The Business of the Quadruple Aim

I first met Asha Gaines on Twitter and connected on LinkedIn. After a few conversations, I finally was able to convince her to share with me her views on the Quadruple Aim

What problem related to healthcare delivery are you passionate about solving?

Medical error is the 3rd leading cause of death in our country. Misaligned incentives are the central dysfunction of our healthcare system. My mission is to accomplish the Quadruple Aim which is to improve the patient experience, to optimize patient outcomes, to lift the clinician experience and to decrease per capita health costs. If our country can align interests to build a workflow that lands a rover on Mars, surely we can find the will to accomplish these 4 healthcare aims and align incentives for Population Health.

When did you see this problem as a problem that needed to be solved?

On day one of my nursing career, 21 years ago I knew my idealized view of care was not the reality of practice. As a healer, I knew the healthcare system was not producing overall healing. This creates a cognitive dissonance or moral distress that leads to feelings of sorrow and grief and contributes to the epidemic of clinician burnout. Accomplishing the Quadruple Aim will return the joy back to healing and healthcare for millions of clinicians.

When did this problem seem like it was bigger than you?

I observed system error after system error, and as a bedside nurse, I saw no viable pathway to fix the root causes of the complex system dysfunction. Misaligned Stakeholder incentives produce sub-par health outcomes because of competing interests. The patient's best outcome should always be at the center of the care we deliver. Nurses are trained to provide whole-person, patient-centered care and are positioned well to offer needed insight as we pivot into new Value Based models of care that create Population Health.


Why do you feel you are uniquely postponed to address or give voice this problem.

I am a change agent. Disruption does not scare me, in fact, I welcome it. It is the pathway to transformation. My outlook has impacted personal choices I have made to the surprise of many loved ones. The journey has not been easy but wholeheartedness is worth the price paid. Purpose, connection to our passion and commitment to self-care produces a power that can move mountains. Breakthroughs often follow the breakdown. I see the Value-Based Care journey similarly. This endeavor will be hard, and we will make mistakes along the way, yet if we remain mission-focused and align incentives to create Population Health, we can manifest transformation that is worthwhile. 

Thank you for sharing that. Tell us more about your thoughts related to preventing illness vs predicting illness?

Healthcare is undergoing a transformational shift in mindset from one of reaction to pro-action. We are also in the midst of a digital revolution. These 2 trends will change everything. AI, Blockchain, and other technologies will allow us to predict risks and prevent potential co-morbidities, through the use of holistic data sources and a robust analytics platform that connects the dots and generates insight. Clinical care accounts for 20% of overall health outcomes, yet we spend 88% of healthcare dollars on clinical care. Restoring this imbalance includes focus on health behaviors, social determinants of health (SDoH), and the physical environment. The Quadruple Aim is a useful framework to develop a plan of action to more effectively cultivate opportunities for health and wellbeing.

What if, any the concern is there related to patient outcomes impacting hospital incomes?

Population Health intersects at the corner of outcome and income. It aligns economic incentives around health outcomes. The income of healthcare organizations will be dependent upon the outcomes it achieves. Cost visibility across the care continuum and transparency are a vital part of achieving the Quadruple Aim. Population Health will require all healthcare stakeholders to be more cost-conscious, internally aligned and to operate with a dynamic governance strategy.

Waste, Fraud and Abuse- Are these topics related to care giver burn out? What are your thought related to these topics?

The IHI (Institute of Healthcare Improvement) estimates that between 27%-41% of healthcare is waste, fraud or abuse. This country spent 3.4 trillion dollars on healthcare last year. That is almost $10,000 for every person in the country, and  $2,700- $4,100 is estimated as WFA. It is no wonder that the health outcomes we achieve are often subpar as compared with other industrialized countries in the world. As the conductors of the healthcare system, nurses are in a prime position to identify issues of WFA. We are intimately aware of the waste encountered in the system, and we are an untapped resource in building more efficient, effective and innovative solutions.

