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 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 improve Population Health.

Why do you feel you are uniquely positioned 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, 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 caregiver 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 most 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 lives. 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 a current or different role is empowering.

Some say, "It's not what you know, it's 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 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 of being the go-to person for educating nurses..

What has the hardest thing been in starting 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 most important resources (books, conferences associations) for a nurse who wants explore business?

NNBA, entrepreneur 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 have worked in the infertility field for 20 years. My company, Fertile Health, was created to educate and enrich nurses in the fertility field. I will be at the 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 his awesomeness and reached out to him. Something similar has happened to me with Our Project Nightingale. In short, getting on the radar of a company is not that hard.

With that said, I want to introduce to you, Andrew Craig, travel nurse and YouTuber. PLUS, he is a co-founder with Adrianne Behning’s podcast,“Med Room Chronicles.” It’s 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 in September of 2017.



Listen to his interview below:

Our guest on this episode of the podcast is Andrew Craig, RN. Andrew and his wife, Sarah, have been working as travel nurses for the past two years, and they have now created their own company as independent contractors. Andrew has found success in creating video content to help and mentor other travel nurses as they consider or begin the profession, as it comes with its unique challenges and opportunities. He realized that he was ready to take the leap into creating this content because he envied people who were sharing their unique knowledge in this way on other topics--and he had his own experiences to help.

Andrew now has several sponsors of his video content, which is geared towards documenting the solutions that he has found to problems associated with being a travel nurse (or being someone who travels for work in general). The relationship with his sponsors is mutually beneficial for the sponsor, for Andrew, and for the listeners. Many people have reached out with positive feedback to his videos, which are paired with his Facebook group and will soon be associated with online courses. Additionally, he and two of his colleagues (Adrianne Behning and Brad McLaughlin) host the Med Room Chronicles: Nursing Uncensored podcast.

For more information about Andrew’s videos and online courses, follow him on Facebook, “Traveler Talk” Facebook Group, and Twitter; subscribe to his YouTube channel; listen to his podcast; and check for updates on his website and track the upcoming launch of www.howtobeatraveler.com.



Connect with Andrew

Channel: Youtube.com/c/andrewcraigrn  

HIs facebook travel nurse group: https://www.facebook.com/groups/TravelerTalk

Linkedin: Linkedin.com/in/andrewcraigrn

Website: AndrewCraigRN.co

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 yourself “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 CNAs. I felt this stemmed from multiple issues. One big issue was a lack of nurse support for CNAs, 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 on my journey. 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 aides only. In the state of Georgia the certifying body is later mentioned. The nurse aide-training program certifying body is the Georgia Medical Care Foundation (GMCF). Please click here for more info GMCF Nurse Aide 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 bookmarked 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 consult 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 mrsvictoriarandle@gmail.com

  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 is 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 receive 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 an assistant 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 have more specific questions I can address.

Thank you SO much for your contribution Victoria Randel! 

Mentorship and Making the Right Choice

By Dr. Dolores Fazzino, DNP, RN, FNP-BC, CRNFA

Back in the mid 1990s, I was deeply up to my eyebrows in my Master's of Nursing Program for my Family Nurse Practitioner Certificate. As I researched through the Nursing Indexes at the campus library and retrieved the articles I needed to write the numerous papers, I had a visionary moment. Though it was 1996, it now was 2006, and I was working on my doctorate. I thought “well, isn’t that interesting!”  I took notice of this, since for other events in my life, I'd had a visioning several years prior to the actual manifestation.

I was interested in the doctorate degrees in nursing. However, at that time, there was a limitation of 2 degrees:  PhD and DNS, neither of which I felt drawn to. My faculty advisor and mentor suggested that I wait a few years, since there was another doctorate degree being created called the DNP, or Doctorate of Nursing Practice. She had the insight to guide me towards that educational opportunity.

I decided after graduating in 1999 with an MSN/FNP to give myself 10 years. I felt that within ten years, I would either have started a doctoral program or I would have graduated from one. 

It was 2005, and a group of 16 fellow nurse practitioners and clinical nurse specialists in San Diego were very interested in the new nursing doctorate, the Doctorate of Nursing Practice (DNP). We learned about an opportunity provided through Case Western Reserve University, Frances Payne Bolton School of Nursing offering a distance program with cohorts set up around the United States. The professors would come to our city, twice a semester for 3-day didactic learning experiences and the rest of the course work (usually a paper or a project) submitted via email. An additional requirement was to complete 6 credits on campus at Case in Cleveland. These were provided in week-long didactic courses. Defending your dissertation on campus was also a mandatory requirement.

So I applied, and was accepted. I chose this program due to its flexibility with my schedule. I continued to work full-time, attend classes for my doctorate, wrote and defended my dissertation, in just over 2 years. I started my DNP program May, 2006 and graduated August, 2008.

In retrospect, I am appreciative of my faculty advisor from my MSN/FNP program for the fore- sight to direct me to where I would best be served with my doctoral education. I am also appreciative of myself for allowing and trusting that outer guidance, along with my inner guidance--you know that voice that tells you to do something, and when you do not, you live to regret it. Without both, I may have ended up somewhere completely different.

