Evidence-Based Practice and the Quadruple Aim in Healthcare Organizations

Master of Science in Nursing Education, Walden University

EB001: Evidence-based practice and the Quadruple aim

Dr.

March 21, 2022

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 Evidence-Based Practice and the Quadruple Aim in Healthcare Organizations

Chrisman et al., (2014), explained evidence-based practice as the process of collecting,

processing, and implementing research findings into the work field with the goal being to

improve the clinical practice, patient outcome, or the work environment. The use of evidence-

based practice allows healthcare professionals to provide the most competent and cost-efficient

patient care using the latest research. Nurses, physicians, and other healthcare professionals

utilize evidence-based practice in their daily duties to answer clinical questions when treating

their patients. For example, in the emergency room practice, how does treating patients based on

acuity differ from treating patients on a first come first serve basis? An evidenced-based

approach facilitates the answers to this and many more clinical questions promptly to prove that

implementing evidence-based research into practice improves patient care and outcomes

(Melnyk et al., 2010). A direct track to achieve and improve patient care delivery and outcomes

is by utilizing evidence-based practice which is highly accepted as the key to the success of

quality and safe healthcare delivery from healthcare professionals (Chien, 2019).

The Quadruple Aim

The quadruple aim is the addition of a fourth aim to the already existing triple aim. The

Triple aim is a framework guiding healthcare delivery in the United States developed by the

Institute for Healthcare Improvement (Longbrake, 2017). The triple aim framework composes of

reducing costs, improving population health, and improving patient care experience. The

additional domain to create the quadruple aim is the well-being of the healthcare team (Arnetz et

al., 2020). The additional fourth aim focuses on the importance of improving healthcare worker

satisfaction in the workplace, for many healthcare organizations, adding the fourth aim to create

the quadruple aim allows joy in the workplace and health equity (Feely, 2017). Wong et al.,

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(2021) explained that the fourth aim increases the understanding that competent health care is

impossible without healthcare workers that are physically and physiologically healthy. Evidence-

based practice can be applied to the quadruple aim through the suggestions of shared decision

making and addressing each component of the quadruple aim to maintain and promote an

excellent health care organization.

Patient Experience

To aid healthcare providers in clinical decision-making and health management, the use

of patient-reported outcome measures can be utilized to achieve the health outcome that is

expected by most patients ( Iglesia et al., 2020). Melnyk et al., (2014) state that a problem-

solving approach in healthcare is defined through evidenced-based practice, it allows merging of

the best evidence from studies that are well designed and integrates it with a patient’s preference,

values, and a clinician’s expertise (internal evidence from patient data). Evidence-based practice

can contribute to the development of the Quadruple aim through the patient experience once

healthcare professionals use well-ordered research skills and apply the evidence of scientific

knowledge to their clinical practice based on the needs of the patient. Evidence-based practice is

a vital part of providing safe and quality healthcare to patients, and healthcare professionals must

be up to date with current practices to provide competent care to those with complicated

conditions.

Research conducted by Skaggs et al., (2018) reports that evidence-based practices

strategies have had a positive influence on patient perceptions of the care they received while in

the emergency department and increased satisfaction ratings including bedside shit report, hourly

rounding, and most importantly AIDET ( acknowledge, introduce, duration, explanation and

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thank you). An important outcome for the quadruple aim is improving patient experience, which

is of important value to patients and their families. The patient experience commonly correlates

to the process of care for disease prevention and management and also the communication with

their health providers. A satisfied patient experience also integrates the patient’s adherence to the

medical advice and treatment plans. For example, a study reported in an article by Agency for

Healthcare Research and Quality (n.d), showed that patients who were hospitalized for heart

attack and reported positive patient experiences with care had better health outcomes after one

year of discharge.

Population Health

Considering evidence-based practice in population health is accomplished by integrating

science-based interventions with community preferences for improving the health of the

population (Jacobs et al., 2012). Utilizing an evidence-based approach concerning population

health could result in direct and indirect benefits to the healthcare system; this could include

better or more access to quality information on best practices, yield success in disease prevention

programs, and increase workforce productivity (Lhachimi, 2016). According to Melnyk et al.,

(2010), without using modern or present-day evidence-based approaches, healthcare practices are

quickly outdated and sometimes can often be detrimental to patients. The authors gave an

example, taken from the task force on sudden infant death syndrome (SIDS) in 2016, relating to

pediatric care; for years healthcare providers encouraged parents to place infants in the prone

position while sleeping as this was the best position to prevent aspiration. However, research

conducted indicated that the prone position increases the risk of sudden infant death syndrome,

now the recommended position for infant sleep is a supine position which has resulted in a

decline in infant mortality caused by sudden infant death syndrome.

