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In 2008, Donald Berwick and colleagues provided a framework for the delivery of high value care in the USA, the Triple Aim, that is centred around three overarching goals: improving the individual experience of care; improving the health of populations; and reducing the per capita cost of healthcare.1 The intent is that the Triple Aim will guide the redesign of healthcare systems and the transition to population health. Health systems globally grapple with these challenges of improving the health of populations while simultaneously lowering healthcare costs. As a result, the Triple Aim, although originally conceived within the USA, has been adopted as a set of principles for health system reform within many organisations around the world.
The successful achievement of the Triple Aim requires highly effective healthcare organisations. The backbone of any effective healthcare system is an engaged and productive workforce.2 But the Triple Aim does not explicitly acknowledge the critical role of the workforce in healthcare transformation. We propose a modification of the Triple Aim to acknowledge the importance of physicians, nurses and all employees finding joy and meaning in their work. This ‘Quadruple Aim’ would add a fourth aim: improving the experience of providing care.
The core of workforce engagement is the experience of joy and meaning in the work of healthcare. This is not synonymous with happiness, rather that all members of the workforce have a sense of accomplishment and meaning in their contributions. By meaning, we refer to the sense of importance of daily work. By joy, we refer to the feeling of success and fulfilment that results from meaningful work. In the UK, the National Health Service has captured this with the notion of an engaged staff that ‘think and act in a positive way about the work they do, the people they …
Contributors All authors assisted in the drafting of this manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health and cost. Health Aff. 2008;27:759–769.
Lucian Leape Institute. 2013. Through the eyes of the workforce: Creating joy, meaning and safer health care. Boston, MA. National Patient Safety Foundation.
NHS employers staff engagement.http://www.nhsemployers.org/staffengagement
AMN Healthcare 2013 survey of registered nurses.http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey.pdf
Aiken LH, Sermeus W, Van Den HeedeKoen, Sloan DM, Busse R, McKee M et al. Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012;344:e1717.
US Department of Labor Bureau of Labor Statistics. Occupational injuries and illnesses (annual) news release. Workplace injuries and illnesses 2009. Oct 21, 2010.http://www.bls.gov/news.release/archives/osh_10212010.htm
Morath, J. The Quality Advantage, A Strategic Guide for Health Care Leaders. AHA Press. 1999: p225
Surveys on Patient Safety Culture.” Agency for Healthcare Research and Quality. Accessed May 4, 2015.http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996
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