This article, titled “Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study”, explores a critical challenge in healthcare: the inherent conflict between striving for the Quadruple Aim and simultaneously improving productivity. Authored by Arnetz et al. and published in BMC Research Notes in 2020, this quasi-experimental pilot study investigates a novel intervention designed to address these competing demands.
The Quadruple Aim framework, which was adapted from the earlier Triple Aim in 2014, serves as a guiding principle for optimizing healthcare system performance. It encompasses four crucial dimensions that healthcare systems must balance:
- Reducing costs.
- Improving population health.
- Enhancing patient experience.
- Fostering healthcare team well-being.
Despite these crucial foci for healthcare quality, systems in the United States also face productivity-based reimbursement models, such as work relative value units (wRVU), from Medicare and Medicaid Services, which are often mimicked by private insurers. This creates a dual challenge: achieving the Quadruple Aim while concurrently increasing productivity. Existing interventions often target specific issues like burnout but frequently fail to address the underlying causes of stress and inefficiency comprehensively in primary care settings.
The EFFECT Intervention Study Design and Implementation:
The study aimed to test an intervention that comprehensively targets the numerous demands faced in primary care delivery by enhancing healthcare efficiency, hypothesizing that this could address demands without requiring additional resources.
- Study Type and Duration: This was a quasi-experimental pilot study conducted over a two-week period (10 working days) in early 2019.
- Participants and Setting: The study took place in a single family practice clinic involving a total of 25 employees, including 6 providers, and their patients.
- Intervention Group: One provider and their team (consisting of one full-time equivalent (FTE) provider, two 1.00 FTE medical assistants (MAs), and one 0.25 FTE registered nurse (RN)) implemented the intervention. This staffing model already existed within the clinic.
- Reference Group: The remaining five providers and their teams (21 employees) comprised the reference group and continued their usual patient care routines.
The intervention was named “Efficiency-focused flow intervention to energize care teams” (EFFECT). It was hypothesized that EFFECT would enable the intervention team to simultaneously meet all Quadruple Aims and clinic productivity goals by improving clinic efficiency. The team set clear goals: increase visit capacity by 50% and complete all administrative and electronic health record (EHR) activities within the 8-hour workday.
Key aspects of the EFFECT intervention included:
- Revising patient flow to allow for preplanning of work tasks, such as tests and procedures.
- Scribing to reduce provider administrative burden.
- Optimizing skills utilization of all team members, ensuring they worked at the top of their licensure.
- Incorporating daily team “huddles” and between-visit “touch-bases” to facilitate planning, communication, and assignment of responsibilities.
- Standardizing appointment scheduling to 20 minutes, with one additional acute visit allotted each hour.
- Redistributing tasks: Medical assistants (MAs) or registered nurses (RNs) took on crucial tasks like lab draws, vaccinations, and all EHR and administrative duties immediately before, during, or after patient visits. This modification allowed the provider to focus fully on the patient encounter without computer-related tasks.
In contrast, the reference team maintained their existing scheduling model (25 minutes for acute needs and 50 minutes for physicals and chronic needs) and usual work processes.
Outcome Measures:
The study measured outcomes across the Quadruple Aims and productivity using a combination of provider/staff and patient surveys, and administrative data.
- Aim 1: Reducing Costs: Measured by visit capacity, defined as the total number of slots available for patient visits per FTE provider. The rationale was that increasing slots allows fixed costs to be distributed over more visits.
- Aim 2: Population Health: Measured by the number of HIV screenings completed per day per FTE provider, used as a proxy for population health procedures, as this measure showed the largest gap in meeting clinical guidelines.
- Aim 3: Healthcare Team Well-being: Assessed using a 14-question survey completed by healthcare team members four times (pre-intervention, days 1 and 10 of intervention, and 7 days post-intervention). Questions, adapted from the Quality Work Competence survey, used a 0-10 visual analogue scale (VAS) (e.g., “I feel fulfilled at work”).
- Aim 4: Patient Experience: Evaluated using a 16-question paper survey given to patients at check-out. Questions were adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and included items like “There is a positive work environment in this clinic,” using a 0-10 VAS.
- Productivity: Calculated by total wRVU and visits completed per FTE provider during the study. Mean wRVU per visit for the intervention provider was also compared before and during the intervention.
- Efficiency: Both patients and the healthcare team rated efficiency using a 0-10 VAS for statements like “My visit was efficient” and “Our clinic runs efficiently”.
Results and Discussion:
The preliminary results of the study were highly promising, supporting the feasibility of substantial process changes to improve both the Quadruple Aims and productivity.
- Data Collection: In total, 46 team surveys, 156 patient surveys, and clinic output data for 467 visits were collected.
- Overall Performance: The intervention team performed better across all Quadruple Aims and productivity measures compared to the reference team.
Specific findings included:
- Aim 1: Reducing Costs (Visit Capacity): The intervention group offered 48% more patient slots than the average reference team. The intervention team demonstrated a significantly higher visit capacity.
- Aim 2: Population Health: The intervention team completed significantly more daily HIV screenings (M = 2.30 vs. M = 0.31 for reference group, p = 0.006). They completed 23 HIV screenings during the two-week intervention, which was more than the 22 screenings completed in the entire six months prior. Anecdotal reports also suggested the intervention team closed or decreased other quality gaps (e.g., immunization, diabetes mellitus indicators, mammography).
- Aim 3: Healthcare Team Well-being: Healthcare team-rated efficiency was positively correlated with professional fulfillment (r = 0.532, p < 0.001) and skills utilization (r = 0.496, p < 0.01), and negatively correlated with stress (r = -0.336, p < 0.05).
- Aim 4: Patient Experience: Patient-rated efficiency correlated positively with patient ratings of their doctor (r = 0.633, p < 0.001) and their willingness to recommend the clinic (r = 0.442, p < 0.001).
- Productivity: The intervention provider generated significantly higher mean wRVU and more total wRVU (267.90 for intervention vs. 143.74 for reference) compared to reference providers. They also completed more visits (200 for intervention vs. 77.18 for reference). Importantly, the intervention provider increased their mean wRVU per visit during the intervention compared to pre-intervention (1.46 vs. 1.34, p < 0.001). This was achieved without adding staff or requiring provider overtime.
The findings support the hypothesis that focusing on efficiency can lead to more effective work habits and processes, improving performance measures while simultaneously reducing work stress. This suggests that addressing work roles and processes through enhanced skills utilization can mitigate challenges like burnout, stress, and access limitations in primary care. By increasing visit capacity, EFFECT also improved patient access, which has been shown to reduce spending on more costly services.
Anecdotal reports from the healthcare team were also positive. The physician reported higher work-life satisfaction and feeling more prepared for complicated patients, while medical assistants felt more knowledgeable about patients, despite perceiving an increase in workload that might warrant higher compensation.
Limitations and Future Research:
The authors acknowledge several limitations to this study:
- It was a small, preliminary study of a previously untested intervention.
- It was conducted at a single site.
- It utilized a small sample size.
- It was conducted over a limited two-week time period.
- Therefore, the results are preliminary and may not be generalizable to other primary care clinics.
The authors conclude that a larger-scale study over a longer time period is warranted to confirm these promising findings and to assess feasibility and cost-effectiveness. The feasibility of implementing these clinical process changes on a larger scale in operationally-strained primary care clinics also needs further evaluation.
Reference: Arnetz, B. B., Goetz, C. M., Arnetz, J. E., Sudan, S., vanSchagen, J., Piersma, K., & Reyelts, F. (2020). Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study. BMC Research Notes, 13(1), 362. https://doi.org/10.1186/s13104-020-05199-8
