There is connectivity between all the points. If we draw the Triple Aim as a triangle and the Quadruple Aim as a square or a cross, we can think of the Quintuple Aim as points on a star - a North Star that may guide our health system forward. Making equity an independent aim - not the byproduct of the other aims - will make clear that each aim reinforces the other. Even the skeptics found over time that pursuing the aims together is how to make progress on all of them.Īnd so it is with equity. But the breakthrough proposition of the Triple Aim was that each aim pursued simultaneously reinforced the others. At the time, some argued that you could not work toward all three aims at the same time without trade-offs. It can be difficult to recall how much resistance the Triple Aim faced when it was first introduced 14 years ago. Many of the failure modes associated with the Triple Aim and the Quadruple Aim (when equity is left out) concentrate where inequities are steepest. Why? Consider how much of the excess morbidity and mortality, poor patient experience, and unmet need is concentrated among populations that are marginalized, under-resourced, disenfranchised, and historically oppressed. I predict that making equity the fifth aim will radically accelerate improvement in population health, enhanced care experience, cost reduction, and improved workforce safety and well-being. Without including equity as an explicit aim, our design choices will miss the opportunity to build equity into all that we do. When we build systems, we build them to aim-based specifications. Improvement scientists and leaders for generations before me have understood that we will not get where we want to go unless we set the right aims. And, as our understanding of what it will take to create a better health-creating system for all evolves, it becomes increasingly clear that the explicit pursuit of health equity is fundamental to all other aims. Many who have resisted prioritizing the well-being of health care workers as a fourth aim have found that it is demonstrably impossible to fully achieve the Triple Aim without seriously addressing workforce safety and satisfaction. My thesis is that the Triple Aim is not achievable without attention to health care burnout and inequity. In contemplating the answers to these questions, I have concluded that the Quintuple Aim is necessary precisely because we have not yet achieved the Triple Aim. I asked many of the questions that I am guessing others have: Does proposing an expansion to the Quintuple Aim just add noise? Are we asking too much of an already overburdened health care system? Can health care focus on so much simultaneously? Should we add more aims when we have not yet achieved the original Triple Aim and health care burnout is worse than ever? ![]() ![]() I imagine some who read this or who have read our JAMA paper will not be sure going beyond the Triple Aim is a good idea. I do not make the case for the Quintuple Aim lightly. Cooper, MD, MPH, and I have proposed adding both a fourth aim of workforce well-being and safety and a fifth aim of advancing health equity - because we cannot achieve safety or high-quality care for all without these additional aims. In a recent JAMA Viewpoint, my co-authors Shantanu Nundy, MD, MBA, and Lisa A. Subsequently, some thought leaders believed it was important to add a fourth aim to address either the growing challenge of burnout in the health care workforce - i.e., exhaustion, professional dissatisfaction, and cynicism - or the significant inequities present in health and health care. In 2008, Don Berwick, Tom Nolan, and John Whittington published a paper that first laid out what they called the Triple Aim - simultaneously improving population health, enhancing the care experience, and reducing costs.
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