MODULE7READING-ImplicationsforPolicy-TheTripleAimQuadrupleAimandinterprofessionalcollaboration..pdf

Nurs Forum. 2020;55:54–64.wileyonlinelibrary.com/journal/nuf54 | © 2019 Wiley Periodicals, Inc.

DOI: 10.1111/nuf.12382

OR I G I NA L AR T I C L E

Implications for policy: The Triple Aim, Quadruple Aim,and interprofessional collaboration

Natalie Bachynsky PhD

East Texas Medical Center Crockett, Crockett

Medical Center Clinic, Crockett, Texas

Correspondence

Natalie Bachynsky, PhD, East Texas Medical

Center Crockett, Crockett Medical Center

Clinic, 1050 E. Loop 304, suite 200, Crockett,

TX.

Email: n.bachynsky@crockettmedicalcenter.

com

Abstract

Healthcare delivery in the Unites States stimulates policy change at a rapid pace. The

Patient Protection and Affordable Care Act of 2010 (ACA) is intended to expand

access to care and ultimately improve the health of Americans. The Triple Aim,

created by The Institute for Healthcare Improvement, delineates policy implications

for improving population health, the healthcare experience, and per capita cost. The

Quadruple Aim adds a fourth policy implication, for example, addressing the needs of

the healthcare provider. Advanced practice registered nurses are key in carrying out

the goals of the ACA and achieving the Triple and Quadruple Aims, via the formation

of interprofessional teams. This article offers insight into these policy implications

and identifies filters through which related nursing policy will be developed.

K E YWORD S

advanced practice, interprofessional education, policy/politics, quality improvement, social

determinants of care

1 | INTRODUCTION

Advanced practice registered nurses (APRNs) play an integral role in

the development of health policy for our nation. Fortunately, the

number of APRNs is growing rapidly and will continue to grow as the

demand for health promotion policy and interprofessional healthcare

services increases. In 2012, the Bureau of Labor Statistics (BLS)

estimated that employment of APRNs would increase 31% by the

year 2022. By comparison, the average growth rate for all employ-

ment groups was only projected to be 11% by 2022.1 APRNs must be

prepared to develop policy that considers the implications of the

patient’s health care needs and psychosocial, environmental, and

financial resources. When APRNs have access to advanced treat-

ments and therapies for patients but high costs prevents them from

obtaining the most effective treatments, both the APRN and the

patient suffer negative outcomes.

The Institute for Healthcare Improvement (IHI) was founded in

1991 in Cambridge, Massachusetts, by a team of forward‐thinkinghealthcare professionals focused on cultivating healthcare policy.

Policy implications demanded improved care for patients while

enhancing interprofessional processes that included APRNs, while

providing health care in a seamless manner. The initial IHI team, led

by Dr. Don Berwick, was committed to redesign the healthcare

system. Policy implications demanded that this system be free of

errors, waste, delay, and unsustainable costs.2 The IHI has evolved

from a small, grant‐funded organization focused on researching and

disseminating evidence‐based practices, to a self‐sustaining enter-

prise committed to leading policy initiatives on major factors that

transform healthcare delivery, that is, incorporate the patient’s

experience and cost of care.

2 | THE TRIPLE AIM

In 2008, The Institute for Healthcare Improvement (IHI) created The

Triple Aim:

A framework for optimizing health system performance

by simultaneously focusing on the health of a popula-

tion, the experience of care for individuals within that

population, and the per capita cost of providing that

care.2

The mission of the IHI is to “improve health and health care

worldwide”.2 The Triple Aim model delineates the key elements

and policy implications that are necessary to achieve this mission

Figure 1, Figure 2, and Box 1, Box 2.

Although the United States delivers some of the best, most

advanced clinical care in the world, the healthcare system fails to

address the policy implications related to obtaining the quality, cost‐effective healthcare services needed by vulnerable populations.4

APRNs often provide care to patients who face barriers such as

poverty and insufficient health literacy, preventing the underserved

from achieving the best health outcomes. Although the Patient

Protection and Affordable Care Act of 2010 has provided insurance

coverage for many individuals and families that could not afford

insurance in the past, these patients continue to be burdened by the

same barriers that existed before the time they obtained healthcare

coverage. One of the major policy implications that APRNs face is

providing health care that is available and that can be maintained for

long‐term health. The team at IHI realized:

the successful health and healthcare systems of the future

will be those that can simultaneously delivery excellent

quality of care, at optimized costs, while improving the

health of the population and believes that that is the

ultimate destination for the high‐performing hospitals and

health systems of the future.2

The Triple Aim provides a structure for APRNs to advocate and

develop policy for healthcare delivery that addresses patients’ needs

and enhances their ability to achieve optimal health with the

resources available. The IHI provides free materials and resources

for organizations and facilities interested in implementing the Triple

Aim. The IHI online site also provides exemplars from real

organizations have implemented the Triple Aim framework, high-

lighting policy implications of common barriers to achieving optimal

health care.