What has been the most rewarding thing about using social media for professional use?

Information is now democratic. It is open and available to anyone with a thirst for knowledge and understanding. I have cultivated a dynamic pop health social network that provides varied healthcare opinions and insights and yields a continuous learning environment. I curate content from my network to share with others because collaboration, connection, and cooperation are the only pathway to accomplishing the Quadruple Aim.


What would you say are the five important resources ( books, conferences associations) for a nurse who wants explore more on the topic?

IHI, RCA (Right Care Alliance), New England Journal of Medicine NEJM, "American Sickness" Rosenthal, "Why Hospitals Should Fly" Nance, Follow healthcare influencers on social media,

What would you like others know about what you do?

I seek to transform healthcare by using my nursing lens to optimize health outcomes. If we can build a workflow that lands a rover on Mars, surely we can design a workflow that accomplishes the Quadruple Aim. Workflow redesign is the heart of healthcare transformation. Let's dream fierce dreams, and work to manifest them into reality. An equitable learning healthcare ecosystem connects the dots across the care continuum and aligns incentives for Population Health. Collaboration, connection, and cooperation centered around our patient’s best outcome. This is the pathway forward. Onward-Forward. #OutcomeEvangelist


The Business of Fertility Education

Thanks to a generation who grew up with social media, more of us are sharing challenging parts of our life. In my own circle, I am learning how many in my age group under 34 are struggling with matters related to Fertility.

There are also unique challenges for moms over 35. What if there was more credible information out there about this topic? Nurses are the largest healthcare workforce and we live in community with women who are facing these challenges. What if more nurses were empowered to educate others about this topic?

Let's talk about how Monica Moore Nurse Practioner has been skillfully addressing this most complex challenge. 

What is your company name?

Fertile Health

What problem does your company solve?

Fertility Nurse education and enrichment.

When did you see this problem that needed to be solved?

20 years ago

Did the problem seem like it was bigger than you?

At times, but feel like I can make a difference.

How did you know you were uniquely positioned to solve this problem?

[I am ] passionate about education and feel that I have the ability to simplify complex processes.

What if, any, concern is there related to nurses not knowing about non-traditional roles?

I think the ability to continue and progress in current or different role is empowering.

Some say, "It's not what you know, it's about who you know". In terms of developing business relationships, do you agree with that statement? Please explain your rationale.

Yes, most of my referrals are word of mouth. I know that I am good at what I do, but need to meet the right [people] who are willing to take a chance on me and my services.

What was the process of moving away from the in clinical role into a business role?

I realized that I was becoming the go-to person for educating nurses, so decided to expand that role [ that is being the] go to person for educating nurses, so decided to expand that role.

What has the hardest thing been in starting in your specific type of business?

How to market myself and accounting and legal intricacies.

What has been the most rewarding thing about being in your type of business?

Love getting feedback. Nurses telling me that they wish they would have met me earlier...etc.

What would you say are the five important resources ( books, conferences associations) for a nurse who wants explore Business?

NNBA, entrapeuneur magazine, presentation blogs, ASRM (for fertility nurses)



What would you like others to know about what you do?

I am trained as an NP in women's health and worked in infertility field for 20 years. My company, Fertile Health, was created to educated and enrich nurses in fertility field. Will be at NNBA conference in November.





Business of Nursing Find Your Niche- Travel Nursing

One of the great things I love about the journey of being in business is meeting other healthcare professionals who are also business owners. When Andrew Craig came on my radar, I immediately reached out for a quick chat, and he said yes! What I love about his story is, while doing his thing and being awesome ( personal branding 101), a company took notice of this and reached out to him. Something similar has happened to me with Our Project Nightengale. In short, getting on the radar of a company is not that hard.

