The Triple Aim should consider adding a fourth quality

The Triple Aim is widely accepted as a compass to optimize health system performance.  It is focused on improving the health of populations, improving the patient experience and reducing the per-capita cost of healthcare. In 2013, in response to the Triple Aim, AHRMM responded to the Triple Aim with its Cost Quality Outcomes (CQO) movement. CQO looks at the intersection of, and the relationship between all costs associated with caring for individuals and communities, care aimed at achieving the best possible health and the financial results driven by exceptional patient outcomes

The CQO definition serves supply chain well in better understanding the concepts of the Triple Aim and to begin to clarify the aspects needed to achieve the Triple Aim. Today I would suggest that the Triple Aim has expanded in to the Quadruple Aim, which adds the goal to improve the work life of healthcare providers. This reinforces the idea that providers must collaborate in the decision making about care delivery.

As many health systems embraced and implemented the concept of the Triple Aim as their framework, they may not have taken into consideration the stressful work life of clinicians and staff and how it is impacting their ability to achieve the Triple Aim goals.  A shortfall of the initial concept was the lack of recognizing the fragmentation of workflow and decision making, as well as the lack of the clinician’s voice in the decisions that impact their ability to deliver high-quality, cost-effective care.  Thus, the Triple Aim should expand to the Quadruple Aim, adding Clinician Experience and its importance the decisions that impact the delivery of care. 

Last August AHRMM released a CQO report based on the clinically integrated supply chain. A task force defined clinical integration in terms of the healthcare supply chain as follows: “An interdisciplinary partnership to deliver patient care with the highest value (high quality, best outcomes, and minimal waste at the lowest cost of care) that is achieved through assimilation and coordination of clinical and supply chain knowledge, data, and leadership toward care across the continuum that is safe, timely, evidence-based, efficient, equitable and patient-focused.”  

The journey of clinical integration in supply chain is not including a nurse or clinician as part of the supply chain team or maintaining a Value Analysis Committee. It must advance beyond the traditional value analysis-defined approach, which is based on the collaboration between clinicians, supply chain, leadership and suppliers.

Time for a 180

Clinical integration is reversing the process to start with the patient. What are the needs of the patient? How do we achieve the best possible outcomes for our patients at the most feasible cost? This means we must look beyond the price of an item or technology and ask how does the item, technology or even process we are evaluating add value to our patient? This requires addressing questions related not only to price but utilization, standardization and variance across the care continuum. Clinical integration must involve the practitioners that are delivering the care, addressing the Quadruple Aim. 

I suggest we have had the process backwards for years. Supply Chain uses the Value Analysis process to “mask” the ask, which historically has been, “We have a new GPO contract and if you (clinician) can please use the item on this new contract we (hospital) will save a lot of money.”  Or when a clinician requests a new product our first step traditionally is answering questions such as, is it on a current contract? Do we have anything already in our item master that does remotely the same thing? How much (more) will it cost us if we approve the item being requested? We may ask the requesting clinician to answer a barrage of questions, usually related to supply chain criteria, prior to the request being added to the long list of new items being considered by a Value Analysis Committee that meets once a month. It is no wonder our clinician are frustrated, burned out and not the Supply Chain department’s best friend. They are requesting what they feel will add value to the care of the patient and Supply Chain has made it a series of hoops to jump through for approval. 

Embracing the clinical integration of supply chain requires starting with asking how a new item, technology or process affects patient care. This should start with the needs of the patients in mind. Then we ask what the evidence indicates about the request. Next, we layer in the needs, requests and preferences of the clinicians. Finally, Supply Chain provides appropriate contracting and negotiations for whatever is decided. 

A clinically integrated methodology with a foundation based on evidence requires more than a Value Analysis committee. It requires developing a process that is based on a robust decision-making criterion that includes all aspects of care. To advance a clinically integrated supply chain approach we must operationalize a process that is fully integrated, transparent, equitable and efficient.

Taking months to approve a request from a clinician is one of the elements that leads us to the expanded Quadruple Aim. We are all tired and burned out with the redundancy of work and requests. We need to develop efficient processes and decision making that is based primarily on the needs of our patients and secondarily on the need of our practitioners to deliver optimum care for the best outcomes at the most feasible cost.