The application of triple aim framework in the context of primary healthcare: A systematic literature review

Highlights

• Operationalization of the Triple Aim framework varies across studies.

• Quality measures were based on locally available data and limited in scope.

• Inconsistency in the implementation of Triple Aim across all dimensions.

• Triple Aim can potentially measure changes in primary healthcare over time.

Abstract

The Triple Aim framework is an increasingly popular tool for designing and assessing quality improvements in the health care sector. We systematically reviewed the empirical evidence on the application of the Triple Aim framework within primary healthcare settings since its inception almost a decade ago. Results show that primary healthcare providers varied in their interpretation of the Triple Aim framework and generally struggled with a lack of guidance and an absence of composite sets of measures for performance assessment. Greater clarity around application of the Triple Aim framework in primary healthcare is needed, especially around the selection and implementation of purposeful measures from locally available data. This review highlights areas for improvement and makes recommendations intended to guide future applications of the Triple Aim in the context of primary healthcare.

Introduction

Modern healthcare organisations are increasingly looking for innovative ways to redesign complex and dated systems in order to achieve effective, efficient and sustainable healthcare delivery [[1], [2], [3]]. There is a pressing need to balance rising costs of medical care with public expectations for delivery of high-quality care. In 2008, the Institute for Healthcare Improvement (IHI) introduced the Triple Aim framework, with the primary goal of “improving the experience of care; improving the health of population; and reducing per capita costs” [4], p. 760. The original intent was to provide a consolidated framework in order to guide systematic improvement initiatives associated with high quality healthcare services. Berwick et al. [4] stressed that a strategic change, focused on all three dimensions simultaneously, at a system level, was needed in order to deliver desired outcomes. The authors believed that gains achieved in one dimension should not be at the expense of another and argued that a balanced and concurrent pursuit of all Triple Aim dimensions would ensure equity and high-quality care delivery [4], p.760.

The importance of the Triple Aim was recognised and adopted as the means of addressing deficits in the healthcare delivery system in the USA [5], by providing a holistic multi-faceted approach. This followed the Affordable Care Act (labelled ‘Obamacare’) in 2010, and Triple Aim’s subsequent adoption as the National Strategy for Quality Improvements in Healthcare [6,7]. Various other developed nations have embraced the principles of the Triple Aim and sought to apply them in healthcare redesign [8].

Since its inception almost a decade ago, the definition of the Triple Aim has remained consistent [9]. Within its individual dimensions, there have been significant refinements to the way in which this framework has been implemented and operationalized globally. In particular, the dimension “health of population” (referred to as population health hereafter) has been increasingly focused on improved health outcomes and equity of care; experience of care concentrated on clinical quality rather than patient satisfaction; and focus on higher efficiency and control of cost [9]. Organisations appear to have consistently modified the Triple Aim framework in order to fit their own strategic objectives and local priorities or fulfil specific quality improvement aims [10]. Further to this, some scholars identified that the original Triple Aim framework did not consider the experience of providers, advocating for inclusion of the critical role played by people tasked with delivery of care, and calling for the extension of the framework into a Quadruple Aim [11,12].

Previous attempts to operationalise the Triple Aim framework have proven challenging, despite IHI publishing an authoritative guide on an informed approach to Triple Aim framework implementation and measures selection [13]; and additional scholarly work on framework design and its operationalisation [14,15]. Most commonly, healthcare organisations have struggled with identifying, in practical terms, what initiatives to pursue and measure within the Triple Aim framework, which essential processes and evaluation tools to implement and track over time, which project and programs to invest in, and how to scale the framework to different levels of care provision [16,17].

Healthcare organisations need guidance to successfully structure their practice environments in order to deliver quality patient care [5,9]. However, little is known about the utility and the operationalisation of the Triple Aim framework, in particular the selection of guiding systems and specific measures that organisations used to deliver desired improvement initiatives.

This paper presents a systematic literature review on the operationalisation and application of the Triple Aim framework within the context of primary healthcare. The review answers the question: What is the evidence of the application of the Triple Aim within primary healthcare since its introduction in 2008? The aim was to investigate: 1) how was Triple Aim defined and operationalised in primary healthcare as primary improvement initiative and 2) how applicable is the Triple Aim within the primary healthcare system context. Addressing this aim allowed researchers to explore what is currently known about the Triple Aim framework as it has been reported within the primary healthcare context, draw conclusions on its usefulness, and consider what recommendations can be made for the future.