With that, I want to introduce to you, Andrew Craig is a travel nurse, a Youtuber. PLUS he is a co-founder with Adrianne Behning’s podcast,“Med Room Chronicles.” Like an official, legit podcast!  As I am super new to this world of audio, I'm a little intimidated by that! But I'm happy he joined me in this experiment with Anchor September of 2017.

Here is a summary of our conversation:

Andrew:  I have been traveling with my wife Sara for the last 2 years. We work together and she's a travel nurse as well. And we recently became independent contractor travel nurses so we started our own LLC Hubble Sweet. We use it for our business purposes while traveling. Then recently, I started a podcast with some colleagues of mine out of the University of Iowa, Adrianne Behning, and Brad McLaughlin. We've been doing podcasts about all types of nursing subjects for the past month and a half or so which is very exciting. We got a pretty good response from that which is a super fun because we just love talking about nursing.

My big project is being involved in the travel nurse community. I started traveling about 3 months ago simply making videos for travel nurses with my cell phone in hopes to just educate and help transition people into this challenging specialty of traveling nursing. Even though there's lots of information out there and it's very very overwhelming and the average staff nurse has no idea where, to begin with, travel nursing.

From that point, my channel and online presence have drastically grown because people have really found the information that I'm putting out there useful as well as helpful. So I've been making more videos on my YouTube channel and then I recently decided to create courses for travelers as a whole, not just travel nurses, because of travelers no matter what profession you are in we have very similar challenges in the traveling realm. Because of that, I made courses to help answer some very important and yet very common questions that people keep asking over and over again and so I'm hoping to make a difference with the courses that I'm creating. So that's spiel that's the main stuff about what you know what I'm up to online.


Amelia: So what I love about what you just shared is that many nurses we see problems and we provide solutions that is what we do, that part of being a nurse. But you saw a problem, lack of information about a particular topic and you decided to start to document what's working. What made you one, decide to start of document what is working? And two, what made you start to share that and build a platform where others can be helped? What prompted you to go from idea I wish I had, to produce it for a community of travel nurses. Tell me more about how/why you bridged that gap.

Andrew: It's  very simple for me the reason why I started making videos is because I envied people that were doing it. I thought wow that is so neat that they are online, they're putting themselves out there and they're making a difference. And so It was just a  truly was a moment where I just woke up and I said I'm gonna write down the top 10 list of things that I would recommend for travel nurses. I made a brief script, I had some basic video editing software I had been playing with it previously, made the video and upload it. In fact, I uploaded it to a major nursing websites and that's when my video went from just a couple of views to a couple of thousand. That’s when people started reaching out to me after that point. As far as building the platform that was really never my intention but I've gotten so much positive feedback from people. People that are interested in learning more about travel nursing as well as travelers, new travelers that are feeling very overwhelmed by my stuff and find it helpful. That positive feedback is what really drives me to create more information for people.

Amelia:  Awesome so tell me a little bit more about how you branched into sponsored video production as we know nurses, we are multi-talented, we have lots of interests and passions that's sort of why we became a nurse. I mean if we could narrow down our interest, there are other fields of medicine we may have considered. Tell me more about going for sponsorship.

Andrew:  That's a great question and I started doing sponsored videos three days after I created my first video. Because the company or rather an organization called the professional association of nurse travelers is a nonprofit organization that advocates for the representation and you know unbiased education for travelers out there. So the founders of that organization contacted me and said, “hey you know what we would like your message. We like the way you approach this topic, we would love to work together “.