3 | THE QUADRUPLE AIM

The US healthcare system today often lacks the capacity to link

medical information over multiple admissions, let alone over multiple

sites. Our healthcare expenditures are higher than those of other

developed countries–nearly double–but the outcomes are no better.

The National Academy of Medicine (formerly IOM) identified six

areas to which “care improvement efforts” should be directed to

provide quality of care, including safety, effectiveness, patient‐centeredness, timeliness, efficiency, and equity.5 Berwick, Nolan,

and Whittington6 encouraged a broader system of linked goals,

known as the Triple Aim, a three‐pronged focus on improving the

healthcare system by improving care, improving the health of the

population, and reducing per capita costs. These three aims were

interdependent goals, for pursuit of one affected the other two either

positively or negatively.

The addition of a fourth aim, known as the Quadruple Aim, added

a fourth prong, which focuses on care of the provider in optimizing

the performance of the healthcare system. The rationale for the

fourth prong is the product of the high incidence of provider burnout,

a factor that often leads to lower patient satisfaction, reduced health

outcomes, and increased patient care costs. The Quadruple Aim is

designed to enhance and improve provider work life and ultimately

patient outcomes.7 The primary concern in maintaining Quadruple

Aim balance is social justice, ensuring equitable gains in health care in

all populations of stakeholders, including the provider.6(p760‐761)

The implications of the Quadruple Aim requires an exercise in

balance for policymakers, for each aim may be subject to constraints,

for example, how to spend resources, what coverage to provide, to

whom to provide it, and how to improve the work life of the provider.

Policy implications related to one or two aims may be seen as

strategic, but the third may not be viewed by stakeholders as being in

the public’s best interest, and the fourth aim as beyond the scope of

health care. For example, a congestive heart failure patient may

receive quality inpatient care resulting in improved health on

discharge; but repeated, long‐term readmissions of this insured

individual are not perceived as cost‐effective by the insurer and

frustrating to the provider.

Berwick et al6(p761) refer to “a tragedy of the commons,” which is a

conflict between common healthcare interests of the individual and the

community. These authors theorize that the Quadruple Aim may only

F IGURE 1 The Triple Aim2 [Color figure can be viewed atwileyonlinelibrary.com]

F IGURE 2 The Quadruple Aim

BACHYNSKY | 55

be achieved by considering the policy implication of overriding common

self‐interests of both groups. Promising innovations, such as medical

homes, retail clinics, telehealth, and medical tourism, have been

developed that challenge traditional healthcare models.

Tools are being developed for measuring healthcare quality,

based upon the Quadruple Aim. The policy implications of measuring

costs and health status are more of a challenge, for knowledge of

actual costs is required from a system that typically hides them. But

gathering of both types of data is facilitated with system‐wide

electronic medical records.6(p761‐762)

3.1 | Preconditions of the quadruple aim

Policy in pursuit of the Quadruple Aim is the exception in

the American healthcare system. To pursue the Quadruple

Box 1 The SBAR Tool*

Situation

Background

Assessment

Recommendation

*Adapted from http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

Box 2 Healthy People 2020: Leading Health Priority Topics and Indicators*

1. Increase the proportion of persons with healthcare insurance and a usual primary care provider.

2. Increase the proportion of persons receiving clinical preventative services, such as routine disease screenings (e.g., colorectal

cancer, hypertension, and diabetes) and immunizations.

3. Improve environmental quality to decrease illness caused by poor air and water quality and specifically decrease children’s

exposure to secondhand smoke.

4. Prevent unintentional injury and violence that that causes negative physical and emotional consequences for the victim and

others impacted by the incidents.

5. Improve maternal, infant, and child health by decreasing the number of preterm births and infant deaths during the first year of

life.

6. Address mental health by reducing the suicide rate and reducing the proportion of adolescents (12‐17 years old) who experience

major depressive episodes.

