Report: Follow Four Principles to Meet Quadruple Aim

Reform of Quality Management Is an Urgent Need, Authors Write

December 12, 2018 01:57 pm News Staff

Current quality management programs are too encumbered by crippling administrative burden, atomized quality indicators and stifling opportunity costs to help primary care physicians care for their patients, but reframing them around four key principles could help, according to new report.

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Such a solution is urgently needed, say the authors of the report, "Core Principles to Improve Primary Care Quality Management,"(www.jabfm.org) published in the Journal of the American Board of Family Medicine's November issue.

"Quality management in American health care is in crisis," they begin. "Performance measurement in its current form is costly, redundant and labyrinthine."

The authors go on to say that this dysfunction increases costs and administrative burden, and they cite a 2015 survey(www.commonwealthfund.org) of primary care physicians and midlevel clinicians in which fewer than a quarter of respondents saw a positive effect from current quality measures.

Yet reworked quality management programs could help achieve the quadruple aim of better health care, better patient experience, lower health care costs and higher clinician satisfaction, the authors write.

Story Highlights
  • Reframing quality management programs around four new principles will help primary care practices better care for patients and clinicians, according to a report in the November issue of the Journal of the American Board of Family Medicine.
  • The failures of current quality management the authors cite are due to "programs unguided by core principles of primary care," they write.
  • To address these failures, the authors call for programs to focus on patient and population health, treat the quadruple aim as a dynamic whole, use measurements as tools rather than outcomes, and prioritize therapeutic relationships.

Because the authors attribute the failures of quality management to "programs unguided by core principles of primary care," they argue that a disciplined rededication to a solid conceptual foundation is the answer.

Specifically, they posit four "foundational principles" that complement the quadruple aim itself, which are identified as:

  • optimizing holistic patient and population health;
  • harnessing the quadruple aim as a dynamic whole;
  • applying measurements as tools for, not outcomes of, quality; and
  • prioritizing therapeutic relationships.

These, the authors write, "serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the quadruple aim."

Principle 1

What the authors call their cornerstone principle advises that "the singular objective of quality management in primary care is to improve the health of patients and populations."

They write that the current model for quality management in primary care does not improve outcomes, costs or patient experience because it is too focused on measuring disease, biomedical data and processes.

"Adherence to this first principle will be particularly essential in the context of the epidemiologic prevalence of multimorbidity and the demographic growth of the geriatric population; precariously little is known about how to accurately and effectively measure quality in these groups."

Principle 2

The original triple aim of better health care, better patient experience, lower health care costs and higher clinician satisfaction, the authors write.The original triple aim of better health care, better patient experience and lower costs "cannot be reached piecemeal," the authors write -- and primary care's fourth aim of clinician satisfaction only makes the vectors more interdependent.

"Whether evolutionary or revolutionary in scope, health policies must be judged by their impact on the quadruple aim in its entirety," they add. "In neglect of this principle, quality programs in primary care have overemphasized the dissemination and collection of metrics while largely ignoring their impact on costs and provider-patient experiences. This neglect is one of the sources of our current quality crisis."

Principle 3

The authors note that recording measures is particularly difficult in primary care, where physicians and other health care professionals "are often juggling an array of medical and psychosocial concerns at once."

Individual data measurements do not adequately account for trajectories, complexity or high-risk environments, the authors write. Such measurements are of limited use in primary care because patient outcomes are vectors more than they are discrete points.

"Future quality programs for primary care must understand that measurements are imperfect proxies for outcomes; as such, policymakers and regulatory agencies must be wary of mistaking points for trajectories."

Principle 4

Primary care, the report says, "relies on high-functioning relationships characterized by trust and professionalism." Current quality management programs, on the other hand, rely on rewards, penalties and requirements.

To succeed, an effective primary care quality management program must recognize that clinicians' key motivation is the desire to improve patient outcomes.

"Our near-exclusive focus on extrinsic programs, quality management's version of 'strangers at the bedside,' risks devaluing provider-patient and provider-community relationships in the quest for quality improvement," the authors write. "In the domain of primary care, this is a risk too great."

Successful Programs

Commitment to these principles, the authors suggest, will be the start of "a primary care bridge across the quality chasm," and it will provide broad rewards.

"If performance measurement moves upstream to include complex psychosocial determinants of health and outward to include patient-centered and patient-reported outcomes, then primary care practices will have a greater opportunity to innovate at the intersection of clinical and community care," the authors write.

Some successful touchstones exist now, they add, including two funded by the Center for Medicare and Medicaid Innovation (CMMI).

One, the Community Aging in Place: Advancing Better Living for Elders program,(onlinelibrary.wiley.com) uses shared goal-setting and improved quality-of-life metrics for adults with functional deficits and complex psychosocial needs. "Program results have yielded substantial cost savings, improvement in person-centered quality metrics and high patient satisfaction with care experiences, all dynamic components of the quadruple aim," the authors note.

And CMMI's Independence at Home program has "implemented less disease-specific and more patient-centered outcome metrics, such as admissions for ambulatory-sensitive conditions and documentation of patient goals of care," the report says. In addition, it has achieved high per-beneficiary cost savings.

These programs, the authors conclude, show what quality-management reform might look like when the foundational principles are observed -- principles that are, like the quadruple aim, "interrelated and synergistic."

Related AAFP News Coverage
AAFP Adopts Principles for Administrative Simplification
Academy Takes Action on FPs' Most Pressing Priority

(1/16/2018)

Additional Resource
Annals of Family Medicine: From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider(www.annfammed.org)
(November/December 2014)