I completely agreed because I had been a member just a couple years prior to that so I knew about them even way before they contact me directly. So we figured up a relationship with sponsored videos. Because sponsors videos is a really great way to tap into a person audience as well as being a kind of like a brand ambassador for them while at the same time getting the message of the organization the sponsored out there. So what I do is very simple, I  focus on comment question that travelers ask and then what I'll do is a brief blip about to sponsor someone organically in the content. Because you know were overwhelmed by ads, are everywhere TV, internet, Facebook the works were overwhelmed by it. So when I do a sponsor relationship I want it to be you know not only mutually beneficial but also not to seem too much like spam essentially. I want people to experience in my videos to be good. From that point, I've got several companies that have contacted me that have said the exact same thing it just like you know what we like your stuff let's work on something together. There are several companies in the works and I'm trying to work out that relationship again, the sponsor relationship video. I haven't done very many sponsored videos lately because I've got so many, I guess irons in the fire is just kind of collaborating and getting things rolling. But I suspect within the next couple of months I'm probably going to be doing a sponsored videos several times a week based upon the interest that I'm receiving so far.


Amelia: Awesome wow so tell me a little bit more about I know that you guys have a separate company that you guys started as independent nurse travelers. Or is that under your LLC?


Andrew: It's not a company is simply a face to my courses that I told you that I'm creating.  The hope is that it is launching of this November first. I've given myself a deadline so that way I have focus because I could let go again and again. It is easy to have a project but without a deadline, you could go on forever and I've made a mistake in the past. So the is simply a website that people can go to that's connected with the teachable platform so that I can this guy dispense my courses efficiently. Because the teachable platform is very convenient for course maker. They take very reasonable cut off the courses, it's like a 5 percent or 10 percent percentage for using their service, so I connect their platform with my URL and the launch is November.


Then so as far as the courses are concerned I'm going to be doing 2 things I'm going to be, there is going to be about 10 or 15 mini-courses that I think I'm gonna price them at five bucks a piece, just because you know I'm not a greedy guy I just want people to have  this information while at the same time you know make a little something just for the time that I put into it.


Then so customers can buy individual topics for five bucks a piece or I think I'm going to lump them all into a big pot of courses that people can purchase as well. Because most the content that  I'm creating if not all is really relevant for the new traveler. So all it would be beneficial and some people might opt to just purchase the whole package right away.


We went on to talk about his podcast and how he does it all- he does not sleep. We talked abou other topic and wrapped up by how to reach out to Andrew:

Andrew: The simplest way because I'm basically on every social media platform is just Google my name Andrew Craig RN and you'll find me. You will find LinkedIn,  my Youtube channel,  my Facebook group, my Facebook page, I'm also moderately active on the website, I do a lot of writing on there. And so my main focus probably is my YouTube channel and you could always go to YouTube and type in Andrew Craig RN and you'll find me I'm the first person that comes up in the search results. I got the Andrew Craig name on lockdown I guess. So that's how you can find me and I love to share this information with people and I feel free to reach out to me anytime.


To hear the entire interview, check it out below.


Connect with Andrew


HIs facebook travel nurse group:



How to start your CNA School

How to start your CNA School by Victoria Randle FNP (Guest Blogger) 

Deciding to become an entrepreneur can be a scary task to tackle, especially if you lack a mentor or support.  You ask your self “ Where do I start? Which way do I go? Who can I trust?” It can all seem so overwhelming that you may give up before you even get started. However, with determination, perseverance, and a strong support team, it can be done! Remember, no one determines your fate but you!

In my practice as an RN, I saw a decline in the quality of CNA’s. I felt this stemmed from multiple issues. One big issue was a lack of nurse support for CNA’s thus causing a lack of pride in their work. I also noticed that many schools seemed so fly by night, “Become a CNA in 10 days!” Are these students really getting the exposure and sense of pride that they need for the job?  That’s when I decided someone has to take action and that someone would be me!

What They Don't Tell You

I had no idea where to start and figured lots of things out along the way. I must say I did some major head bumping along the way. I met people who were very helpful, people who donated time and money in my vision and then there where those who of course just wanted my money and gave me only half of what I needed. Unfortunately, we can’t always see those people coming. Nevertheless, it took me two years to get my CNA program up and running. I would like to share with you the steps to get moving in the right path. I happen to be in the state of Georgia so much of this will be Georgia based, however other states are very similar.