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 According to Crabtree (2016), a critical link in bringing evidence-based into the clinical

practice that will have a positive effect on population health are nurses. According to Dawes et

al., (2005) and Hockenberry et al., (2008), as cited in Crabtree et al., (2016), best practice occurs

when healthcare professionals continually question treatment and care, uses resources and

necessary skills to search and evaluate evidence, and then implementing that evidence into

practice to determine the effectiveness on population health. Therefore, once health practitioners

utilize evidence-based practice, they can meet the demands for a systemic approach to solving

problems associated with population health yielding measurable outcomes (Jacobs et al., 2012).

Costs

One of the most challenging factors for healthcare facilities and patients seeking

healthcare is costs, it is also an important outcome for the quadruple aim. High medical costs

have been a significant impediment in patients seeking and receiving medical treatment, and this

may even cause some to suffer or even succumb to their illness due to this issue. According to

Longbrake (2017), the aim of the triple aim as it relates to costs is to cause a reduction in

healthcare costs; and this is adapted in the quadruple aim. As health systems adapted globally,

they struggled with the challenge of improving healthcare while lowering healthcare costs (Sikka

et al., 2015). However, does the reduction in healthcare costs benefit the patient or the healthcare

facilities? This is where evidence-based practice comes into play. Melnyk et al., (2010) report

that evidence-based practice promotes a high-value healthcare delivery which includes

improving health outcomes, enhancing the quality and rehabilitation of health care, and most

importantly reducing the variation of costs.

Applying evidence-based practice yields better patient outcomes which in turn will

decrease the demand for healthcare resources and further reduce the expenses on healthcare

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facilities. For example, some hospitals may use cheaper outdated practices that may have utilized

equipment or products that are no longer necessary for certain procedures or techniques; but this

may cause longer hospital stay for the patient and increase the costs for healthcare by the patient.

Facilities should in co-operate evidence-based practice by utilizing the most modern technology

and practices, it will automatically increase the cost of healthcare for the facility, but the benefits

of the cost, in the long run, will outweigh the use of outdated technology for both the patient and

healthcare facility. Adilyet al., (2004), argues that the application of evidence-based healthcare

practice has the potential to be the most effective and efficient way to cope with the inevitable

rise in healthcare costs.

Work-life of healthcare providers

A valued component of a favorable healthcare environment should support the

collaboration of health professionals. Acknowledging the concerns and importance of our nurses,

doctors and other healthcare professionals contributing to the health system is vital, as this

provides a sense of confidence and empowerment in their practice. According to Fridman &

Frederickson, 2014; Kim et al., 2016, 2017 as cited in Melnyk et al., 2010 results from studies

have indicated that healthcare professionals feel empowered with a higher job satisfaction when

they engage in evidence-based practice. With the addition of a fourth aim, the quadruple aim

addresses the importance of improving the experience of those who provide care (Sikka et al.,

2015). Burnout and depression among health care professionals from pressure to deliver quality

and safe care under heavy patients loads have increased over the years. However, Melnyk et al.,

(2010) report that the use and teaching of evidence-based practice may be the key to not only

providing competent care but also reducing the high turnover rate of healthcare professionals due

to burnout and depression.

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 One way of improving the work-life of healthcare providers is by listening to their

concerns, this can be done through simple surveys; and previous surveys can be used in

evidence-based practice to improve the work-life of healthcare professionals (Sikka et al., 2015).

In a previous US survey conducted in 2013, 51 percent of nurses expressed that their job affected

their health, while another 35 percent reported feeling to resign from their current job due to

dissatisfaction. These results can be included in evidence-based practice to find solutions to these

issues healthcare professionals face (Sikka et al., 2015). Evidence-based practice also has

enabled research in technological advancements to promote healthcare professionals' well-being;

one such example is charting. Take for example the use of technology in today’s workspace

through the use of the electronic medical record (EMR) that replaced the time-consuming and

tedious paper charting.

