less than 32 weeks) and its associated substantial decreased costs that NICUs across the country began to implement the intervention as standard of care (Melnyk & Feinstein, 2009; Melnyk et al., 2006).

If not for an improvement in “so-what” outcomes (outcomes of importance to the healthcare system, such as decreased length of stay and costs), COPE would not have been translated into NICU settings to improve outcomes in vulnerable children and their families. On the other hand, many interventions or practices that do not have a solid body of evidence to support them continue to be implemented in healthcare, including double-checking pediatric medications, assessing nasogastric tube placement with air, and taking vital signs every 2 or 4 hours for hospitalized patients. These practices that are steeped in tradition instead of based upon the best evidence result in less than optimum care, poor outcomes, and wasteful healthcare spending.Evidence-Based Practice And The Quadruple Aim Essay.

Definition of evidence-based practice
As EBP evolved, it was defined as the conscientious use of current best evidence to make decisions about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Since this earlier definition, EBP has been broadened to include a lifelong problem-solving approach to how healthcare is delivered that integrates the best evidence from high-quality studies with a clinician’s expertise and also a patient’s preferences and values (Melnyk & Fineout-Overholt, 2015; see Figure 1.1).Evidence-Based Practice And The Quadruple Aim Essay.

Incorporated within a clinician’s expertise are:

Clinical judgment
Internal evidence from the patient’s history and physical exam, as well as data gathered from EBP, quality improvement, or outcomes management projects
An evaluation of available resources required to deliver the best practices
Some barriers inhibit the uptake of EBP across all venues and disciplines within healthcare. Although the strongest level of evidence that guides clinical practice interventions (i.e., Level I evidence) are systematic reviews of randomized controlled trials followed by well-designed randomized controlled trials (i.e., Level II evidence), there is a limited number of systematic reviews and intervention studies in the nursing profession. Single descriptive quantitative and qualitative studies, which are considered lower-level evidence, continue to dominate the field; see Table 1.1 for levels of evidence that are used to guide clinical interventions.Evidence-Based Practice And The Quadruple Aim Essay.

However, all studies that are relevant to the clinical question should be included in the body of evidence that guides clinical practice. In addition, clinicians often lack critical appraisal skills needed to determine the quality of evidence that is produced by research. Critical appraisal of evidence is an essential step in EBP given that strength or level of evidence plus quality of that evidence gives clinicians the confidence to act and change practice. If Level I evidence is published but is found to lack rigor and be of poor quality through critical appraisal, a clinician would not want to make a practice change based on that evidence.Evidence-Based Practice And The Quadruple Aim Essay.


(Click image to enlarge)





Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs)


Evidence obtained from well-designed RCTs


Evidence obtained from well-designed controlled trials without randomization


Evidence from well-designed case-control and cohort studies


Evidence from systematic reviews of descriptive and qualitative studies


Evidence from single descriptive or qualitative studies


Evidence from the opinion of authorities and/or reports of expert committees

Source: Modified from Elwyn et al. (2015) and Harris et al. (2001) .

The seven steps of evidence-based practice
Evidence-based practice was originally described as a five-step process including (Sackett et al., 2000):

Ask the clinical question in PICOT format.
Search for the best evidence.
Critically appraise the evidence.
Integrate the evidence with a clinician’s expertise and a patient’s preferences and values.
Evaluate the outcome of the practice change.
In 2011, Melnyk and Fineout-Overholt added two additional steps to the process, resulting in the following seven-step EBP process (see Table 1.2).





Cultivate a spirit of inquiry within an EBP culture and environment.


Ask the burning clinical question in PICOT format.


Search for and collect the most relevant best evidence.


Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, synthesis, and recommendations).


Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change.Evidence-Based Practice And The Quadruple Aim Essay.


Evaluate outcomes of the practice decision or change based on evidence.


Disseminate the outcomes of the EBP decision or change.

