Patient safety and the Triple Aim

The cost of healthcare has been increasing rapidly in many countries, which creates tension in relation to the costs involved in increasing patient safety. The Institute of Healthcare Improvement's (IHI) Triple Aim, in its emphasis on reducing per capita costs of healthcare, reflects the recognition that the relationship between expenditure on healthcare and patient outcomes is not linear. As shown in Table 1, healthcare costs have been increasing rapidly in many countries, typically more rapidly than gross domestic product (GDP) per capita (Fig. 1 shows this for New Zealand as an example). Thus, expenditure as a percentage of GDP has also increased. Furthermore, poorer countries need to spend a higher proportion of their GDP to invest the same absolute amount in healthcare as countries with a higher GDP per capita (e.g. New Zealand vs Australia). Paradoxically, increasing the proportion of GDP spent directly on healthcare leaves less money for things such as social security, infrastructure (including housing and transport) and education, which also impact substantially on health. This tension is heightened in relation to the cost of patient safety programmes. Many patients are harmed by the very healthcare intended to help them.3-5 This iatrogenic harm makes a substantial contribution to the cost of healthcare directly and through the compensatory and legal costs that often follow. The human cost in avoidable injuries, illness, suffering and loss of life is even more compelling. In the year 2000, the Quality of Healthcare in America Project, initiated by the US Institute of Medicine, stated as one of its goals the reduction of error in medicine by 50% within 5 years.6 The World Health Organisation followed with three global patient safety challenges: Clean Care is Safer Care in 2005, Safe Surgery Saves Lives in 2008 and Medication Without Harm in 2017.7 However, the savings that result from safety initiatives often impact more on society in general than on hospitals’ accounts, so those responsible for financing healthcare have to balance the costs of safety programmes with the ongoing and escalating pressure for investment directly into front-line services. Furthermore, safety is but one of the elements of quality in healthcare.8, 9 Universal access to healthcare is particularly problematic in many countries, and sick or injured patients are not served well if the costs of healthcare make it unaffordable. Enter the IHI and the Triple Aim. The IHI was founded in 1991 by Don Berwick, to ‘improve health and healthcare worldwide’.10 In 2008, in response to the aforementioned tensions, Berwick, Nolan and Whittington introduced the concept that improving the USA healthcare system in particular would require ‘the simultaneous pursuit of three aims: improving the experience of care, improving the health of populations and reducing per capita costs of healthcare’.11 The Triple Aim reflects a recognition that the relationship between expenditure on healthcare and patient outcomes is not linear: greater expenditure on healthcare does not necessarily translate into better outcomes for patients.12 It has been adopted widely as a framework for institutional, organisational or regional improvement in the USA and elsewhere.13 New Zealand provides an example of the adoption of the Triple Aim as a guiding framework for the improvement of healthcare across a whole nation. A national government agency for healthcare improvement, the Health Quality and Safety Commission (the Commission) was established in November 2010 (soon after the promulgation of the Triple Aim). The Commission adopted the Triple Aim but, in collaboration with the Ministry of Health and other relevant organisations, modified its wording. The New Zealand Triple Aim is ‘the simultaneous pursuit of improved quality, safety and experience of care for individuals, improved health and equity for all populations and best value for public health system resources’.14 These modifications were thought necessary because the context of healthcare in New Zealand is very different from that in the USA. As can be seen from Table 1, New Zealand spends considerably less than half as much per capita on healthcare as does the USA. Thus, the modified third aim reflects an imperative in New Zealand to avoid waste of limited resources rather than to reduce expenditure. The modified second aim explicitly refers to ‘all populations’ to emphasise New Zealand's commitment to addressing inequities in health outcomes, notably in relation to obligations under the Treaty of Waitangi. This brings us to the IHI's first aim: ‘improving the experience of care’. This aim is interesting. Presumably, it is intended to direct attention to the care of individual patients. Experience is distinct from satisfaction, in that it is observable and can be related to predefined desirable or undesirable processes, infrastructure and outcomes. However, as others have commented,15 there are limitations to using measures of patient experience for the comprehensive assessment of progress towards better healthcare. In fact, experience of care is arguably a reflection of the extent to which care is patient-centred, which is just one element of quality, albeit an important one.8, 9 In New Zealand, therefore, the words ‘safety’ and ‘quality’ were added to the first aim, to make their importance explicit. Since safety and patient experience are both recognised elements of quality it could be argued that including these words is something of a tautology. In fact, they are included for emphasis, and it is interesting to note, by contrast, that the word ‘safety’ does not appear anywhere in the IHI version of the Triple Aim. So, has progress been made in advancing patient safety in the USA or in New Zealand since the introduction of the Triple Aim? In the USA, there have been some impressive successes, notably in the reduction of bacteraemia through the implantation of a simple bundle of care practices during the insertion and subsequent management of central