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