7. Improve nutrition and physical activity and decrease obesity in adults, children, and adolescents by increasing the number of

adults that meet physical activity guidelines and increase the proportion of children and adults that consume the adequate

amount of vegetables.

8. Improve oral health by increasing the proportion of children, adolescents, and adults who use the oral healthcare system within

the past year.

9. Address sexual and reproductive health by increasing the proportion of 15‐ to 44‐year‐old sexually experienced females receiving

reproductive health services within the past year and increasing the proportion of persons with HIV that are aware of their

serostatus.

10. Address social determinants (personal, social, economic, and environmental factors) that impact health, specifically increasing the

proportion of students that graduate with a regular diploma four years after starting the ninth grade.

11. Decrease the rate of substance abuse by decreasing the proportion of adolescents using alcohol or illicit drugs during the past 30

days and decreasing the proportion of adults engaging in binge drinking during the past 30 days.

12. Address the use of tobacco by reducing cigarette smoking in adults and reducing the use of cigarettes by adolescents during the

past month.

*Adapted from U.S. Department of Health and Human Services.3 Leading health indicators. Retrieved from http://www.healthypeople.gov/

2020/Leading‐Health‐Indicators

56 | BACHYNSKY

Aim, consideration of the following policy implications are

necessary:

1. the population must be recognized as the point of concern;

2. policy constraints must be overcome; and,

3. an integrator, the key facilitator to services in all four aims, must

exist.

3.1.1 | The population and policy constraints

The first policy implication is to specify a population that is a point of

concern. In this instance, population is defined as persons enrolled in

a registry that will track the Quadruple Aims over time, that is, access

to care, health status, and costs of care. The second policy implication

is policy constraints, which occur within the processes of decision‐making, politics, and social contracting of the population involved,

that is, implementation of, access to, and cost of health care under

the Patient Protection and Affordable Care Act of 2010.6(p762‐763)

3.1.2 | The integrator

The integrator function is the third policy implication, which is the

entity, often the insurer, responsible for all aspects of policy

development for the Quadruple Aim, especially for a specified

population. An effective integrator links healthcare organizations for

working as one system within the policy implications of overlapping

boundaries, providing coordinated care for a defined population. The

integrator is responsible for five basic functions in facilitating policy

development supporting the Quadruple Aim.

3.1.3 | Integrator function #1

First, the integrator is responsible for involving individuals and

families, to ensure the patient population is informed about the

policy implications of health status and the benefits and limitations of

individual healthcare policies and specific practices and procedures.

Integrators work with individuals and groups through policy

development designed for providing a plan of care, guiding patients

through acute care, and providing advocacy and interpretation within

the complex healthcare system.6(p763‐764)

3.1.4 | Integrator function #2

Second, integrators work for “redesign of primary care services and

structures,” to strengthen the infrastructure for primary care within

the population. Primary care providers are expanded, for example,

through the medical home. The expanded role of providers allows for

development of policy focused on the implications of long‐termrelationships between the patient and care team, shared care plans,

coordinated care, providing access to subspecialties, and innovative

scheduling and access to care facilitated by the electronic medical

record.6(p764)

3.1.5 | Integrator function #3

The third policy function of the integrator is “population health

management,” through policy development deploying resources or

specifying how resources will be deployed. Internet information may

assist segments of the population to identify options for treatment

and management through self‐care. Integrator facilitated policies also

analyze the implications of the value and resources necessary for

preventive self‐care management of high risk behaviors such as

smoking, violence, physical inactivity, poor nutrition, and other

unsafe healthcare practices.6(p764)

3.1.6 | Integrator function #4

The fourth function involves analysis of the policy implications of

financial management, thtat is, the integrator allocates payments and

resources supporting the Quadruple Aim. The first implication of

financial management is focused on policy implications of “…cost

control…defining, measuring, and making transparent the per capita

cost of care for a defined population.”6(p764) A second implication

would be to reduce and control costs and eliminate valueless

services. A third implication, and the most powerful, would be to

match supply and resources to underlying needs and to eliminate

unnecessary duplication of providers, equipment, and facilities. The

fourth implication and final component would be to “…cap total annual

spending, with strictly limited year‐on‐year growth targets.”6(p765)

3.1.7 | Integrator function #5

Fifth, the integrator’s policy implications must also focus on “system

integration at the macro level,” to produce individual and population‐based care and interventions that are evidence‐based. Providing the

best interventions and outcomes would imply access to state‐of‐the‐art knowledge; standardized definitions of, for example, quality and

cost; and trustworthy measurement of evidence.6(p765) In summary,

Porter and Teisberg8 indicated analysis of the policy implications of

health care would result in the best healthcare outcomes at the

lowest costs and would provide the greatest value within the

healthcare system.