lines.16 On the other hand, it is clear that iatrogenic harm is still common, and it is difficult to find any metric, or set of metrics, that captures the overall state of patient safety across the entire country. Whittington et al. recently reviewed the progress of its implementation, mostly in a USA context.13 These authors concluded that various organisations have found the Triple Aim useful in focusing efforts to unite the pursuit of better healthcare with that of lower cost. However, despite its adoption into the USA national strategy for healthcare in 2010, notably in the implementation of the Patient Protection and Affordable Care Act (ACA) of 2010, these efforts appear somewhat scattered and they quote Berwick as saying ‘… actual, systemwide, progress on all 3 aims simultaneously has proven elusive. If the past 5 years have witnessed the embrace of the Triple Aim as the proper way-finder, the next 5 years ought to be the time of real implementation and spread of “Triple-Aim-Capable” delivery system designs’. Clearly there is enormous variation in the quality of healthcare across the USA, with some examples of outstanding care. However, the 2017 report of the Commonwealth Fund's17 overall ranking of quality of healthcare places the USA last out of 11 evaluated countries (with Australia second and New Zealand fourth). In large part, this is a reflection of inequity, which it must be said is a problem in many other countries too, including New Zealand and Australia. The importance of equity (amongst other prerequisites for health) was recognised in the Jakarta declaration, which also stated that health is a basic human right.18 The recent wrangling in the USA over the future of the ACA of 2010 is worrying in this regard. Put simply, it is difficult to see how patient safety can be well served in the absence of universal access to adequate healthcare. In New Zealand, measurement of the quality and safety of the health and disability services of the nation is one of the responsibilities of the Commission. A framework of interacting measures has been established in an attempt to achieve this.19 A set of quality and safety indicators address the six aims outlined in the Institute of Medicine's manifesto, Crossing the Quality Chasm: safety, patient experience, effectiveness, equity, access and efficiency.8 This is done explicitly within the framework of the New Zealand Triple Aim. These indicators function at the level of the system, and cover high-level metrics such as, for example, amenable mortality, healthcare cost per capita/GDP and access to primary healthcare. Underneath these quality and safety indicators, novel quality and safety markers are used to evaluate particular safety initiatives. An illustration can be found in New Zealand's national falls reduction programme. The markers typically combine a measure of a relevant process (for the falls reduction programme, assessing patients on admission to hospital in respect of their risk of falling, and implementing an individual plan to mitigate risks if identified) with a measure of one particular outcome (in this case, in-hospital fracture of the hip). Importantly, no attempt is made to measure all relevant outcomes: that would be prohibitively expensive, and the aforementioned financial pressures apply to measurement as much as to any other aspect of healthcare. Instead, an affordable measure is chosen that provides an indicator of progress. The falls programme has succeeded in reducing harm from falls in New Zealand's hospitals.20 Interestingly, this was achieved not by the traditional approach of prescribing a particular bundle of measures, but instead from an accretion of improvements gained by focusing on each individual in the context of each specific situation and implementing tailor-made solutions relevant to each time, place and person. The overall result was attributed to the ‘aggregation of marginal gains’. New Zealand can also claim success in reducing central line associated bacteraemia, following the lead of the USA programme,21 and is beginning to see reductions in the rate of infections after arthroplasty and hip surgery.22 Where national programmes have concentrated on reducing harm, in most cases these harms have reduced. Significant, sustained reductions for falls in hospital which lead to a broken hip, wound infection following surgery, blood clots following surgery, and infection from central lines in intensive care units have occurred across New Zealand. We estimate that the subset of reduced harms and potentially wasted expenditure covered in this report has led to avoided costs of $90 million, and additional value to New Zealanders of nearly $400 million. It is not surprising that no single metric can capture the safety of healthcare within a country or organisation. Iatrogenic harm comes in many forms, and its reduction requires many different initiatives in many diverse fields of healthcare. In the end, as with the falls programme, improving patient safety depends on the ‘aggregation of marginal gains’ from these multiple initiatives. Equally, it is not any particular conceptual framework (be it the Triple Aim or any other) that brings about improvement in patient safety. Rather, it is the long-term commitment to continuous quality improvement across the entire health and disability system. Nevertheless, we are convinced that the Triple Aim does provides a useful framework for initiatives to improve quality and safety in healthcare, and for measuring that improvement, particularly across entire nations, although we do recommend that it be modified for local context, as was done in New Zealand. The avoidance of harm to patients should not need financial justification: its importance has been enshrined in healthcare since Hippocrates stressed that we should first do no harm. Nevertheless, the New Zealand experience has also convinced us that the reduction of iatrogenic harm is in fact of value financially, and that investing in patient safety is an important part of controlling the escalating costs of healthcare.