Deciding on doctoral study, be it a PhD, DNS, or DNP, is an individual choice based on what your career passions and goals are. I chose a DNP since I spent my entire nursing career in hospitals and clinics as an entrepreneur. The DNP has allowed me more flexibility, credibility, and creativity in the realms of healthcare delivery.

What is important to note is that DNP programs are now available all through the country and many are virtual. The best part is that you have access to a wealth of information through your computer, access to libraries, search engines, and ability to receive your articles for papers and projects right from the comfort of your home office. 

To recap, the Doctorate of Nursing programs (MSN to DNP)

  • Care-based focus on scientific knowledge

  • Creates nurse leaders in interdisciplinary healthcare teams

  • Translates evidence into practice

  • Project or dissertation

  • Distance/on-line programs

    • On-line programs with on-campus sessions typically once, possibly 3 times per semester (often on weekends)

  • Shorter time (5 semesters versus 4 to 5 years)

  • MSN with Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist, Nurse Midwife, Nurse Administrator, Executive Leadership or Health Informaticist degrees

  • Yes, you can work full-time or part-time and complete this degree


My best advice is to have a clear vision of what you want to accomplish with your career, make the correct choice for you, and be patient and kind to yourself. Sometimes it’s a timing concern….is it the right time to start?


Dr. Dolores Fazzino (Doctor of Nursing Practice) has recently partnered with ONA Healthcare, a startup company in Utah focusing on wellness care instead of sick care, offering a solution to health concerns. ONA Healthcare has a functional medicine approach to wellness that gets to the root cause of illness and starts healing from that place. With nearly 4 decades of nursing experience, Dr. Fazzino has assisted in approximately 9000 surgeries and empowered her clients to take ownership of their health and wellness. She enthusiastically shares this specific expertise via Recovering Healthcare and her Concierge Surgical Coaching Program TM. Please see her website for more about this special offering.  

Business of Nursing BLS Instructor

I met Alvionna Brewster as a Community Manager of a Facebook community of over 3,500 black nurse entrepreneurs. Being a nurse in business can be especially lonely. The fact is that many investors are only looking for the next Zuckerberg and not the next Katheryn Finney. Their loss. The truth is that is that Pattern Matching is real. Some minorities are learning to play the game. I know of a few female founders who have even rented a White Guy

Being a nurse who is a minority has its unique challenges. There is a common experience that this group has comfort in sharing with one another. Alvionna has grown an online community of like-minded nurses who are ready to support one another. Her own entrepreneur story was inspired by her mom who had various side gigs. Alvionna turned to crafting as a way to relieve work-related stress. Here she will share about her latest business venture as a BLS Instructor. In her own words:


My Journey to BLS Instructor

As told by Alvionna Brewster


I did it!  Those were my words to my group, Black Nurse Entrepreneurs, in February of 2016.  I did something I had been wanting to do for years for many reasons.  I had become a BLS Instructor.  When my dear friend Amelia reached out to me to talk about my journey, she emphasized that what a person learns during the process is just as important as the process itself.  So, therefore, I am honored to share my experience thus far.



My motivation wavered throughout the years on completing this task. For many years, I had written it down as a goal that I wanted to reach, but never put forth the effort to complete it. I always dreamed that I would have classes at area churches or local small businesses but never did it. As I connected more and more with my Black Nurse Entrepreneur family, I received amazing support, encouragement, and motivation from entrepreneurs just like me to pursue this.    


The process for taking the class was a lot easier than I had anticipated. I went onto www.heart.org (American Heart Association’s website), researched training centers in my area, contacted one and got the ball rolling. They explained what I needed to do before class started. I attended a class one Saturday, completed a few other requirements like online updates that were requested by the training center, and then I was on my way.



Finding supplies was a little more challenging and the supplies cost a little more than I had originally expected. I used so many gift cards and reward cards during this time to minimize expenses. I also did a lot of research and asked a lot of questions to those who had done this prior to me. I found the majority of the equipment on Amazon. Oh, the great joy I felt on the day that my manikins, Ambu bags and training defibrillator came in!  I sealed my joy by picking up my stamp from Staples to formally stamp the CPR cards with my name and instructor ID. I felt so official and ready to start.  


Getting started was equally as challenging as finding the motivation for signing up for the class. I went through waves of, “I can’t do this," "I don’t want to do this anymore," "I don’t have time for this," "This is more than I anticipated.”  I suppose these are normal feelings when doing something that is challenging for me. I had to set myself goals, have accountability partners and make deadlines.

Although the process was relatively simple, I found that I often get in my own way of reaching goals with fear, lack of motivation and my busy schedule. During these times, the Bible verse “faith without works is dead,” becomes so relevant. When we want to be great, it is imperative that we put forth the work regardless of the trials.

Very few feelings are as special and as precious as saving a person’s life. For me, helping to inspire someone to follow their dreams is just as priceless. I hope my experience will motivate you to do so.    


Alvionna J. Brewster, BSN, RN