3.2 | Precedents and possibilities

Stakeholders addressing the policy implications of the Quadruple

Aim include the following entities:

1. government‐sponsored or owned healthcare systems with legally

defined duties to a specific population, that is, Veteran’s

Administration Medical Centers;

2. classic staff and group‐model health maintenance organizations

(HMOs), that is, Kaiser Permanente; and,

3. other national and governmental healthcare systems with global

budgets, for example, National Health Service of the United

Kingdom.6(p765‐766)

BACHYNSKY | 57

HMOs were designed to act as integrators in pursuit of the

Quadruple Aim. However, the HMO model often cannot overcome

the policy implications of barriers to care, for example, choice of

providers or specialists. Because of these barriers, managed care

actually managed money, not health care. But encouraging signs for

virtual integrated care, via electronic support systems and instant

communication capabilities, have emerged within HMOs.6(p766‐767)

Progress toward the goal of integrated care within the Quadruple

Aim depends upon the following policy implications:

1. political action and policy essentially focused on budget caps on

spending for specific populations;

2. measurement and fixed accountability for health status and needs

of specific populations;

3. improved, standardized measures of care, and per capita costs;

4. changes in payment models so that financial gains from cost

reduction are shared between those who pay and those who

invest; and,

5. evolving professional education accreditation, ensuring capable

and improving care processes and skills.6(p767‐768)

4 | INTERPROFESSIONAL HEALTHCAREDELIVERY

Interprofessional education is a key implication or consideration for

development of policies designed to resolve the complex problems of

the healthcare system. Patients often require care from multiple

health professionals, especially when managing a chronic condition

and the disjointed healthcare system of the past has been

detrimental at best. In 1999, the Institute of Medicine (IOM, now

the National Academy of Medicine) published the well‐known study,

To Err Is Human, which revealed the devastating number of

healthcare errors that harmed or killed patients. This study pointed

to the fragmented nature of healthcare delivery, especially in

instances where patients see multiple providers in different settings

that do not have access to complete information.9 When systems are

in place that do not safeguard patients from preventable healthcare

errors, patients, and families are harmed and may lose faith in the

healthcare community. By contrast, employing processes that

facilitate open and thorough communication between and among

team members decreases the number of mistakes by individual

healthcare providers because the plan of care is transparent and

actively monitored by every healthcare professional caring for the

patient.

In To Err Is Human, the IOM concluded that the majority of

healthcare errors do not result from individual recklessness but

instead are caused by faulty systems, processes, and conditions

that lead people to make mistakes or fail to prevent them.9 The

policy implications of interprofessional care, where two or more

individuals from different professions work together, has been

emphasized in health care since the IOM report. The primary

goal of interprofessional collaboration, improved quality of

healthcare delivery, is at the forefront of interprofessional policy

implications.10

The policy implications of the APRNs role in interprofessional

healthcare delivery, serve as the “connector” for the other profes-

sionals who comprise the healthcare team. In The Future of Nursing:

Leading Change, Advancing Health, nurses are called to collaborate

with other healthcare professionals, such as physicians, physical and

occupational therapists, social workers, and pharmacists to provide

quality care to patients with complex conditions.11 Policy promoting

the best interprofessional collaboration outcomes provides opportu-

nities for optimal use of the skills and knowledge of all health

professionals working together as a team to deliver comprehensive,

integrated care over which the patient ultimately maintains

control.10

Despite the evidence‐based policy supporting interprofessional

collaboration and care, human factors often hinder effective

implementation of this practice. The attitudes of the team members

are a significant policy implication in the outcomes of the team. The

concept of “interprofessionality” takes the mindset of the individuals

into account as a key implication impacting the functionality of the

team. Interprofessionality impacts interprofessional collaboration and

occurs when healthcare professionals “reflect on and develop ways of

practicing that provide an integrated and cohesive" approach to

meeting the needs of patients and families.12(p9)

Interprofessional collaboration is difficult for healthcare profes-

sionals when open communication, transparency, and shared‐decision‐making are required. The paternalistic and hierarchical

system of the past was based upon the healthcare model in which

the physician diagnosed the patient, prescribed the treatment, and

evaluated the outcome, often without feedback from the other

members of the healthcare team or the patient. The policy

implications of interprofessional collaboration consider giving voice

to all team members and encouraging dialog based upon different

perspectives and viewpoints.