Step #0: Cultivate a spirit of inquiry within an EBP culture and environment
The first step in EBP is to cultivate a spirit of inquiry, which is a continual questioning of clinical practices. When delivering care to patients, it is important to consistently question current practices: For example, is Prozac or Zoloft more effective in treating adolescents with depression? Does use of bronchodilators with metered dose inhalers (MDIs) and spacers versus nebulizers in the emergency department (ED) with asthmatic children lead to better oxygenation levels? Does double-checking pediatric medications lead to fewer medication errors?Evidence-Based Practice And The Quadruple Aim Essay.

Cultures and environments that support a spirit of inquiry are more likely to facilitate and sustain a questioning spirit in clinicians. Some key components of an EBP culture and environment include (Melnyk, 2014; Melnyk & Fineout-Overholt, 2015; Melnyk et al., 2012a, 2016):

An organizational vision, mission, and goals that include EBP
An infrastructure with EBP tools and resources
Orientation sessions for new clinicians that communicate an expectation of delivering evidence-based care and meeting the EBP competencies for practicing registered nurses (RNs) and advanced practice nurses (APNs)
Leaders and managers who “walk the talk” and support their clinicians to deliver evidence-based care
A critical mass of EBP mentors to work with point-of-care clinicians in facilitating evidence-based care
Evidence-based policies and procedures
Orientations and ongoing professional development seminars that provide EBP knowledge and skills-building along with an expectation for EBP
Integration of the EBP competencies in performance evaluations and clinical ladders
Recognition programs that reward evidence-based care
Step #1: Ask the burning clinical question in PICOT format
After a clinician asks a clinical question, it is important to place that question in PICOT format to facilitate an evidence search that is effective in getting to the best evidence in an efficient manner. PICOT represents:Evidence-Based Practice And The Quadruple Aim Essay.

Sometimes, there is not a time element; therefore you see PICO rather than PICOT. P: Patient population
I: Intervention or Interest area
C: Comparison intervention or group
O: Outcome
T: Time (if relevant)
For example, the clinical questions asked in Step #0 that all involve interventions or treatments should be rephrased in the following PICOT format to result in the most efficient and effective database searches:

In depressed adolescents (P), how does Prozac (I) compared to Zoloft (C) affect depressive symptoms (O) 3 months after starting treatment (T)?
In asthmatic children seen in the ED (P), how do bronchodilators delivered with MDIs with spacers (I) compared to nebulizers (C) affect oxygenation levels (O) 1 hour after treatment (T)?
In hospitalized children (P), how does double-checking pediatric medications with a second nurse (I) compared to not double-checking (C) affect medication errors (O) during a 30-day time period (T)?
In addition to intervention or treatment questions, other types of PICOT questions include meaning questions, diagnosis questions, etiology questions, and prognosis questions that are addressed in Chapter 3.Evidence-Based Practice And The Quadruple Aim Essay.

Step #2: Search for and collect the most relevant best evidence
After the clinical question is placed in PICOT format with the proper template, each keyword in the PICOT question should be used to systematically search for the best evidence; this strategy is referred to as keyword searching. For example, to gather the evidence to answer the intervention PICOT questions in Step #1, you would first search databases for systematic reviews and randomized controlled trials given that they are the strongest levels of evidence to guide practice decisions.Evidence-Based Practice And The Quadruple Aim Essay.

However, the search should extend to include all evidence that answers the clinical question. Each keyword or phrase from the PICOT question (e.g., depressed adolescents, Prozac, Zoloft, depressive symptoms) should be entered individually and searched. Searching controlled vocabulary that matches the keywords is the next step in a systematic approach to searching.Evidence-Based Practice And The Quadruple Aim Essay.

In the final step, combine each keyword and controlled vocabulary previously searched, which typically yields a small number of studies that should answer the PICOT question. This systematic approach to searching for evidence typically yields a small number of studies to answer the clinical question versus a less systematic approach, which usually produces a large number of irrelevant studies. More specific information about searching is covered in Chapter 4.

