Healthcare Workforce Wellness: A Quadruple Aim?

Rodolfo "Rudy" Zaragoza

Rodolfo "Rudy" Zaragoza , MD

Vice President of Transformational Care

Published November 24, 2015

During a recent ED shift, a colleague and I began to discuss provider wellness when the topic of the "Quadruple Aim" emerged.

For many healthcare organizations, achieving the Institute for Healthcare Improvement’s Triple Aim — improving population health, enhancing the patient experience and reducing cost — has become a core strategic goal for achieving success in the modern healthcare environment.

Yet without healthy and engaged medical providers, this achievement will remain elusive and challenging to attain.

In a 2014 article in the Annals of Family Practice, Thomas Bodheimer, MD, and Christine Sinsky, MD, set out to expand this paradigm. Our current epidemic of provider and staff burnout, they state, is "associated with lower patient satisfaction, reduced health outcomes and it may increase costs."

They propose a fourth aim be added — one that calls for optimizing the work-life balance of our healthcare workforce.

The paper clearly struck a chord, and other professionals soon added their voices to the cause. In a 2015 BMJ Quality & Safety editorial, Rishi Sikka and colleagues endorsed the Quadruple Aim model, which they believe properly acknowledges workers' critical role in transforming healthcare.

Rising Expectations

It's no wonder the healthcare workforce is stressed. Never have the demands on providers and staff been so high, nor occurred on so many fronts:
  • More stringent documentation demands
  • Increasing patient expectations
  • Online ratings
  • Government regulations
  • Greater administrative task burden
  • An aging population with complex needs

Technology, much of it designed to promote the Triple Aim, has also had unintended consequences for healthcare workers. Bodheimer and Sinsky reference a 2014 study that found EHR functionalities like patient email portals, physician order entry, alerts and reminders are actually associated with increased provider burnout and intent to leave practice.

These challenges come at a time when healthcare organizations are demanding unprecedented levels of efficiency and customer service. Although medicine has always been a demanding profession, wellness expert Mcepike Paskavitz recently told FiercePracticeManagement that policy and demographic shifts are exacerbating the stresses on today's physicians:

Physicians are being measured in ways that previous generations never were. They're also facing an increase in the population and the population that needs the most healthcare, plus the shortage of primary care physicians.

So what does this mean for work-life balance? Well, first let's look at the bad news.

Quantifying Stress and Burnout

The statistics on the well-being of healthcare workers (or lack thereof) are both voluminous and troubling. A 2012 paper published in the Archives of Internal Medicine found that an "alarming" 46 percent of 7,288 physicians surveyed reported at least one symptom of burnout as assessed by the Maslach Burnout Inventory:
  • 38 percent scored high in "emotional exhaustion"
  • 29 percent scored high in "depersonalization" (detached, cynical feelings toward patients and colleagues)
  • 12 percent scored low in "sense of personal accomplishment"

In addition, 38 percent screened positive for depression symptoms, and 48 percent "agreed" or "strongly agreed" that their careers did not allow enough time for personal or family life.

Findings suggest that stress and burnout affect some specialties more than others. At highest risk are "front-line" providers, such as those in emergency medicine, general internal medicine, family medicine, neurology and radiology.

Physicians aren't the only ones struggling. Thirty-four percent of hospital nurses report burnout symptoms, according to a 2011 report in the journal Health Affairs. And while the problem is less studied among physician assistants and nurse practitioners, anecdotal evidence suggests they're feeling the heat too.

The statements Bodheimer and Sinsky report hearing from providers are sobering:

“I can’t tell you how defeated I feel…The feeling of being punished for delivering good care is nerve-wracking.”

“I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”

So what does this mean for patients, providers and healthcare organizations?

The Case for Prioritizing Provider Care

For healthcare organizations operating on slim margins, investing in a concept as nebulous as provider wellness may be a hard sell.

However, when it comes to achieving the Triple Aim, the importance of care team well-being can't be overestimated. A 2009 Lancet paper described physician wellness as a crucial but often-overlooked healthcare quality indicator:

When physicians are unwell, the performance of healthcare systems can be sub-optimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality healthcare.

There are several reasons that investments in provider wellness are likely to pay off for organizations.

First, satisfied, engaged providers tend to deliver higher quality care. For example, research suggests patients are more likely to comply with treatment when they have positive relationships with their providers. They also recover faster after surgery.

Second, patient-provider relationships are a big deal to the people we care for. In hospitals, provider satisfaction (especially among nurses) is correlated with patient satisfaction. Also, a large body of evidence suggests that patients of relatable providers are less likely to bring malpractice suits.

Third, provider burnout is a major threat to patient safety. When care teams are exhausted, frustrated or disengaged, communication suffers, and the likelihood of poor decisions increases. Studies have linked burnout to surgical errors, major medical errors and increased liability risk.

Finally, there's the staggering cost of turnover. Providers who leave stressful practices in search of more balanced career situations cost their groups hundreds of thousands of dollars in direct and productivity losses.

In summary, when providers feel burned out and depersonalized, the well-being of the patient relationship and patient-centered approach are likewise threatened. So, what can organizations do to promote provider wellness?

One Practice's Approach

Vituity is committed to delivering the support providers need to lead long, satisfying careers. In a way, provider wellness is part of our DNA as a democratic practice. We value the input, opinions and assertions of everyone in our organization. And we offer our hospital-level teams considerable autonomy to run their own practices.

In addition, we've implemented several programs aimed at improving work-life balance:
  • Standardized workflows that promote collaboration and increase efficiency.
  • Our scribe service provides high-quality documentation while freeing providers to spend more time at the bedside delivering care. (No more treating the chart!)
  • We also practice Team Care, a series of processes that bring the care team together to facilitate important steps in the patient journey (initial assessment, discharge, etc.). This fosters collaboration, communication and provider satisfaction.

Through Vituity’s Credentials and Partnership Affairs Committee (CPAC) and the leadership of champions like Jim Dietz, MD, the following projects were developed:
  • The Emergency Medicine Resiliency Program, aimed at preventing and addressing provider burnout.
  • "Optimizing Wellness and Longevity for Night Shift Providers," a CME module.
  • The Provider Wellness Balanced Scorecard, which seeks to enhance career satisfaction and promote passion for the practice of medicine.
  • A sabbatical program that allows physicians the opportunity to take two to six months off every five years in order to recharge and avoid professional burnout.

As you can see, we put a lot of effort into promoting workforce wellness. Over time, we'll be able to measure the effectiveness of these approaches for our providers.


Fundamental to the Quadruple Aim concept is the belief that a healthy workforce provides enormous and essential benefits for patients.

This vision has been validated by experience. A great resource in this vein is "In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices." (Sinsky is the lead author.) While the focus is on primary care, many of the best practices highlighted — e.g., proactive care planning, improved communication and teamwork — can be easily adapted for acute care settings.

In summary, provider stress and burnout imperil the worthy ideals of the Triple Aim. Personally, I'm all for adding a fourth aim, with the goal of improving the work-life balance of healthcare clinicians and staff.

I'll close with a quote from Sikka and colleagues that cuts to the heart of this matter:

The precondition for restoring joy and meaning is to ensure that the workforce has physical and psychological freedom from harm, neglect and disrespect. For a health system aspiring to the Triple Aim, fulfilling this precondition must be a non-negotiable, enduring property of the system.

Really, who can argue with that?

Partnering to improve patient lives

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