Following the IOM’s recommendation to implement interprofes-

sional care (IPC), healthcare systems transitioning to IPC had to

consider the policy implications embedded in barriers and resistance

arising from seasoned healthcare professionals. These policy implica-

tions encompassed the impracticalities in mandating team care for

healthcare professionals not trained in interprofessional collabora-

tion, that is, team working skills to foster communication and shared‐decision‐making. The IOM further anticipated the policy implications

and challenges in actually implementing IPC in existing healthcare

systems, addressing the importance of integrating interprofessional

collaboration within continuing education courses and the didactic

and clinical curriculums of healthcare profession students.

4.1 | Interprofessional education

Interprofessional education (IPE) is defined as “‘members (or students)

of two or more professions associated with health or social care, to

be engaged in learning with, from and about each other”’ (p12).13 IPE

provides students with structured learning experiences for working

58 | BACHYNSKY

with other health profession students. In the United States, academic

accrediting bodies for dentistry, medicine, nursing, occupational

therapy, pharmacy, physical therapy, physician assistant, psychology,

public health, and social work programs now require interprofes-

sional education.14 Some universities have also begun to prepare

students to incorporate the Triple and Quadruple Aims into their

initial practice, that is, including educational activities and case

studies involving designing a healthcare system focused on the policy

implications of the Aims.

Mahan and Clinchot15 analyzed the shift in healthcare education

and related policy implications:

to prepare graduates for the continued explosion of

healthcare knowledge, technological development, and

expanded patient and societal expectations that increas-

ingly characterize this century. The following five im-

portant developments in healthcare education drive these

re‐imaging and redesign efforts: (a) patient, societal and

governmental pressure to deliver on the Triple Aim;

(including the Quadruple Aim); (b) conceptualization of

healthcare education as a translational science; (c)

healthcare knowledge and technology (continuing) to

expand and accelerate the pace of new development; (d)

new expectations of present and future generations of

learners; and, (e) better understanding of the neurobiology

of learning (p137).

Ideally, students in health professions programs are exposed to

students in other associated professions throughout academic

preparation. Educational policy can be designed to facilitate clarifying

roles, breaking down stereotypes, and increasing mutual respect

between members of other professions. Student buy‐in and engage-

ment are key policy implications and foundations for accomplishing

these tasks.

Two significant challenges are making interprofessional educa-

tion a relevant policy implication, for example, future workplace

needs and developing IPE projects in which students are clinically

stimulated and engaged.16 IPE projects that incorporate the Triple

and Quadruple Aims as part of the required curriculum have the

potential to provide students with applicable evidence‐based knowl-

edge that can be carried forward into policy development after

graduation.

4.2 | Interprofessional collaboration

4.2.1 | Equity and social justice

The key implication for healthcare policy development is to provide

equity and social justice, two ethical concepts that embody the

desired outcomes of policy. The health of our nation depends heavily

on both access to and quality of care. However, views are often

divided when it comes to health equity and social justice in the

1990s, Margaret Whitehead, the leader of the World Health

Organization Collaborating Centre for Policy Research on the Social

Determinants of Health, said:

equity in health implies that ideally, everyone should have

a fair opportunity to attain their full health potential and,

more pragmatically, that no one should be disadvantaged

from achieving this potential if it can be avoided

(p.168).17

Whitehead went on to specify equity in health care “as equal

access to available care for equal need, equal utilization for equal

need, equal quality of care for all” (p.168).17

4.2.2 | Definition of equity

Health equity is another policy implication that drives the healthcare

community. APRNs play an integral role in the pursuit of health

equity, particularly by serving patients in areas where a lack of access

to care has contributed to low rates of preventive healthcare

measures in the past. APRNs who work toward achieving health

equity demonstrate patient advocacy, defined as:

pursuing health equity means striving for the highest

possible standard of health for all people and giving

special attention to the needs of those at greatest risk

of poor health, based on social conditions (p. 6).18

4.2.3 | Definition of social justice

Kelly Buettner‐Schmidt and Marie Lobo reviewed the literature and

established the following definition of social justice:

full participation in society and the balancing of benefits

and burdens by all citizens, resulting in equitable living

and just ordering of society. Its (policy implications)

included: (a) fairness; (b) equity in the distribution of

power, resources, and processes that affect the sufficiency

of the social determinants of health; (c) just institutions,

systems, structures, policies, and processes; (d) equity in

human development, rights, and sustainability; and (e)

sufficiency of well‐being.19(p948)

Since the days of Florence Nightingale, nurses have played a part

in social justice by striving to provide holistic, patient‐centered care.

