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The Triple Aim: Why We Still Have a Long Way to Go

By Donald Berwick | Thursday, February 14, 2019

While IHI President Emeritus and Senior Fellow Don Berwick may not be the originator of the Triple Aim, he has been its most visible proponent for over a decade. In the following interview, he describes the societal role of the Triple Aim, comments on the so-called quadruple aim, and describes how the Triple Aim continues to surprise him.

What were the origins of the Triple Aim?

The Triple Aim was the brainchild of two of IHI’s faculty, John Whittington and Tom Nolan, who came up with it in about 2006. It was a real breakthrough.

The goal they had in mind was to articulate, in a very cogent way, the aims of health care from the viewpoint of the society it serves. You can’t define or pursue quality if you don’t know your aims. The proper way to think about goals is that they’re external to the organization, external to the industry. They lie in the world of the people we help, the customer, the patient, the consumer. So, what would society say it’s hiring health care to do? That’s the key initial question in quality.

Up until that time, the best answer would have referenced the Institute of Medicine Crossing the Quality Chasm report which had laid out six dimensions of need they called Aims for Improvement. Most people in the field now know them:

  • Safety — Don’t hurt me;
  • Effectiveness — Promise me science;
  • Patient-centeredness — Honor me as an individual;
  • Timeliness — Let’s have no delays that aren’t instrumental;
  • Equity — Close racial and socioeconomic gaps in health; and
  • Efficiency — Don’t waste money, space, or any other resources.

Whittington and Nolan said, “No, wait a minute. Those aims apply when you need or use the care. Those properties should be there in the individual experience of care when we care for your heart attack, your broken arm, your depression, or you get your checkup.” They identified another component they called the health of the population. Why do you have your heart attack? Why did you break your arm? Why are you depressed?

The causes of these health burdens don’t lie in health care. The cause of illness isn’t the absence of health care; health care’s a repair shop. Whittington and Nolan asserted that, “Society also needs us to help you stay healthy.” They included that second component. The first aim is the better experience of care. The second aim is better health for the population.

The third aim they included, which I think was particularly brilliant, is [pursuing the first two aims] while reducing per capita cost. That is because the needs of the people we serve go beyond health care. People may need to pay a college tuition. A corporation maybe want to be more competitive and pay its workers more. Government may need to put money into roads or schools.

Whittington and Nolan posited this system of aims — better care for individuals, better health for populations, and lower per capita cost — as a more complete statement of the social need [health care is] here to fill. It’s like a compass that helps us define success. Their framing became known as the Triple Aim.

I got to co-author the paper about it, but it’s always embarrassed me that people often think I came up with it. I didn’t think of the Triple Aim. That was John Whittington and Tom Nolan.

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Why did so many people think the Triple Aim was a radical idea when it was first proposed?

A lot of people thought — and possibly many of them still do — that the Triple Aim is a very radical idea for a couple of reasons. One, it forces health care delivery out of its own box. The first component of the Triple Aim — better care of individuals — that’s our sweet spot. That’s why we’re here. We give care for you when you get sick.

It’s disruptive to tell a hospital or even the health care enterprise as a whole, “You’ve got a second job,” which is to address the health of populations. Is that really my job? We know that bad housing causes poor health. We know that good health depends on good transportation. We know that racism is the enemy of health. Does that mean I’m supposed to work on housing and transport and racism?

Whittington and Nolan said, “Yes.” Hospitals don’t have a plan, mostly, to work on the causes of heart attacks; they work on the heart attacks. Adopting the Triple Aim implies a major shift in process.

The second real disruption is the lower per capita cost part of the Triple Aim. People in systems that are struggling the way ours are always feels like they don’t have enough money. The natural response to the challenge is, “What do you mean, ‘lower costs?’ I need more money. I must take care of more people. People are sicker, they’re older.” Whittington and Nolan said, “No, we can lower costs by working on waste and activities that aren’t value-added.” That’s the premise.