Step #3: Critically appraise the evidence
After relevant evidence has been found, critical appraisal begins. First, it is important to conduct a rapid critical appraisal (RCA) of each study from the data search to determine whether they are keeper studies: that is, they indeed answer the clinical question. This process includes answering the following questions:Evidence-Based Practice And The Quadruple Aim Essay.

Are the results of the study valid? Did the researchers use the best methods to conduct the study (study validity)? For example, assessment of a study’s validity determines whether the methods used to conduct the study were rigorous.
What are the results? Do the results matter, and can I get similar results in my practice (study reliability)?
Will the results help me in caring for my patients? Is the treatment feasible to use with my patients (study applicability)?
Rapid critical appraisal checklists can assist clinicians in evaluating validity, reliability, and applicability of a study in a time-efficient way. See Chapter 5 for one example of an RCA checklist for randomized controlled trials and Melnyk & Fineout-Overholt (2015) for a variety of RCA checklists. After an RCA is completed on each study and found to be a keeper, it is included in the evaluation and synthesis of the body evidence to determine whether a practice change should be made. Chapter 5 contains more information on critically appraising, evaluating, and synthesizing evidence.Evidence-Based Practice And The Quadruple Aim Essay.

Step #4: Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change
After the body of evidence from the search is critically appraised, evaluated, and synthesized, it should be integrated with a clinician’s expertise and also a patient’s preferences and values to determine whether the practice change should be conducted. Providing the patient with evidence-based information and involving him or her in the decision regarding whether he or she should receive a certain intervention is an important step in EBP. To facilitate greater involvement of patients in making decisions about their care in collaboration with healthcare providers, there has been an accelerated movement in creating and testing patient-decision support tools, which provide evidence-based information in a relatable understandable format (Elwyn et al., 2015).Evidence-Based Practice And The Quadruple Aim Essay.

Step #5: Evaluate outcomes of the practice decision or change based on evidence
After making a practice change based on the best evidence, it is critical to evaluate outcomes—the consequences of an intervention or treatment. For example, an outcome of providing a baby with a pacifier might be a decrease in crying. Outcomes evaluation is essential to determine the impact of the practice changes on healthcare quality and health outcomes. It is important to target “so-what” outcomes that the current healthcare system considers important, such as complication rates, length of stay, rehospitalization rates, and costs given that hospitals are currently being reimbursed based on their performance on these outcomes (Melnyk & Morrison-Beedy, 2012). A more thorough discussion of approaches to outcomes evaluation is included in Chapter 7.Evidence-Based Practice And The Quadruple Aim Essay.

Step #6: Disseminate the outcomes of the EBP decision or change
Silos often exist, even within the same healthcare organization. So that others can benefit from the positive changes resulting from EBP, it is important to disseminate the findings. Various avenues for dissemination include institutional EBP rounds; poster and podium presentations at local, regional, and national conferences; and publications. More detailed information about disseminating outcomes of EBP is included in Chapter 9.Evidence-Based Practice And The Quadruple Aim Essay.

Rationale for the new EBP competencies
To accelerate the uptake of EBP and ensure that nurses are competent in the delivery of evidence-based care, a new set of EBP competencies was recently developed for practicing RNs and APNs. Competencies are typically developed and used to ensure the delivery of high-quality, safe nursing care, which should be an expectation from the public (American Nurses Association, 2010; Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). The process of developing these competencies along with the research conducted to further validate them are described in Chapter 2. Evidence-Based Practice And The Quadruple Aim Essay.
This chapter discussed how evidence-based practice (EBP) improves healthcare quality, patient outcomes, and cost reductions, yet multiple barriers persist in healthcare settings that need to be rapidly overcome. Ensuring that clinicians meet the newly established EBP competencies along with creating cultures and environments that support EBP are key strategies to transform the current state of nursing practice and healthcare delivery to its highest level. This chapter discussed how evidence-based practice (EBP) improves healthcare quality, patient outcomes, and cost reductions, yet multiple barriers persist in healthcare settings that need to be rapidly overcome. Ensuring that clinicians meet the newly established EBP competencies along with creating cultures and environments that support EBP are key strategies to transform the current state of nursing practice and healthcare delivery to its highest level.Evidence-Based Practice And The Quadruple Aim Essay.

