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Who Cares? Caring for the Caregiver: The Fourth Principle in the Quadruple Aim

The Triple Aim – enhancing patient experience, improving population health, and reducing costs – has been widely adopted as a set of principles for reform not only in the U.S., but also within many organizations around the world. The successful achievement of the Triple Aim requires a highly effective organization with an engaged and productive workforce – clinicians and staff who have found meaning in their work and a sense of accomplishment regarding their contributions. Recognizing that more and more is expected – if not demanded – of clinicians and staff, it has been urged that we modify the Triple Aim to the Quadruple Aim and add improving the experience of providing care as the Fourth Aim.

Reflecting on the Quadruple Aim, we see parallels in the patient, physician, staff, and organizational trajectories, which are traveling through an environment of regulatory demands, financial constraints, and human fallibility.

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We search for meaning in receiving and providing healthcare. Why has the treatment or medication been ordered? Why does it matter? Who will it affect? What will it cost? Will it change anything? What do we hope for? What do we fear? The work has meaning beyond the task – a shared understanding of the work is a bond among physicians, patients, staff, and organizations.

We want a sense of accomplishment – that we are acting rather than reacting, taking steps, making changes. Calling on our experience and expertise, being focused but flexible in responding, we are constantly learning, setting a tone of partnership among the members of the healthcare team.

We hope for a feeling of belonging – for identity, respect, courtesy, reliability, predictability – for safety. We want to be seen, known, listened to. We would like as few surprises as possible – unless they are really good surprises! We would like people to do what they say they will do.

The challenge to physicians, patients, staff, and organizations is to work together to create and maintain a healthy supportive workplace in the area, however small or large, that we manage. We are unavoidably joined together in this enterprise, using the resources at hand to care for and protect physicians, patients, staff, and the organization.

We can begin by ensuring that we are mobilizing communication in all its forms, providing information and education to empower and hold accountable, and receive feedback from every member of the team. We can set standards of performance and behavior and provide patient education and staff training and development to implement and reinforce them. We can be relentless in our attention to detail to an ongoing critical evaluation of systems and to their consistent implementation.

In such a dynamic environment, physicians, patients, staff, and organizations can share a sense of pride in their care of and for each other, making the Quadruple Aim a reality.


Carole Lambert is Vice President, Practice Optimization for CAP. Questions or comments related to this article may be sent to