  1. Identify your authorizing body for the CNA program in your state. Each state is different. The CNA program may be governed by the Health Department, the State Board of Nursing, or a separate branch that is specific to nurse aids only. In the state of Georgia the certifying body is later mentioned. The nurse aid-training program certifying body is the Georgia Medical Care Foundation (GMCF).  Please click here for more info GMCF Nurse Aid info. In the state of Georgia you must attend a FREE two-day workshop offered by the state called “ Train the Trainer” in order to become a CNA instructor and/or start a CNA school.  Dates for this workshop can also be found at the link above. Please note this workshop fills up FAST and is offered once a month so have the site booked marked and check it religiously every day to catch an open spot. I would also like to note you do not have to be a nurse to own a CNA school, however you must have a nurse (RN) be on staff to coordinate the program.

  2. In many states you are responsible for writing your own curriculum and submitting it for approval. This affords you the ability to expound upon certain aspects you may feel are important to teach and can help you create a unique set of CNA graduates that facilities will seek out. The state of Georgia requires that your curriculum be at least 85 hours of instruction, lab and facility time. You can choose more hours if you wish. Choosing a book and writing a curriculum is VERY time consuming. It took me a year to write my own.  Many states are open to which book you can use but be sure to check with your state to ensure you choose an approved book. In Georgia they discuss how to write your curriculum and which books are approved at the Train the Trainer workshop. If you still feel stuck or overwhelmed feel free to consults someone like myself who has been there and done that. I will be happy to provide a consult to help you with your curriculum. Just email me at

  3. Submitting your curriculum and waiting for approval can take up to three months in Georgia.  If you are lacking any documents or something needs to be corrected in your first submission, you have two additional chances to re-submit in a one-year period.  If your curriculum fails all three times, you must try again in a year so you must be diligent! In the event your curriculum passes (which it will because you will be diligent) you are contacted for a site visit by the state and the site visit can occur up to 3 months after the curriculum has been approved. It is imperative you have a site identified and all required items ready at the site for inspection.  An equipment list can also be found at the link above.

  4. WHAT SOMEONE NEVER TOLD ME!! There are additional items that need to be submitted with your curriculum. In the state of Georgia, there are a multitude of forms you have to craft such as: Clinical sign in sheet, Class sign in sheet, instructor evaluation form, student evaluation form etc. If these are missing, you must resubmit, even though it is not part of the curriculum. Also the entire curriculum and all these forms MUST be printed out and hand delivered to GMCF for approval. All additional documents must be resubmitted the same way so have plenty of paper and ink handy because you will become a self made Kinkos!  

  5. Once your curriculum has been approved and you pass the dreaded site visit, they let you know right then and there if you are approved to start, however you cannot open the doors of the facility until you received an actual letter in the mail. Being completely approved is the best feeling in the world!!!

More Advice

Personal words of advice: PLEASE!  PLEASE! PLEASE! Have a business plan written. Ensure you have a solid marketing plan and be sure to have a strong partner (this was my failure). There is no way you can do this on your own. You need someone who is just as vested as yourself in the endeavor.  Of course you will need an instructor to help teach and secretary to secure those students when they call, but you certainly need someone to help you in the background.  Ordering supplies, marketing, accounting, building community partnerships, preparing for annual state inspections, cleaning the building, I mean the list goes on!!! I promise you, you cannot do it all alone.  Both of you must understand this is not an instant cash business and you will initially be working for free just as you would with any other entrepreneur endeavor.  However, with determination and perseverance, you will strive for success and you will succeed!


Victoria Randle FNP

I am excited about your venture and hope this article was helpful. This is just an over view as there are many other in-depth items and situations to ponder that may come up.  Never get discouraged and remember the goal in mind.  You can do this! Please feel free to ask any questions below in the comments section or email me if you are more specific questions I can address.

Thank you SO much for your contribution Victoria Randel!