Book authors:
Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN , is associate vice president for health promotion, university chief wellness officer, and professor and dean of the College of Nursing at The Ohio State University. She also is professor of pediatrics and professor of psychiatry at Ohio State’s College of Medicine.

Lynn Gallagher-Ford, PhD, RN, DPFNAP, NE-BC, is director of the Center for Transdisciplinary Evidence-based Practice (CTEP) and clinical associate professor in the College of Nursing at The Ohio State University.Evidence-Based Practice And The Quadruple Aim Essay.

Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, is the Mary Coulter Dowdy Distinguished Nursing Professor in the College of Nursing & Health Sciences at the University of Texas at Tyler.

Eighteen years ago, an alarming report on preventable deaths from medical errors was released by the Institute of Medicine (IOM, 2000). That report featured the estimate that approximately 100,000 people in the United States die each year because of preventable medical errors. A subsequent IOM report (2003) called for all health professionals to be better prepared to keep patients safe, focusing on five core competencies for health professions education: patient-centered care, interprofessional collaboration, evidence-based practice, quality improvement, and informatics.

Visionary leaders in nursing education were ahead of the curve, responding to the call for safer and more effective care via the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007). In 2008, the Institute for Healthcare Improvement announced a major initiative—the Triple Aim—which focuses on “simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick, Nolan, & Whittington, 2008, p. 759). Subsequently, Bodenheimer and Sinsky (2014) proposed a fourth—a quadruple—aim to improve the work life of health care providers, both clinicians and staff.Evidence-Based Practice And The Quadruple Aim Essay.

What progress has been made during the past 19 years since the IOM report, with 10 years of QSEN education, and 9 years after the Triple Aim was launched? Improvements in some health outcomes have been reported. For instance, the United States has seen a 15% reduction in infant mortality rates compared with 2005 (Kochanek, Murphy, Xu, & Tejada-Vera, 2014). Numbers of hospital-acquired conditions, such as central line-associated bloodstream infections (CLABSIs), pressure ulcers, and falls with injuries have significantly decreased from 2010 to 2013, according to a recent report from the American Hospital Association (2015). However, in terms of better care and lower costs, we are not yet there. James (2013) has estimated annual hospital patient deaths due to preventable harm to be over 400,000 per year.Evidence-Based Practice And The Quadruple Aim Essay. Reports from consumers of health care continue to include stories of poor care experiences, including lack of compassion and frustrations in navigating the complexities of the care system. Further, the aim of lower costs per capita has yet to become reality. Although an estimated 20 million people were newly insured through the Patient Protection and Affordable Care Act (ACA, 2010), political challenges to the ACA remain, including rising costs, high out-of-pocket expenses, and access to affordable insurance.Evidence-Based Practice And The Quadruple Aim Essay.

In the world of leadership, there is a term referred to as the sweet spot, where economic health and the common good coexist and are the keys to achieving viable and sustainable solutions (Savitz & Weber, 2008). Is it possible to reach the sweet spot of the Quadruple Aim? Academy Health and the Robert Wood Johnson Foundation are partnering to pursue this formidable aim, proposing that care delivery systems collaborate across multiple sectors to provide an affordable approach to improving population health (Hacker, 2017).Evidence-Based Practice And The Quadruple Aim Essay.

