Implementing the Quadruple Aim in Behavioral Health Care

Brief review and suggested item(s). Some authors have suggested that the Triple Aim framework is incomplete and have proffered compelling arguments that provider well-being and the quality of work life constitutes a fourth aim.² Provider burnout is prevalent in both medical^2,189 and behavioral health care.^190,191 Burnout among health care professionals has been associated with higher rates of perceived medical errors,¹⁹² lower patient satisfaction scores,^189,193 lower rates of provider empathy,¹⁹⁴ more negative attitudes towards patients,¹⁹⁵ and poorer staff mental and physical health.¹⁹¹

Burnout is also associated with higher rates of absenteeism, turnover intentions, and turnover.^{190,191,196,197} However, burnout is not the only predictor of staff turnover; for example, turnover rates are a useful proxy for staff quality of work life for several reasons.¹⁹⁸ First, turnover is associated with substantial direct and indirect costs, including lost productivity, increased errors, and lost revenue and recruitment costs, with some turnover cost estimates as high as $17 billion for physicians and $14 billion for nurses annually.^199-201 Second, research indicates that staff turnover can have a deleterious impact on implementation of evidence-based interventions.^202-205 Finally, consistent with the philosophy of utilizing existing data sources for the CD measures, turnover can be relatively easily extracted from administrative data for operated or contracted programs, and its collection does not place any additional burden on staff. As a large behavioral health system that is both a provider and payer of care, BHD will therefore examine the turnover rates of its internal administrative and clinical staff as well as the turnover of staff in its contracted provider network as its measures for the Staff Quality of Work Life CD.

Clinical Implications

These metrics can be deployed at any level of the organization. Clinicians may use 1 or more of the measures to track the recovery of individual clients, or in aggregate for their entire caseload. Similarly, managers can use these measures to assess the overall effectiveness of the programs for which they are responsible. Executive leaders can evaluate the impact of several programs or the system of care on the health of a subpopulation of clients with a specific condition, or for all their enrolled members. Further, not all measures need be utilized for every dashboard or evaluative effort. The benefit of a comprehensive set of measures lies in their flexibility—1 or more of the measures may be selected depending on the project being implemented or the interests of the stakeholder.

It is important to note that many of the CDs (and their accompanying measures) are aligned to/consistent with social determinants of health.^206,207 Evidence suggests that social determinants make substantial contributions to the overall health of individuals and populations and may even account for a greater proportion of variance in health outcomes than health care itself.²⁰⁸ The measures articulated here, therefore, can be used to assess whether and how effectively care provision has addressed these social determinants, as well as the relative impact their resolution may have on other health outcomes (eg, mortality, self-rated health).

These measures can also be used to stratify clients by clinical severity or degree of socioeconomic deprivation. The ability to adjust for risk has many applications in health care, particularly when organizations are attempting to implement value-based purchasing models, such as pay-for-performance contracts or other alternative payment models (population health-based payment models).²⁰⁹ Indeed, once fully implemented, the CDs and measures will enable BHD to more effectively build and execute different conceptual models of “value” (see references 210 and 211 for examples). We will be able to assess the progress our clients have made in care, the cost associated with that degree of improvement, the experience of those clients receiving that care, and the clinical and social variables that may influence the relative degree of improvement (or lack thereof). Thus, the CDs provide a conceptual and data-driven foundation for the Quadruple Aim and any quality initiatives that either catalyze or augment its implementation.