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On the Quintuple Aim: Why Expand Beyond the Triple Aim?

Why It Matters

" . . . [W]e can think of the Quintuple Aim as points on a star — a North Star that may guide our health system forward."


In 2008, Don Berwick, Tom Nolan, and John Whittington published a paper that first laid out what they called the Triple Aim — simultaneously improving population health, enhancing the care experience, and reducing costs. Subsequently, some thought leaders believed it was important to add a fourth aim to address either the growing challenge of burnout in the health care workforce — i.e., exhaustion, professional dissatisfaction, and cynicism — or the significant inequities present in health and health care.

In a recent JAMA Viewpoint, my co-authors Shantanu Nundy, MD, MBA, and Lisa A. Cooper, MD, MPH, and I have proposed adding both a fourth aim of workforce well-being and safety and a fifth aim of advancing health equity — because we cannot achieve safety or high-quality care for all without these additional aims.

I do not make the case for the Quintuple Aim lightly. I imagine some who read this or who have read our JAMA paper will not be sure going beyond the Triple Aim is a good idea. Initially, I was not sure either. I asked many of the questions that I am guessing others have: Does proposing an expansion to the Quintuple Aim just add noise? Are we asking too much of an already overburdened health care system? Can health care focus on so much simultaneously? Should we add more aims when we have not yet achieved the original Triple Aim and health care burnout is worse than ever?

In contemplating the answers to these questions, I have concluded that the Quintuple Aim is necessary precisely because we have not yet achieved the Triple Aim. My thesis is that the Triple Aim is not achievable without attention to health care burnout and inequity. Many who have resisted prioritizing the well-being of health care workers as a fourth aim have found that it is demonstrably impossible to fully achieve the Triple Aim without seriously addressing workforce safety and satisfaction. And, as our understanding of what it will take to create a better health-creating system for all evolves, it becomes increasingly clear that the explicit pursuit of health equity is fundamental to all other aims.

Improvement scientists and leaders for generations before me have understood that we will not get where we want to go unless we set the right aims. When we build systems, we build them to aim-based specifications. Without including equity as an explicit aim, our design choices will miss the opportunity to build equity into all that we do.

I predict that making equity the fifth aim will radically accelerate improvement in population health, enhanced care experience, cost reduction, and improved workforce safety and well-being. Why? Consider how much of the excess morbidity and mortality, poor patient experience, and unmet need is concentrated among populations that are marginalized, under-resourced, disenfranchised, and historically oppressed. Many of the failure modes associated with the Triple Aim and the Quadruple Aim (when equity is left out) concentrate where inequities are steepest.

Five Points on a Star

It can be difficult to recall how much resistance the Triple Aim faced when it was first introduced 14 years ago. At the time, some argued that you could not work toward all three aims at the same time without trade-offs. But the breakthrough proposition of the Triple Aim was that each aim pursued simultaneously reinforced the others. Even the skeptics found over time that pursuing the aims together is how to make progress on all of them.

And so it is with equity. Making equity an independent aim — not the byproduct of the other aims — will make clear that each aim reinforces the other. If we draw the Triple Aim as a triangle and the Quadruple Aim as a square or a cross, we can think of the Quintuple Aim as points on a star — a North Star that may guide our health system forward. There is connectivity between all the points. The aims are synergistic. They build upon one another. They are interdependent.

I was recently reviewing some of the work of Russell Ackoff. He was a pioneer in systems thinking who had this brilliant way of explaining complex concepts. He was giving TED Talks before there were TED Talks.

In some of his lectures, he used the example of a car to ask some interesting questions: What is an automobile? What is the value of an automobile?

Ackoff noted that the value of a car is that it gets us from point A to point B. No single car part can do that. You need each of the parts.

But even having all the parts is not enough. If I take a car apart and put all the pieces in a room, you can no longer take that car from point A to point B. It is the collection of those parts put together in a particular way and the interaction between those parts that creates the value to a consumer. In other words, a system is more than just the sum of its parts.

This is also the story of the Triple Aim. It is the story of the Quintuple Aim. The five aims create something that is more than the sum of each aim independently.

Before the JAMA paper on the Quintuple Aim was published, I spoke with John Whittington and Don Berwick, the two surviving authors of the original Triple Aim. I was reflecting on Don’s ambitious “Ten Teams” Forum keynote. In it, Don urged health care leaders to establish teams to address a wide range of health determinants, including health insurance coverage, housing security, and voting rights.

This is no doubt exhausting to contemplate within our current system set up — essentially trying to “do everything for everyone forever.” We would fail in today’s health and care ecosystem. But Don is right: To do our job well, health care must address health determinants. This is exactly why we need a powerful new compass to guide us to a fundamentally different future.

I do not know precisely what shape the future system will take. It is hard these days to see three to four months into the future — much less beyond that — but I do know the five-part aim of health, experience, cost, staff well-being, and equity will be what guides us to that different future.

Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.

You may also be interested in:

IHI white paper — Achieving Health Equity: A Guide for Health Care Organizations

Healthcare Executive — Workforce Safety Key to Patient Safety