Are we as a profession just going to sit back and wait for that to happen? I believe that nurse educators are well positioned to lead the way to this lofty sweet spot goal. Nursing schools and nurse educators already work across multiple sectors to prepare nurses at all levels, from prelicensure to doctoral education. Nurse educators are already in all settings across the care continuum as practitioners themselves and as mentors to nursing students applying theory in practice. Many, if not most, prelicensure through DNP nursing students have been well prepared with the QSEN competencies. Those at the graduate level are leading evidence-based systems improvement initiatives as a part of their practice immersion and culminating projects.Evidence-Based Practice And The Quadruple Aim Essay.

I have seen the power of what nurses can do to bring the multiple sectors together in the interest of patient safety, quality, population health, and affordable care. Faculty and students have taken a Quadruple Aim approach. Working in communities and across the globe, they have engaged with community and global leaders and local health advocates, such as Promotores (lay Hispanic health advocates), to partner for better health outcomes. Faculty and students have conducted community needs assessments to identify health priorities. They have provided health education and health screening.Evidence-Based Practice And The Quadruple Aim Essay. They have applied the processes and tools of the science of improvement to community-based projects to facilitate collaboration across sectors to improve health outcomes. They have been part of teams who have provided resources that communities often cannot afford alone. They have gathered and analyzed the metrics to measure results. The response from local leaders and health advocates is consistently positive, acknowledging their contributions. And both students and faculty have benefitted from these practice experiences.Evidence-Based Practice And The Quadruple Aim Essay.

My greatest concern is that those who lead national associations in both education and practice have not found a way to rise above their respective self-interests with a genuine commitment to work in partnership towards the Quadruple Aim sweet spot. Some have not yet learned what visionary 20th century organizational leadership pioneer Mary Follett Parker taught about the distinction between power with versus power over (Briskin, Erickson, Ott, & Callahan, 2009). Power over depends on relationships of polarity, suspicion, and differentials in power. Power with relies on relationships of respect, stakeholder engagement, and multisector approaches, resulting in co-created power.Evidence-Based Practice And The Quadruple Aim Essay.

Faculty and students typically work in collaboration with their patients and families, as well as their clinical partners across sectors, to improve health care and health outcomes. That is what QSEN has taught us. Through care coordination models, we typically collaborate in a power with stance to reach both optimal learning and optimal health outcomes, contribute to cost-effectiveness, and contribute to quality of life. Coordination of care, including patients as partners in care, is one evidence-based strategy for reaching the Triple Aim. Care coordination is a philosophy and attitude as much as it is a process. We need to teach our politicians and public officials about the care coordination model and how it addresses gaps in care in order to achieve optimal health outcomes.Evidence-Based Practice And The Quadruple Aim Essay. I have seen this facilitative education around care coordination take place when students and faculty are present at the policy table as important health care issues are addressed, specifically relating to homelessness and care for children and families who are at high risk for foster care. Conversations have moved beyond debate to generative dialogue because nurses (faculty, students, nurse leaders, and nurses as board members) have been at the table.Evidence-Based Practice And The Quadruple Aim Essay.

Faculty, students, and their preceptors could teach many organizational and political leaders by modeling how leveraging a power with approach is a viable pathway to the Quadruple Aim’s sweet spot. Power with is what makes clinical nurses, nurse educators, and nurse leaders so effective and so special. With a rising emphasis on population health, we have many more opportunities to communicate with political leaders and other policy makers. We must believe in ourselves as leaders of the Quadruple Aim and act accordingly if we are ever going to reach the sweet spot.Evidence-Based Practice And The Quadruple Aim Essay.

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.Evidence-Based Practice And The Quadruple Aim Essay.

Key Words:
primary health care
patient-centered care
health care workforce
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Since Don Berwick and colleagues introduced the Triple Aim into the health care lexicon, this concept has spread to all corners of the health care system. The Triple Aim is an approach to optimizing health system performance, proposing that health care institutions simultaneously pursue 3 dimensions of performance: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of health care.1 The primary Triple Aim goal is to improve the health of the population, with 2 secondary goals—improving patient experience and reducing costs—contributing to the achievement of the primary goal.Evidence-Based Practice And The Quadruple Aim Essay.