From the acute‐care setting to the mission field, nurses often serve

as the voice of patients who are disadvantaged by factors that

prevent them from obtaining equitable care and achieving optimal

health. APRNs have the potential to address the policy implications

of social justice now more than ever before, by pursuing a full scope

of practice and empowering patients by making them partners in

their own health care.

BACHYNSKY | 59

APRNs serving on interprofessional teams have the opportunity

to engage team members in conversations addressing the policy

implications of processes that hinder best outcomes for patients. The

ability to look at the whole picture is of great value in establishing

attainable health goals, regardless of the patient’s societal status. As

advocates, APRNs make a sustained effort to raise the issue of the

injustices that impact vulnerable patients by exercising “their voice in

influencing the social and political trends that are shaping inequities”

and are implications for corrective policy development.20(p83)

4.2.4 | Safety and quality of care

Numerous studies have demonstrated that interprofessional care

increases safety and improves the quality of care for patients. Via

IPC, many professionals are involved in caring for each patient. The

following policy implications can serve as a guide for team members

to ensure the patient is receiving safe care from the appropriate

provider:

(a) [P]practitioners need to understand that they are part

of a diverse team; (b) practitioners must communicate

effectively with the patient and the family; (c) practi-

tioners need to know what other team members do to

limit duplication and prevent gaps in care; and (d)

practitioners need to know how to work together to

optimize care so that the patient journey from inpatient to

care to home care, or from primary care to the specialist

clinic is experienced as seamless.21

The open communication and active engagement required in

interprofessional care is a policy implication for all team members to

speak up to promote safety and improve the quality of care provided.

4.2.5 | TeamSTEPPS

A policy implication for developing functional teams and integrating

interprofessional care has been the use of established models such as

TeamSTEPPS. The TeamSTEPPS Model, that is, Team Strategies and

Tools to Enhance Performance and Patient Safety, was developed by

the Department of Defense’s Patient Safety Program in collaboration

with the Agency for Healthcare Research and Quality (AHRQ). The

policy implications for the use of TeamSTEPPS are that this model

provides a curriculum and resources to train healthcare professionals

to improve communication and teamwork skills.22 Although some

nurses may not have full awareness of the elements that comprise

the TeamSTEPPS model, most have been trained in at least one

aspect, the “SBAR” tool.

SBAR is often a policy implication for nurses and other healthcare

professionals to organize pertinent patient information and prevent

the inadvertent elimination of data or findings that need to be

shared. In addition to providing tools to improve the transfer of

information between healthcare professionals, TeamSTEPPS ad-

dresses policy implications for providing training on establishing

mutual trust, resolving conflict, and debriefing to improve patient

safety and quality of care.22 When healthcare systems promote

teams that function as one unit, communication, care‐coordination,and shared‐decision are policy implications for improving processes

and patient outcomes.23 A great policy implication for TeamSTEPPS

exists in establishing a culture where team‐based, interprofessionalhealthcare delivery is the expected standard of care. Through policy

promoting TeamSTEPPS, nurses and APRNs are empowered to

advocate for safe, patient‐centered care on interprofessional teams.

4.2.6 | Cultural sensitivity

Each healthcare profession has its own culture, which includes

values, beliefs, attitudes, behaviors, and customs that are passed on

to novices through educational policy directing initial clinical

practice.24 Although members of the different health professions

have always worked in common environments, artificial boundaries

often prevented sharing opinions and information between and

among the professions. Before the concept of interprofessional care

emerged, healthcare professionals often fell into the practice of

“working in silos,” which led to a fragmented approach to care. The

silo‐based policy was detrimental not only to patients but also to the

individual healthcare professional, as the lack of communication

often led to resentment or assumptions based on stereotypical views

of the other professions. Fortunately, recent educational policy

implications incorporate interprofessional education in preparatory

curricula exposing health professions students to cultural norms and

stereotypes that promote team communication. New healthcare

providers will likely have participated in interprofessional activities

with policy implications that encouraged active dialog about

healthcare issues.

