Posted on: 8 April 2022



In this edition, our feature article will be an introduction to the Institute for Healthcare Improvement’s (IHI) Triple aim and the evolution of the Quadruple aim.

Our improvement story this month is from Sally Lydamore and the Camden School Nursing Service.

Each month we will be sharing great examples from across CNWL where individuals and teams are improving systems and processes to ensure that we deliver the best evidence-based service user and carer experience where ever teams are delivering care across the trust. We also have exciting updates from the Improvement Academy and share great educational opportunities that are coming up.


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An introduction to the IHI triple aim and the evolution of the Quadruple aim


In this month’s newsletter we would like to explore the Institute for Healthcare Improvement (IHI) Triple aim, it’s origins and how it has evolved. This journey commenced in the late 1990’s with healthcare researchers in the US. This commenced with two seminal books: ‘To Err is Human’ & ‘Crossing the Quality Chasm’. The first of these ground-breaking books was ‘To Err is Human’ that broke the silence that surrounded medical errors and their consequence. The authors focus was not on pointing the fingers at caring healthcare professionals who make honest mistakes, as they state that to ‘err is human’. Instead this paper established a roadmap agenda for reducing medical errors and improving patient safety through the design of safer healthcare systems (Kohn, Corrigan & Donaldson, 2000). The second book, ‘Crossing the Quality Chasm’, identified and recommends six dimensions of quality healthcare where improvement efforts could be focused; These were patient safety, care effectiveness, patient/service user-centeredness, timeliness, care efficiency and equity of access (Institute of Medicine, 2001).

On the backdrop of this work and based on the collective healthcare experience at the IHI, the Triple AIM framework was conceived and describes an approach to optimising health system performance (Institute for Healthcare Improvement, 2006). At that time, it was the IHI’s belief that new strategies must be developed to simultaneously pursue three dimensions, which they called the “Triple Aim”:

  • Improving the patient experience of care (including quality & satisfaction)
  • Improving the health of our population
  • Reducing the per capita cost of healthcare



(Institute for Healthcare Improvement, 2006)


Since Don Berwick and his colleagues at the IHI introduced the ‘Triple Aim’ to the language of Healthcare, it has become widely accepted as a guiding compass to optimise healthcare system performance and has spread to all four corners of the globe. This being said, Bodenheimer & Sinsky (2014) found that members of the healthcare workforce had reported widespread burnout and dissatisfaction. Burnout has been associated with lower patient satisfaction, reduced health outcomes and at times has also increased healthcare delivery costs (Bodenheimer & Sinsky, 2014). Burnout consequently jeopardises the Triple Aim. Bodenheimer & Sinsky (2014) recommended that the Triple Aim be expanded to a ‘Quadruple Aim’, adding the goal of improving the working life of our healthcare workforce.