In visiting primary care practices around the country,2 the authors have repeatedly heard statements such as, “We have adopted the Triple Aim as our framework, but the stressful work life of our clinicians and staff impacts our ability to achieve the 3 aims.” These sentiments made us wonder, might there be a fourth aim—improving the work life of health care clinicians and staff—that, like the patient experience and cost reduction aims, must be achieved in order to succeed in improving population health? Should the Triple Aim become the Quadruple Aim?Evidence-Based Practice And The Quadruple Aim Essay.

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Society expects more and more of physicians and practices, particularly in primary care. Patients want their health to be better, to be seen in a timely fashion with empathy, and to enjoy a continuous relationship with a high-quality clinician whom they choose.3 A patient-centered practice has been described as, “They give me exactly the help I need and want exactly when I need and want it.”4 Yet for primary care, society has not provided the resources to meet these lofty benchmarks.Evidence-Based Practice And The Quadruple Aim Essay.

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The wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of burnout. Widespread across specialties, burnout is especially prevalent among emergency department physicians, general internists, neurologists, and family physicians.5 In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew.6 Professional burnout is characterized by loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment and is associated with early retirement, alcohol use, and suicidal ideation.5,7 According to a recent RAND Corporation survey, the principal driver of physician satisfaction is the ability to provide quality care.7 Physician dissatisfaction, therefore, is an early warning sign of a health care system creating barriers to high-quality practice.Evidence-Based Practice And The Quadruple Aim Essay.

We have heard physicians making such statements as:

“The joy of practicing medicine is gone.”

“I hate being a doctor…I can’t wait to get out.”

“I can’t tell you how defeated I feel…The feeling of being punished for delivering good care is nerve-racking.”

“I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”

In a 2011 national survey, 87% of physicians named the leading cause of work-related stress and burnout as paperwork and administration, with 63% indicating that stress is increasing.8 Forty-three percent of physicians surveyed in 2014 reported spending over 30% of their day on administrative tasks.9 Physicians spend more time on non–face-to-face activities (eg, letters, in-box management, and medication refills) than with patients.10 Even when in the exam room with patients, primary care physicians spend from 25% to 50% of the time attending to the computer.11 Between 2009 and 2010, primary care physicians at a Veterans Affairs facility spent 49 minutes per day responding to inbox-type alerts in addition to documentation of care provided. One-half of such alerts have little clinical significance or could be handled by other team members; 80% of the text in the alerts is unnecessary. The volume of alerts and texts overshadows important information that requires action. Moreover, the alerts create interruptions known to adversely affect patient care.12,13

A 2013 survey of 30 physician practices found that electronic health record (EHR) technology has worsened professional satisfaction through time-consuming data entry and interference with patient care.7 Emergency medicine physicians spend 44% of their day doing data entry, with 4,000 EHR clicks per day; only 28% of the day is spent with patients.14 In a 2011 survey, over three-quarters of physicians reported that the EHR increases the time it takes to plan, review, order, and document care.15

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Burnout affects not only physicians, but also other members of the health care workforce. Thirty-four percent of hospital nurses and 37% of nursing home nurses report burnout, compared with 22% of nurses working in other settings.16 On the front lines of practice, receptionists have a stressful job, with 68% experiencing verbal abuse from patients.17 Most receptionists feel that physicians fail to appreciate the complexity of their work. Sources of stress include finding appointments for patients and feeling caught between doctors’ and patients’ demands.18 A 2013 survey of 508 employees working for 243 health care employers found that 60% reported job burnout and 34% planned to look for a different job. Complaints included heavy patient loads, small staffs, and high stress levels.19