On the other hand, professional cultures and their policies may

be a significant barrier for seasoned professionals, including nurses

and physicians, who are expected to participate in new models of

interprofessional practice. Novice members of the healthcare team

should be sensitive to the cultural differences between and among

professions (including generational differences) and work toward

achieving an interprofessional team that employs the diverse abilities

of each member. The most successful interprofessional teams will

exhibit a blending of professional cultures whose policy implications

involve sharing information, skills, and knowledge to improve the

quality of patient care.25 This type of interprofessional interaction

will build on the most valuable aspects of each profession with policy

implications for achieving a holistic approach to even the most

complex healthcare issues.

5 | HEALTHCARE PRIORITIES: HEALTHYPEOPLE 2020

Healthy People 2020 is comprised 42 topics, with policy implications

addressing over 1200 objectives for improving the health of

Americans.26 Although all of the topics are significant, the “Leading

60 | BACHYNSKY

Health Indicators” assist healthcare providers to focus on high‐priority health issues. The list of Leading Health Indicators was

developed with recommendations based on evidence provided by the

IOM, the National Academy of Sciences, and the Secretary’s Advisory

Committee on National Health Promotion and Disease Prevention

Objectives for 2020 and aligned with the National Prevention

Strategy which is mandated by the PPACA.3 The list of Leading

Health Indicators is typically updated every 10 years.

APRNs are well‐prepared to address the related policy implica-

tions of providing primary care through independent practice and on

interprofessional teams. The Nurse Practitioner Core Competencies,

which guide academic programs for nurse practitioners, identify

policy implications for APRNs competent in providing screening and

diagnostic strategies; coaching the patient and caregiver for positive

behavioral change; providing a full spectrum of services including

health promotion, disease prevention, health protection, anticipatory

guidance, counseling, disease management, and palliative care.27

APRNs are especially adept at addressing the policy implications of

partnering with patients to set health goals inclusive of environ-

mental, social, and spiritual aspects.

5.1 | Health disparities

Policymakers in the United States recognize that the term “health

disparities” indicates worse health among socially disadvantaged

people, particularly members of certain racial groups and economic-

ally disadvantaged people within any racial group.18 In 2010, it

became evident that more specific definitions were necessary to

adequately address the social issues that serve as barriers to

promoting health and improving outcomes. Healthy People 2020

defined a health disparity as:

a particular type of health difference that is closely linked

with economic, social, or environmental disadvantage.

Health disparities adversely affect groups of people who

have systematically experienced greater social or econom-

ic obstacles to health based on their racial or ethnic group,

religion, socioeconomic status, gender, age, or mental

health; cognitive, sensory, or physical disability; sexual

orientation or gender identity; geographic location; or

other characteristics historically linked to discrimination

or exclusion.3

Innovative programs utilize APRNs to provide care that is

accessible to patients despite policy implications that might prevent

them from seeking primary health care, screening, or treatment for

chronic conditions. These healthcare programs are critical as

continued wide‐spread disparities will lead to a perpetuation of poor

health indicators in the United States despite higher cost expendi-

tures when compared with other developed countries.4 Creating

services appropriately managed by RNs is based upon policy

implications expanding access to care.

5.2 | Vulnerable populations

Many healthcare programs and initiatives focus on “vulnerable

populations.” Vulnerable populations include:

the economically disadvantaged, racial and ethnic mino-

rities, the uninsured, low‐income children, the elderly, the

homeless, those with human immunodeficiency virus

(HIV), and those with other chronic health conditions,

including severe mental illness, and rural residents, who

often encounter barriers to accessing healthcare services

(p. S348).28

Unfortunately, policy implications often complicate matters even

more as poverty and inadequate education prevent these individuals

from advocating for themselves to achieve optimal health. As this

population often has multiple healthcare needs, an interprofessional

team approach works best. For example, the Boston Health Care for

the Homeless Program engages nurse practitioners, physicians,

dentists, mental health specialists, and social workers to provide

integrated care to over 12 000 homeless people each year.29 These

policy implications improve health for the population and prevent

unnecessary hospitalizations for manageable symptoms of chronic

illnesses.

