The role of nurses in the triple aim

In the continuous movement toward higher levels of quality, safety and cost effectiveness, hospitals and health systems strive to meet a number of patient- and systems-related goals. In 2007, the Institute for Healthcare Improvement proposed a theoretical model — the Triple Aim, which collapsed the various goals to an interdependent set of three. The model suggests that U.S. healthcare system performance improvement will come through the simultaneous pursuit of improving the broadly defined experience of care, improving the health of populations and reducing the per capita cost of healthcare.

This content is sponsored by Capella University.

The Triple Aim became a fundamental component of healthcare reform under the Affordable Care Act. More recently, it has been suggested that an additional aim, improving healthcare providers' work lives — making it a quadruple aim — is needed if the model is to produce a transformed healthcare system.

The Triple Aim plays a key role in the lives of healthcare professionals across the country, including those of nurses. Here, F. Patrick Robinson, PhD, RN, dean of Minneapolis-based Capella University School of Nursing and Health Sciences, reflects on nurses' role in the Triple Aim and how institutions are supporting nurses' ability to impact Triple Aim initiatives.

Question: How do nurses play a role in each aspect of the Triple Aim?

Patrick Robinson: Nurses play key leadership roles independently and as members of an interprofessional team in driving toward the Triple Aim.

Improving the experience of care means far more than satisfaction. What we're talking about is care that's safe, effective, patient-centered, timely, efficient and equitable. In terms of nursing's role in that, nurses represent the largest number of healthcare workers in the U.S. healthcare system. Given our continuous contact with patients, we have an enormous role in assuring that all the dimensions of the experience of care are addressed in a comprehensive and coordinated manner. For example, we manage the process of transitioning patients to and from places and levels of care, a time when many errors could be made and inefficiencies introduced if there is poor communication and coordination.

Moving on to improving the health of populations, a population can be broadly or narrowly defined based on a number variables, including demographics, disease states, culture, geography or even behavioral choices. Population health improvement includes figuring out where problems occur and where interventions will have significant aggregate impact. Nurses are placed strategically within the healthcare system to understand its nuances and direct strategies at health promotion, disease prevention and progression, and restorative health.

Healthcare costs without reference to a population are not that meaningful. The per capita aspect means decreasing the cost of healthcare per the population, so there are more resources that can be used on other common good initiatives. Nurses make decisions on various aspects of resource utilization, including equipment use and readiness to make a transition of care, which can significantly drive up the cost for a particular population or individual. As such, nurses are in prime positions to decrease cost. 

However, it's important to understand it's not three separate aims — it's a Triple Aim. The Triple Aim is a singular concept. If one would pursue only one of the aims, you could throw one of the other aims off. It's the simultaneous pursuit of all three parts of the Triple Aim that will result in improved performance.

Q: Do nurses play a bigger role in one aspect of the Triple Aim than in the two others? Why or why not?

PR: Our disciplinary perspective may lead us toward one or the other, but that way of thinking is problematic.

The nursing model of care is holistic. Nurses are not only skilled knowledge workers, but also compassionate caregivers. We have rightfully earned the trust of the public as evidenced by our consistent top Gallup poll ratings on honesty and ethical standards. That likely did not happen because we've focused on the per capita cost of care.

Some nurses may bristle regarding that part of the Triple Aim — the per capita cost of care. But by focusing solely on the experience of care, you could exponentially increase the per capita cost. The education and professional formation within our academic programs and our continuing daily dialogues have to move away from the idea that you can hit one prong without hitting the others.

For many nurses and other healthcare professionals, true transformation will start with significant shifts in ways of thinking. We are a fiercely individualistic society — it's all about us, our healthcare and what we have access to. In our professional lives, it's about this patient and this singular episode of care. These foci have driven us to a high standard of care and technology, but low levels of quality and poor overall outcomes when you consider where we're ranked compared to similarly economically developed countries accompanied by limited access and out-of-control spending.

Q: How can nurses become better educated to meet the Triple Aim?

PR: In general, nursing education lags behind the realities of clinical practice for many challenging reasons, but not for a lack of understanding or unwillingness to address the gap. The question is, "What should the additional content or objectives in our nursing programs be to meet the Triple Aim and other recently evolved or emerging issues?"

The argument is that there's too much content already — true enough! But what have we been teaching? And maybe more importantly, how have we been teaching it and in what context? For example, in teaching basic skills, is the connection to quality, cost and system outcomes included? When we begin the process of facilitating the development of the clinical decision-making skills in advanced practice students, how are concepts relevant to the Triple Aim made explicit? It's about rethinking and restructuring how we educate; giving students a toolkit of foundational competencies that can be leveraged for future learning.

Q: How is Capella University's School of Nursing and Health Sciences working to better equip its graduating nurses to meet the Triple Aim?

PR: We are well connected to the practice community through our advisory board and key partnerships with high-performing healthcare systems. We listen and act on their advice. What's more, we engage in nimble curriculum change processes to narrow the gap between education and practice, thus allowing students to immediately apply cutting edge competencies in their practice settings. That is one of the aspects that attracted me to the Capella deanship. A key part of our university mission is to be relevant. It's the only ethical way we can support our learners.

At the beginning of this year, the nursing faculty developed a curricular conceptual framework, of which the Triple Aim — and the quadruple aim — are very much a part. As we revise and move forward, our faculty has decided those aspects are an important focus. The curricula at Capella is always evolving to assure the relevancy that is so central to our mission.

Q: On an individual level, what can nurses do to meet the Triple Aim?

PR: The impact is always at the individual level in many ways. The majority of my colleagues spend their days one-on-one with patients. The change happens at the patient level. Part of it is for nurses to be acutely aware of the initiatives in their particular organization, be it a public health clinic, an insurance company, a hospital or a health system. It's all about ensuring nurses are empowered to be leaders and equal partners in the interprofessional pursuit of the Triple Aim.

There is also the ability to impact health policy. Policymakers in Washington and state houses need to hear from nurses. We are a strong and trusted collective and our perspective is vital. I believe it is our professional and ethical obligation to advocate for health policy that is commensurate with our discipline's values.

Q: Have you seen progress in achieving the goals of the Triple Aim framework?

PR: There has been some movement and commitment. The IHI has published some thoughtful analysis on the success of their original collaborating organizations. However, we have to remember that the Triple Aim would have become just another good idea in the canon of noble efforts at reform if it were not for its inclusion in some aspects of the ACA. As is well known, garnering bipartisan support for anything is currently a challenge and there has been much opposition to the continued implementation of the ACA. It's an election year and all the presidential candidates have made their policy views and strategies related to healthcare clear. Of course, the potential for shifts in power in one or both houses will also impact where U.S. healthcare is heading. So maybe the best way to sum it up is that we are at the beginning and the future is unclear.

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