Physician and staff dissatisfaction feed on each other. “It’s really rough to be around a burned-out doctor. They’re cynical, sarcastic, and wonder, ‘what’s the use anymore?'” It can go the other way, too. A burned-out staff member may not be doing his or her job, resulting in more stress for the already overworked doctor.20 Adequate numbers of well-trained, trusted, and capable support staff with low turnover predict greater physician satisfaction.7

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Burnout among the health care workforce threatens patient-centeredness and the Triple Aim. Dissatisfied physicians and nurses are associated with lower patient satisfaction.16,21 Physician and care team burnout may contribute to overuse of resources and thereby increased costs of care.22–24 Unhappy physicians are more likely to leave their practice; the cost of family physician turnover approaches $250,000 per physician.25 Dissatisfied physicians are more likely to prescribe inappropriate medications which can result in expensive complications.26

Physician burnout is associated with reduced adherence to treatment plans, resulting in negatively affected clinical outcomes.27 Burnout also leads to lower levels of empathy, which is associated with worsened clinical outcomes for patients with diabetes.28 Patient safety is threatened by nurse dissatisfaction; many nurses report that their workload causes them to miss important changes in their patients’ condition.16 Dissatisfied physicians are 2 to 3 times more likely to leave practice, thereby exacerbating the growing shortage of primary care physicians and complicating the achievement of a healthy population.29

Practices working toward the Triple Aim may increase physician burnout and thereby reduce their chances of success. Higher scores on a patient-centered medical home assessment may be associated with greater clinician burnout in safety-net clinics.30 More EHR functionalities—email with patients, physician order entry, alerts and reminders—intended to promote the Triple Aim are associated with more burnout and intent to leave practice.31

Group Health Cooperative implemented primary care reforms in the early 2000s aimed at improving Triple Aim performance. The unintended consequence was increased physician burnout and resultant quality reductions and cost increases. In 2006, Group Health changed direction, focusing first on clinician work life by increasing visit length and reducing panel size. Burnout dropped substantially with significant gains in clinical quality, patient experience, and cost reduction. The Group Health story demonstrates that without addressing the work life of those providing care, Triple Aim measures are likely to worsen.32

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How can health care organizations work toward the fourth aim, improving the work life of clinicians and staff? For primary care physicians the following list suggests some practical steps:Evidence-Based Practice And The Quadruple Aim Essay.

Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture. Team documentation has been associated with greater physician and staff satisfaction, improved revenues, and the capacity of the team to manage a larger panel of patients while going home earlier.33,34

Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results35

Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders33,36

Standardize and synchronize workflows for prescription refills, an approach which can save physicians 5 hours per week while providing better care37

Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day38

To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice2,39

In the longer run, to address the chasm between society’s expectations and primary care’s capacity, more financial and personnel resources should be dedicated to primary care. One study estimates that a 59% increase in staffing, to 4.25 FTE staff per physician, is needed to achieve the patient-centered medical home.40

Patient-centeredness and the Fourth Aim
The barriers to achieving the Triple Aim include improving population health in a society experiencing obesity and diabetes epidemics and growing income disparities, rising health care costs, and a dispirited and disengaged health care workforce. If the gap continues to widen between society’s expectations for primary care and primary care’s available resources, the feelings of betrayal and the wearing down from daily stress voiced by primary care practitioners will grow. The negative impact on patient-centered care will be deep and long lasting. On the other hand, if an emphasis on the workforce comes at the expense of patients’ needs, this focus could have negative consequences. Health care is a relationship between those who provide care and those who seek care, a relationship that can only thrive if it is symbiotic, benefiting both parties.Evidence-Based Practice And The Quadruple Aim Essay.

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The Triple Aim has provided society with a compass, pointing the way forward for our health care system. The positive engagement, rather than the negative frustration, of the health care workforce is of paramount importance in achieving the primary goal of the Triple Aim—improving population health. Leaders and providers of health care should consider adding a fourth dimension—improving the work life of those who deliver care—to the compass points of better care, better health, and lower costs.Evidence-Based Practice And The Quadruple Aim Essay.

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