All modern quality theorists think that there’s a wide terrain of opportunity to improve quality, the experience of the person you’re helping, and reduce cost at the same time. Every mature company in the competitive world globally is trying to do that. Health care needs to do that, but that’s not our mentality. It’s always, “We need more.” Health care is 16 percent, 17 percent, 18 percent of the gross domestic product, and there appears to be no limit yet to our claim on the economy.

With the Triple Aim, Whittington and Nolan tried to put an end to that claim. They said, “No, no, no. Lowering per capital cost is also your duty. If we work on better care for individuals and better health for populations, we can lower per capita cost effectively.” I believe that but think of all the health care lobbyists that are on Capitol Hill arguing for more money. Think about the health care system that wants to build the next building and expand its work. To say we don’t need more is disruptive, to say the least.

Nonetheless, I go to countries around the world that I’ve never been in before — that may not even know that IHI exists — but they’re using the Triple Aim. We see it at all levels. We see it at a hospital level, clinics, individuals, all the way up to ministries of health. There are ministries of health in the world that are setting their goals as nations by using the Triple Aim as the compass. It’s interesting that the framework has gotten that much traction.

Does the Triple Aim represent health care taking responsibility for its role in society?

Health care is a big part of society. Economically, we’re a sixth of the economy in our country and similar proportions in other countries. People care about it. I may not be in health care very much, but I’m in my own health all the time. It matters if my knee hurts or if I’m feeling ill or depressed all the time, not just when I’m in health care.

On the cost side, the question is, “How much do we think we’re entitled to?” Do we really think that health care is entitled to everything it can possibly get? I don’t think that’s so, because health care is taking resources from other places. And when you’re conscious of waste, of non-value-added activities, overuse, failures of coordination, administrative nonsense, pricing games, and the costs of defects, it’s hard to justify taking dollars from the public schools or from a government that needs to fix roads or from a corporation that wants to be more globally competitive. If we’re wasting money, we’re not entitled to more of it. Our costs are in part confiscation, and we need to stop it.

Health care costs can seem so abstract. How do you connect it to everyday realities?

As I learned from Tom Nolan and John Whittington, health care is ground zero for all sorts of conflict. It is, for example, a central issue in labor negotiations. Nolan and Whittington ask, “Where does the money come from? This $3 trillion in health care costs, this 18 percent of the economy, this money we want more of, where’s it coming from?”

In the end, it’s coming from only one source: wages. The only source of money for health care in any country, including the United States, is wages for the hard work of people. They go to work, they get paid, and that money leaves their hands through taxes, through out-of-pocket payments, through employer’s putting money into a health insurance plan instead of giving it to workers because it’s their contribution to premiums. Every dollar that health care spends came from a worker, so we ought to think very hard about whether health care is entitled to take that money.

Of course, if everything we did worked, if every dollar we spent contributed to health and well-being and peace of mind and longevity, then, yes, it’s important and maybe we can claim, “Well, we need that money and we should get it.” But not when we have the defect rates and the waste rates that we have.

When I first got into the arena of health care quality 40 years ago, people often said, “Don’t talk about money. The doctors and the nurses don’t want to hear you talk about the money.” I guess that’s still true, but it’s not a mature attitude. It’s not owning our responsibility. Every patient’s the only patient. We need to do everything we can for everybody, but we must also turn our eyes toward the idea that the money is not ours. It’s someone else’s, and we shouldn’t waste it.

What have we learned about what it takes to successfully pursue the Triple Aim?

  • You must be a systems thinker. No lone individual can achieve the Triple Aim. Even just better care for individuals — with the burdens of chronic illness and the enormous technologies we can bring to bear in health care — demands extraordinary, unprecedented levels of cooperative work. The Triple Aim makes it clear that we’re a team and we’ve got to act like one.
  • Properties of communities make us sick, or help us stay well, and we must work as communities on those properties to successfully pursue population health. We need to make sure every kid is ready for school, birthing is safe, work is supportive of morale and physical health and safety, elders have the respect and the nurturing they need, communities are resilient, we’re fair, and that equity exists.
  • Reducing costs must be cooperative. I may need to spend money to help you save money. We must be systems thinkers, and I believe that payment systems should respect that way of thinking.
  • Habits run deep. For example, the habit of asking for more is hard to break. Part of the Triple Aim is lowering per capita cost. One of the 10 health care redesign principles proposed by IHI’s Leadership Alliance is to “return the money.” Lower prices, lower costs, and give the money back. This is hard because the habits of retention are well-enforced by the payment systems.
  • The roles of leaders and boards are more apparent with the Triple Aim. You must help the workforce organize itself across these boundaries to deliver what the Triple Aim contemplates. It’s very tough. I can see places that are approximating pursuit of the Triple Aim, but no one’s really got it yet.

