Author + information
- Published online March 19, 2018.
- C. Michael Valentine, MD, FACC, President, American College of Cardiology∗ ()
- ↵∗Address for correspondence:
Dr. C. Michael Valentine, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
The concept of the “triple aim” was first introduced by the Institute for Healthcare Improvement in 2007, right in the middle of fierce debate over reforming health care in the United States. The goal: to provide a framework for a health care system focused not on volume, but on improved quality and patient satisfaction, better outcomes, and reduced costs (1).
Fast forward a decade, and the triple aim has become more than just a concept—it is the foundation of everything from laws to strategic plans, including that of the American College of Cardiology (ACC) (2). During this time, the triple aim has also had time to be tested by the realities of the health care environment as it transitions from fee-for-service to value.
What does this mean? Like most things, there is a need to grow and adapt over time. Although the focus on better outcomes, improved care, and lower costs is still fundamental, increasing administrative, regulatory, and professional burdens are leading to clinician burnout and running counter to the goals of the triple aim. This has led to a call for a fourth aim addressing professional well-being.
“The wide gap between societal expectations and professional reality has set the stage for 46% of U.S. physicians to experience symptoms of burnout,” wrote Thomas Bodenheimer, MD, and Christine Sinsky, MD, in their 2014 paper published in the Annals of Family Medicine calling for a move from the triple to a quadruple aim (3). Similarly, Colin P. West, MD, PhD, noted in a 2016 piece in the Journal of General Internal Medicine that a “Quadruple Aim would ensure that changes to the health care system optimally serve the entire system, including individual patients, populations, and the professionals engaged in delivering care” (4).
Medscape data published in the March/April 2016 issue of Cardiac Interventions Today found that more than 50% of clinicians involved with critical care, emergency medicine, family medicine, and internal medicine claim burnout. Those involved in pulmonary medicine and cardiology followed closely behind, at 47% and 46%, respectively. In terms of severity of burnout, those in cardiology ranked second, only behind nephrology (5).
Causes of burnout on a broad scale include too many regulations, computerization of practices, number of hours worked, health care reform laws, and lack of professional fulfillment. The ACC’s latest professional life survey of its members shows similar results, with cardiovascular professionals citing implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, work-life balance, maintenance of certification (MOC), reimbursement challenges, electronic health record challenges that take away from patient time, prior authorization, and quality reporting among the top issues keeping them up at night (6). Additionally, the shift from private practice to hospital ownership or integration has left many cardiologists frustrated and feeling underappreciated with little options for recourse.
As these and other demands on practices and clinicians continue to grow, a recent opinion piece published in the Journal of the American Medical Association notes that understanding the business case to reduce burnout and promote engagement “is not only [an] organization’s responsibility, it is also the fiscally responsible one” (7).
“Evidence suggests that improvement is possible, investment is justified, and return on investment measurable,” the authors write (8).
I and other ACC leaders agree. A robust, diverse, and healthy workforce is key to achieving the College’s new vision of “a world where innovation and knowledge optimize cardiovascular care and outcomes” (9).
As such, the College has incorporated the expanded quadruple aim into its current strategic priorities, as well as its 2019 to 2023 Strategic Plan. To date, the College is in the middle of a multiyear effort to help members implement Quality Payment Program requirements created as part of MACRA. From a comprehensive online education hub to focused sessions at the College’s annual Cardiovascular Summit and Scientific Session, the ACC is working to meet members where they are. Additionally, the College continues to develop and refine tools and resources, including its NCDR (National Cardiovascular Data Registries), to help streamline participation in Quality Payment Program–related programs.
Similarly, advocating on behalf of its members around MOC remains a major priority. The College, working with its partners in the internal medicine community, has been in ongoing negotiations with the American Board of Internal Medicine regarding the highly controversial MOC requirements. These discussions have been successful in reversing or suspending some of the more egregious requirements, including the double jeopardy provision and MOC Part IV requirement. Additionally, the American Board of Internal Medicine had decoupled the initial board examination from MOC participation and streamlined the ability for practitioners to get both continuing medical education and MOC Part II credit. We are also in detailed talks around an alternative to the 10-year examination, which would leverage the College’s Self Assessment Products like ACCSAP.
Reducing members’ administrative and professional burdens continues to be of the highest priority. Efforts are under way to reduce participant data collection burden by enhancing NCDR integration with electronic health records and other data sources. Leveraging technology to deliver education and knowledge also continues with the development of online continuing medical education/MOC activities and mobile apps, like the ACC Guidelines Clinical App, that puts evidence-based care literally in the palms of clinicians’ hands.
More recently, the ACC joined the National Academy of Medicine Action Collaborative in formally committing to promote clinician well-being and combat burnout. More than 130 organizations are part of this collaborative, which aims to support clinician well-being through sustained attention and action at the organizational, state, and national levels, as well as investment in research and information-sharing to advance evidence-based solutions. The ACC is proud to be a part of this effort and is fully committed to helping its members find, implement, and share innovative solutions to burnout, attrition, and poor team functioning.
We will not stop here. Increasing the relevance of the ACC as the cardiovascular professional home; generating and delivering actionable knowledge; and advancing quality, equity, and value of cardiovascular care are all part of the next Strategic Plan. In addition, helping members achieve and support balance and well-being in their roles and workplaces is also woven into the fabric of the College’s new core values (8).
A plenary session at the recent 2018 Cardiovascular Summit in Las Vegas in February focused on the importance of cardiovascular professionals finding joy in their jobs. The Cardiovascular Summit also provided many opportunities for ACC members to share best practices and learn from each other about ways to improve efficiency and quality in practice. A “Scribe Program” that I learned about and took back to my practice from the Cardiovascular Summit 2 years ago has greatly improved the lives of my partners and returned joy to our outpatient office providers.
As your professional home, the ACC is committed to helping its members learn from each other, share ideas, and find that joy and balance so that together we can most effectively deliver on the triple aim of improved outcomes, better health, and lower costs. This will require “shifts in policy and culture to address a system that remains broken for many, and to allow for creative and flexible solutions that promote physician well-being,” as noted in a recent New England Journal of Medicine editorial (9).
For the majority of physicians, we practice medicine because of our passion for improving and saving the lives of patients. We can and must take care of ourselves to best take care of those we took an oath to serve.
- 2018 American College of Cardiology Foundation
- Berwick D.M.,
- Nolan T.W.,
- Whittington J.
- ↵American College of Cardiology. The ACC’s Strategic Plan. Available at: http://www.acc.org/about-acc/our-strategic-direction. Accessed March 5, 2018.
- Bodenheimer T.,
- Sinsky C.
- West C.P.
- ↵Sobal L, Jaskie S. What’s missing from the triple aim of health care? Cardiac Interventions Today. March/April 2016. Available at: https://citoday.com/2016/04/whats-missing-from-the-triple-aim-of-health-care/. Accessed March 5, 2018.
- Lewis S.,
- Mehta L.,
- Douglas P.,
- et al.
- Shanafelt T.,
- Goh J.,
- Sinsky C.
- Wright A.,
- Katz I.
- ↵American College of Cardiology. About ACC. Available at: http://www.acc.org/about-acc. Accessed March 12, 2018.