Quadruple Aim (New Triple Aim) in Occupational Therapy


Recently, a quadruple aim has been proposed by many allied health professionals to expand on the quadruple aim. As we will see, the proposed quadruple aim has many implications on the original triple aim of improving client care, but also has an effect on clinicians.

Let’s review the triple aim.


  • The Triple Aim is a framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to optimizing health system performance.
  • The US healthcare system is costly and continues to grow with service utilization from the aging population longevity, chronic health problems, and global health challenges.
  • COVID-19 has put a stress on society and the healthcare system.
  • The Triple Aim entails ambitious improvement at all levels of the system to advocate for a systematic approach to change.

“Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care.

Patients can expect less complex and much more coordinated care and the burden of illness will decrease.

Importantly, stabilizing or reducing the per capita cost of care for populations will give businesses the opportunity to be more competitive, lessen the pressure on publicly funded health care budgets, and provide communities with more flexibility to invest in activities, such as schools and the lived environment, that increase the vitality and economic wellbeing of their inhabitants.”

The 3 Dimensions

  1. Improving the patient experience of care (including quality and satisfaction)
  2. Improving the health of populations
  3. Reducing the per capita cost of health care

Quadruple Aim

As occupational therapists know, it is not solely the client who is in the healthcare system. They interact and collaborate with many allied and non-allied health professionals in their care. The other component is the clinician, such as the occupational therapist.

The triple aim’s focus is on the patient or client.

The idea behind the quadruple aim is that without an improved clinical experience on the provider side, the three other patient-centric aspects won’t reach their full potential.

For many organizations, the 4th dimension in the quadruple aim is attaining joy at work, or pursuing health equity. Other priorities have been highlighted by other organizations. See our blog post on what some employees value as important workplace benefits.

The IHI stresses that:

  • The triple aim is about patients.
  • The goal for the triple aim has not been reached — one could argue that this may be due to the lack of the proposed 4th dimensions that is preventing the original 3 dimensional goals from being attained.
  • We should not lose focus of the triple aim.
  • Measurement matters for outcomes.

Has your organization incorporated (officially or unofficially –coincidentally) a 4th dimension for a quadruple aim?

In today’s healthcare environment of high demand on the system (such as due to COVID-19), high productivity requirements, decreased confidence in the healthcare system, and other factors such as limited organizational resources – many healthcare providers are at high risk for decreased job satisfaction, burnout, mental, and physical health problems. Organizations could be facing high turnover rates and/or having to staff with traveling agencies.

As patients and clients do not exist in isolation, a consideration of the entire context which includes clinicians and healthcare providers would be very beneficial in reaching the original triple aim goals and therefore improve societal health and wellness on a macro level. A proposed 4th dimension can be broadly defined as some improvement for the clinician (experience, joy/satisfiaction, health). But there should be no one-size fits all dimension as each organization has its own strengths, weaknesses, problems, and goals that trickle down to their employees. And as IHI stresses, it is important to implement changes in a quadruple aim model that has ways to measure success and outcomes.

  • In what ways can your organization implement a quadruple aim to continue to improve the satisfaction and outcomes for clients?
  • Would an approach that focuses on clinicians be a way to achieve this?
  • How would you measure success from both parties?
  • Should there be an additional dimension for the systems/organizations and not solely the client and clinician? — the context of which they both provide and receive services include a physical (or virtual) space with a set of policies, services, equipment, other personnel, even a brand image — all of which affect quality, health, and costs.
  • What are some successful models from other countries that can inspire your organization?