What do you think about the so-called “quadruple aim”?

People sometimes now talk about the quadruple aim with joy in work as the fourth part. You can’t get to better care for individuals, better health for populations, and lower costs with a demoralized workforce. It won’t work. We must have the energy to work together and confidence that we can succeed. It’s too hard in a stressed environment with burnout and people losing confidence. As President Emerita and Senior Fellow Maureen Bisognano says, “You can't give what you don’t have.”

We can’t have the Triple Aim without joy in work, but I’ve resisted the label “quadruple aim” for a technical reason: the original idea of the Triple Aim is to define what society wants from us, which is external. Joy in work is internal. It’s important, but it’s not quite on the same playing field as the social need, though I recognize that it’s essential for meeting the social need.

The Triple Aim isn’t biblical. It’s not chiseled in tablets and people are certainly entitled to do anything they want with the term. But sometimes people say, “The Triple Aim is better care, better satisfaction, and lower cost.” No, the satisfaction of patients is part of the first aim. I’ve heard people talk about it as quality, safety, and service. Anyone can list three aims and go ahead and do it.

I’m not saying there’s one right definition, but if you want to go back to the origins, it’s very clear: It’s better care for individuals, better health for populations, and lower per capita cost while maintaining the first two.

What has surprised you most since the Triple Aim idea was first proposed?

One is the stickiness of the concept. I had no idea it would take off the way it has. It’s almost magical. It would be interesting to figure out why. Why is this framing so helpful?

Partly, it’s helpful because it is so simple. It’s an elegant way to name why we’re here: better care for individuals, better health for populations, and let’s not waste. That sounds just about right. But I remain surprised by how many people have embraced it, top to bottom, in organizations.

My second surprise is a little more negative. Waste is everywhere. You can watch the non-value-added work. You just put on what the Japanese call “Muda glasses” — or waste glasses — and you can see it every day. It drives me nuts. It’s bad for patients.

When Whittington and Nolan proposed the lower per capita cost component of the Triple Aim, I thought it would be embraced and people would say, “Yeah, let’s stop wasting.” And you know what? It really hasn’t happened. Maybe people don’t see it, maybe they’re worried: “Your waste is my job and you’re telling me this activity isn’t needed?” It’s been hard to get organizations and individuals oriented around stopping non-value-added stuff. People think that changing the payment system toward value-based payment may do that. I don’t know. All I know is that returning the money is the hardest part.

The other more recent surprise for me is the second part of the Triple Aim, better health for populations. I knew about social determinants of health. I knew the words. I’m a pediatrician. I’ve been a faculty member in a school of public health. But in the past year or two, I’ve really dug in and begun to understand the power of these community determinants of health.

And you know what? These determinants are monsters. This isn’t a nice little thing to do while we do our real work of treating the heart attacks. We should treat the heart attacks and we should do our organ transplants and we should do our coronary surgery and our chemotherapy, absolutely, but when you say we’re on earth to help people stay healthy, the leverage is in community determinants of health.

There’s more rhetoric about that now. There are some good programs. Some countries have programs and approaches that we need to copy, but we are taking baby steps so far on the health of populations and giant progress is available if we want to go for it.

Editor’s note: This interview has been edited for length and clarity.

Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow, Institute for Healthcare Improvement.

You may also be interested in:The Triple Aim: Care, health, and cost (This is the original Health Affairs article that first proposed the Triple Aim.)

Don Berwick's 2018 IHI Forum keynote "Start Here: Getting Real About Social Determinants of Health"

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