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The paper by Sikka, Morath and Leape is spot on (1). The authors call
for adding a fourth aim to the Triple Aim: improving the experience of
those providing care--physicians, nurses and others. This builds on our
previous work "From Triple to Quadruple Aim: Care of the Patient Requires
Care of the Providers" in which we make a similar recommendation (2).
We also agree with the importance of creating conditions w...
We also agree with the importance of creating conditions where
healthcare workers can thrive, and find meaning and joy in their work
Widespread physician and other health professional dissatisfaction
can be taken as an early warning sign of dysfunction within the healthcare
system. At present many front line clinicians experience a toxic
environment, with near-constant multi-tasking, heavy documentation
burdens, frequently shifting performance measures, high cognitive
workloads and what is often perceived to be oppressive regulatory
Remedying the widespread burnout among physicians and other health
professionals will require empathy, sympathy and compassion for those on
the front lines of care, and directing efforts to the intrinsic motivation
and professionalism of the workforce.
For healthcare organizations we recommend regularly measuring and
improving workforce well-being, making this a vital measure on an
institution's data dashboard. For policy makers we recommend evidenced-
based regulation, coupled with studies demonstrating the time-costs of
compliance. For technology vendors we recommend the humility to understand
clinicians' workflow and incorporate human factors, efficiency and the
ability of clinicians to maintain relationship with patients into design.
For payers we recommend payment models that align with the values and
goals of the healthcare system, and the documentation for which are
minimized and manageable. For all stakeholders, before a new expectation
is established, we recommend asking: What will busy clinicians forego to
manage this new requirement?
Well-being of the healthcare workforce is a shared responsibility. As
part of that shared responsibility, we have contributed to a set of on-
line, free, interactive practice transformation resources designed to help
physicians and their practices increase efficiency, improve the quality of
care, strengthen relationships and thereby increase joy in the practice of
1. Sikka R, Morath JM, Leape L. The quadruple aim: care, health, cost
and meaning in work. BMJ Qual Saf. Published on line
2. Bodenheimer T, Sinsky CA. From triple to quadruple aim: care of the
patient requires care of the provider. Ann Fam Med 2014;12:573-576.
3. Sinsky CA, Willard R, Schutzbank AM, Sinsky TA, Margolius D,
Bodenheimer T. In search of joy in practice: a report of 23 high-
functioning primary care practices. Ann Fam Med 2013;11:272-278
4. Lucien Leap Institute. The National Patient Safety Foundation. Through
the eyes of the workforce: creating joy, meaning, and safer health care.
5. Wallace, Jean E et al. Physician wellness: a missing quality indicator.
The Lancet , Volume 374 , Issue 9702 , 1714 - 1721