Evidence-based practice is an approach to clinical practice that has been gaining attention

since it was introduced in 1992 (Chrisman et al., 2014). Healthcare professionals have been

exposed to evidence-based research and practice since the beginning of their professional

journey and it has vastly contributed to the quadruple aim. The additional aim to the triple aim to

develop the quadruple aim has fostered quality patient outcomes while empowering the medical

clinicians. The implementation of evidence-based practice in health care has benefited the

overall patient experience, health of the population, costs, and the well-being of healthcare

professionals.

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 References

Adily A., & Ward J. (2004). Evidence-based practice in population health: A regional survey to

inform workforce development and organizational change. Journal of Epidemiology &

Community Health 58, 455-460. http://dx.doi.org/10.1136/jech.2003.012278

Agency for healthcare research and quality. (2020). Why improve patient experience? Retrieved

from: https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/2-why-

improve/index.html

Arnetz, B., Goetz, C., Arnetz, J. (2020). Enhancing healthcare efficiency to achieve the

quadruple aim: An exploratory study. Biomedical central, 13(362).

https://doi.org/10.1186/s13104-020-05199-8

Chien, L. (2019). Evidence-based practice and nursing Research. The journal of nursing

research, 27(4), 29. https://doi.org/10.1097/jnr.0000000000000346

Chrisman, J., Jordan, R., Davis, C., Williams, W. (2014). Exploring evidence-based practice

research. Nursing made incredibly easy, 12(4), 8-12. doi:

10.1097/01.NME.0000450295.93626.e7

Crabtree, E., Brennan, E., Davis, A., & Coyle, A. (2016). Improving patient care through nursing

engagement in evidence-based practice. Worldviews on evidence-based nursing, 13(2),

172–175. doi:10.1111/wvn.12126

Feeley, D. (2017). The triple aim or the quadruple aim? Four points to help set your strategy.

Retrieved from: http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-

aim-four-points-to-help-set-your-strategy

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Iglesia, E., Greenhawt, M., & Shaker, M. (2020). Achieving the quadruple aim to deliver value-

based allergy care in an ever-evolving health care system. Annals of Allergy, Asthma &

Immunology, 125(2), 126-136. https://doi.org/10.1016/j.anai.2020.04.007

Jacobs J., Jones E., Gabella B., Spring B., & Brownson R. (2012). Tools for implementing an

evidence-based approach in public health practice. http://dx.doi.org/10.5888/pcd9.110324

Lhachimi, S., Bala, M., & Vanagas, G. (2016). Evidence-based public health. BioMed research

international. https://doi.org/10.1155/2016/5681409

Longbrake, K. (2017). Focusing on the quadruple aim of health care. American nurse today,

12(7). Retrieved from: https://www.americannursetoday.com/focusing-quadruple-aim-

health-care/

Longbrake, K. (2017). Focusing on the quadruple aim of health care. American Nurse Today,

12(7). Retrieved from: https://www.americannursetoday.com/focusing-quadruple-aim-

health-care/

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-

based practice: Step by step: The seven steps of evidence-based practice. American

Journal of Nursing, 110(1), 51–53. doi:10.1097/01.NAJ.0000366056.06605.d2

Melnyk, B., Fineout-Overholt, E., Stillwell, S., & Williamson, K. (2010). Evidence-based

practice: Step by step: The seven steps of evidence-based practice. American Journal of

Nursing, 110(1), 51–53. doi:10.1097/01.NAJ.0000366056.06605.d2

Melnyk, B., Gallagher-Ford, L., Long, L. E., & Fineout-Overholt, E. (2014). The establishment

of evidence-based practice competencies for practicing registered nurses and advanced

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 practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality,

reliability, patient outcomes, and costs. Worldviews of Evidence-Based Nursing, 11(1), 5–

15. doi:10.1111/wvn.12021

Sikka, R., Morath, J. & Leape, L. (2015). The quadruple aim: Care, health, cost and meaning in

work. BMJ Quality & Safety, 24(10), 608. http://dx.doi.org/10.1136/bmjqs-2015-004160

Skaggs, M., Daniels, J., Hodge, A., & DeCamp, V. (2018). Using the evidence-based practice

service nursing bundle to increase patient satisfaction. Journal of emergency

nursing, 44(1), 37–45. https://doi.org/10.1016/j.jen.2017.10.011

Wong, A., Ahmed, R., Ray, J., Khan, H., Hughes, P., McCoy, C., Auerbach, M. & Barach, P.

(2021). Supporting the quadruple aim using simulation and human factors during

COVID-19 care. American journal of medical quality, 36(2), 73–83.

https://doi.org/10.1097/01.JMQ.0000735432.16289.d2

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