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The Triple Aim or the Quadruple Aim? Four Points to Help Set Your Strategy

Why It Matters

IHI's Derek Feeley shares his advice regarding the strategic use of the Quadruple Aim.


Over the last few years, people from all over the world have often asked me the same question: Why doesn’t IHI add a fourth component to the Triple Aim?

Others have done it, turning IHI’s Triple Aim — improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care — into the “Quadruple Aim.” For many organizations, the fourth aim is attaining joy in work. For others, it’s pursuing health equity. Some organizations highlight other priorities. The Military Health System, for example, has added readiness as their fourth aim.

IHI fully supports other organizations prioritizing these worthy efforts if pursuing a Quadruple Aim helps you to deliver on your organizational strategy.

If you do, I urge you to keep four points in mind:

  • Remember that the Triple Aim is about patients. At its core, the focus of the Triple Aim is to improve the lives of our patients. Triple Aim outcome measures put patients at the center of care. Any modifications to the original Triple Aim should not take us away from our highest priority.
  • We haven’t finished pursuing the original Triple Aim. In almost every organization I’ve seen, and in almost every environment that I can think of, we still have a long way to go to achieve Triple Aim outcomes. There are still gaps in the health of the populations that we serve. We miss too many opportunities to improve the care experience. We haven’t done enough to improve health care quality while reducing costs.
  • Don’t lose focus. Don’t let a fourth aim turn your organization’s capacities and capabilities away from optimal delivery of the Triple Aim. No organization has unlimited resources, so we must deploy what we have in an intentional, purposeful way. Make sure you respond truthfully to a hard question: Will we spread ourselves too thin if we pursue more than three aims?
  • Measure what matters. If you pursue a Quadruple Aim, you’ll need to reconsider your measurement strategy as a whole. Since I rarely hear anyone complain about measuring too few things, be mindful of limitations on your staff’s bandwidth, and use deliberation and consideration to determine what data you really need, and how to collect and analyze it.

Elevating Health Equity and Joy in Work

Some would argue that it’s important to add health equity or joy in work to the Triple Aim to rightfully elevate their significance. I agree that it's important to seek both higher levels of joy in work and meaningful progress on securing health equity.

In fact, I would argue that efforts to improve population health outcomes will always be incomplete without understanding and addressing the unjust distribution of those outcomes. To secure population health progress for every person, family, and community we serve, we must use interventions aimed at tackling disparities and inequities.

Likewise, raising joy in work is a key strategy in the pursuit of the Triple Aim. Even in the best-performing health care organizations, staff burnout has a direct negative effect on the experience of care for the patient. There’s also a correlation between high levels of staff engagement and high level of patient engagement. Staff are much more likely to be enthusiastic and positive about securing the best outcomes for patients when they feel supported, empowered, and respected.

Feel free to interpret the Triple Aim in a way that makes sense for you and your organization and what you need to achieve, but do so in a way that is deliberate and strategic. Whether you choose to work on the Triple Aim or the Quadruple Aim, understand that you can’t ignore joy in work or equity and expect to secure Triple Aim outcomes.

Derek Feeley is IHI President and CEO. 

Editor's note: Look for more from Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.