All health care professionals recognize the Triple Aim, which is focused on outcomes, costs, and patient experiences. However, a fourth aim was added, which focuses on an essential, yet often forgotten, contribution to the successful delivery of the original Triple Aim: the workforce. This alternate version would be called the Quadruple Aim, with the fourth aim specifically addressing better clinician experience in order to strengthen the workforce. More comprehensive clinical pathways may be one way to address the aging health care workforce and high burnout rate due to increasing administrative responsibilities, decreasing compensation, and more demands from patients and payers.
The Triple Aim is the simultaneous pursuit of 3 aims: enhancing patient experience, improving population health, and reducing costs.1 It is widely accepted as the compass to optimize health system performance. Yet some health care professionals think another dimension of care is missing: the well-being of care professionals. Widespread burnout and dissatisfaction have been reported by physicians and other members of the health care workforce.2 Burnout is associated with lower patient satisfaction and reduced health outcomes, and it may increase costs. 2 Burnout thus imperils the Triple Aim and may need to be considered alongside the other established aims. The article “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider”3 by Bodenheimer and Sinsky recommends that the Triple Aim be expanded to a Quadruple Aim, which adds a focus on improving the work life of health care providers, including clinicians and staff. Formation of The National Academy of Medicine Action Collaborative has suggested that progress here requires methodologically sound studies, adequate funding, and collaborative efforts.2
Opportunities exist for clinical pathways to help in this fourth dimension, especially via reduction of administrative burden through provision of efficient and effective care processes that also improve accountable outcomes. Clinical pathways are routinely used and thought of as tools to optimize treatment decisions for complex illnesses, but they hold the potential to make a much greater impact. More comprehensive clinical pathways could be developed that are optimized with decision support tools beyond treatment options and improved information integration capabilities. Pathways can be developed to function as much more advanced tools—offering more than simply direction to recommended treatments based on a certain diagnosis. Indeed, when one realizes the power of clinical pathways, there is the ability to improve care in all of the aims starting with improving clinical outcomes, reducing administrative burden, and improving care coordination, which will, in turn, improve compensation (Table 1).
Efforts aimed at improving outcomes will subsequently impact provider compensation. Beyond clinical outcomes, pathways can be used to promote gains in risk-based agreements. In addition, besides providing process guidance, clinical pathways are supported by economic evidence that supports the return from investment through pathway use.
While clinical pathways have historically focused on traditional health care issues such as diagnosis and treatment guidelines, they have not included external factors. These external factors (Figure 1) include the power of social determinants of health (SDoH).4 It has been estimated that these factors contribute 60% to health outcomes compared to just 20% from our health care system and 20% from genetics.5
With well over 50% of health outcomes coming from SDoH, clearly clinical pathways should address this area. For example, clinical pathways for lung cancer treatments could include environmental air improvement as well as smoking cessation.
Addressing the significant administrative burden nationally, the American College of Physicians (ACP) developed a position paper outlining policy recommendations to address the issue of administrative tasks to mitigate or eliminate their adverse effects on physicians, their patients, and the health care system as a whole.6 The paper outlines a cohesive framework for analyzing administrative tasks through several lenses to better understand any given task that a clinician and his or her staff may be required to perform. In addition, a scoping literature review and environmental scan of existing efforts were done to assess the effects on physician time, practice and system cost, and patient care due to the increase in administrative tasks. The findings from the scoping review, in addition to the framework, provide a backbone of detailed policy recommendations from the ACP to external stakeholders (such as payers, governmental oversight organizations, and vendors) regarding how any given administrative requirement, regulation, or program should be assessed then potentially revised or removed entirely.
While most discussion on administrative burden is argued in the broad, national context (ie, powerful external factors), there are certainly opportunities for intervention at the organizational and clinical levels to reduce provider administrative burdens. Clinical pathways, specifically, can provide an opportunity to help reduce the high level of administrative burdensome process through several way strategies. First, health care professionals should ensure that the clinical pathway promotes an efficient and effective process for providers. Take for example the situation where the clinical pathways direct to office-based infusion, if that is outside the typical process this would cause a burden to figure out how best to accommodate these patients.
Inclusion in the clinical pathways for paperwork or language that is needed to gain access to treatments such as that required for payer approval through their utilization management process. This is best when it is directly included in the electronic medical records or at least provides the information needed for these electronic fields. Led by pharmacists, one article reviews the evolution of the clinical pathways, describing their clinical and economic impact, and identifies ways pharmacy directors can successfully implement these pathways into their institutions.7
Care Team Coordination
Finally, as health care delivery becomes more and more integrated, clinical guidelines should specifically outline the needed team members and their role and responsibility along the continuum of care. This is especially critical with more complex illnesses that require multiple team members, such as in oncology where there are separate but related professionals needed for management of the illness beyond the oncologist (eg, surgeons, radiation oncology, and other specialists). There are many tools to assist in team development, such as the Health Information Technoloy Toolkit8 developed by Stratis Health, an independent nonprofit organization and an authority on collaboration and innovation in health care quality and patient safety. his tool provides an overview of the new roles of health care professionals in a community-based care coordination program and describes why communication among the health care team is vitally important for patient safety and satisfaction, as well as for satisfactory working relationships among team members.9 It includes links to numerous resources to help facilitate a culture that supports team communication and collaboration. This resource and others can be used to guide development of enhanced clinical pathways to ensure appropriate team utilization.
More comprehensive and integrative clinical pathways are needed that can facilitate improved clinical outcomes, reduced administrative burden, and better care team coordination and thus better compensation. These enhanced clinical pathways offer an opportunity for care model innovators to address each dimension of the Quadruple Aim, which includes the strengthening of our all-important workforce as well.
1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs (Millwood). 2018;27(3):759-769.
2. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals, a call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. https://nam.edu/wp-content/uploads/2017/07/Burnout-Among-Health-Care-Professionals-A-Call-to-Explore-and-Address-This-Underrecognized-Threat.pdf. Published July 5, 2017. Accessed February 20, 2018.
3. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
4. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. 1991; Stockholm, Sweden: Institute for Futures Studies.
5. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(suppl 2):19-31.
6. Erickson SM, Rockwern B, Koltov M, McLean RM; Medical Practice and Quality Committee of the American College of Physicians. Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. Ann Intern Med. 2017;166(9):659-661.
7. Hipp R, Abel E, Weber RJ. A primer on clinical pathways. Hosp Pharm. 2016;51(5):416-421.
8. Stratis Health. Health information technology toolkit for critical access and small hospitals. Stratis Health website. http://www.stratishealth.org/expertise/healthit/hospitals/htoolkit.html. Accessed February 23, 2018.
9. Stratis Health. Establishing the care team: roles and communications. https://www.stratishealth.org/documents/HITToolkitcoordination/3-Establishing-the-Care-Team-Roles-and-Communications.pdf. Updated December 31, 2014. Accessed February 20, 2018.