6 | HEALTHCARE FINANCING ANDREIMBURSEMENT

6.1 | Reforming Medicare

Medicare is a health insurance program for Americans age 65 and

above, for people under age 65 with certain disabilities that qualify

for Social Security benefits, and for people with End‐Stage Renal

Disease of any age. Medicare is comprised Part A (ie, coverage for

hospital care that is usually premium‐free because the person or

spouse has already paid for it through payroll taxation), Part B (ie,

coverage for healthcare care such as outpatient visits, paid by a

monthly premium), and Prescription Drug Coverage (usually paid by a

monthly premium).30 Medicare‐eligible participants may also choose

Part C, or Medicare Advantage, which is optional but provides

additional benefits through managed healthcare plans. Since 2004,

the number of enrollees in Medicare Advantage has increased even

though this program requires fees in addition to Part B premiums.4

The PPACA31 included changes to Medicare that were designed

to increase visits for preventive healthcare and screenings. Policy

implications of two of the dimensions of the Triple and Quadruple

Aims, improving the health of populations and reducing the per

capita cost of healthcare, are heavily impacted by the aging

population. The IHI described increased longevity and chronic health

problems as a challenge that is placing new demands on healthcare

and social services.2

APRNs are well‐positioned to provide care to patients who are

covered by Medicare, but policy implications must address significant

BACHYNSKY | 61

barriers to reimbursement for services. Some states do not recognize

APRNs as primary care providers in health plan networks, that is, a

physician must be listed as the primary care provider. In such cases,

the APRN will only be reimbursed if delivering “incidental care”

strictly supervised by a physician on site in accordance with the

physician’s treatment plan.32

Medicare policy implications also result in restriction of APRNs

from ordering home healthcare or durable healthcare equipment for

patients, even if designated as the primary care provider.32 Of the

population 65 years or older, 90% have at least one chronic disease,

and APRNs are essential in managing these diseases through holistic,

team‐based care to optimize health.33 As Medicare reform continues,

APRNs will remain diligent in voicing the need for promoting policy

implications enabling the practice to the full scope required to

address the needs of aging patients and those with chronic illnesses.

6.2 | Healthcare reimbursement

The PPACA31 also brought forth new policy implications for

rewarding healthcare systems for meeting certain performance

standards. For example, hospitals are scored based on the “Hospital

Value‐Based Purchasing” program criteria, and value‐based incentive

payments are made when a hospital meets or exceeds the

performance standards established with respect to designated

measures.34 Nurse leaders are instrumental in addressing these

policy implications. Policy implications for the patient’s complete care

require measurement by outcomes and cost, which often includes

services provided by a multidisciplinary team.35

New policy models that focus on value are being implemented in

hospital and community settings. For example, MD Anderson Head

and Neck Center utilizes a process map in patient care planning.

Process maps are beneficial as a way to identify policy implications

and “the resources required for each activity and often reveal

immediate opportunities for process improvement and cost reduc-

tion.”35 Healthcare systems will continue to address policy implica-

tions by measuring the value of care, and APRNs must be ready to

provide information that emphasizes how APRN care is essential and

cost‐effective.

7 | NURSING LEADERSHIP ININTERPROFESSIONAL HEALTH CARE

Nurses are an integral part of organizing and aligning policy and

teams to effectively meet the healthcare needs of patients.

Innovative policies and programs that foster active interprofessional

collaboration are being developed across the United States. One such

program, Healy‐Murphy Wellness Center, is located within an

alternative high school in San Antonio, Texas, where 50% of the

students are pregnant or parenting. This innovative program is

facilitated by an interprofessional team comprised pediatric nurse

practitioners, dieticians, and certified diabetes educators36 and

meets the Triple Aim Objectives (and three of the four aims of the

Quadruple Aim) while providing care that is focused on the health

priorities and policy implications outlined in the National Prevention

Strategy. Nurses in leadership roles must be forthcoming with

information‐sharing, as they continue to be challenged to design and

implement pioneering programs to improve health and manage

chronic diseases with a holistic approach. Successful policy models

can and should be replicated to address the implications for

expanding nurse‐led initiatives.

8 | FILTERS AFFECTING POLICYIMPLICATIONS IN INTERPROFESSIONALEDUCATION

8.1 | Ethical filters

Nursing, often called the most‐trusted profession, is grounded in the

belief that the patient’s best interest guides the care provided.

Clinical practice exposes APRNs to ethical issues that require

thoughtful consideration. The evolving structure of interprofessional

healthcare teams may present instances where the APRN’s decisions

are questioned or criticized, and the APRN will be required to have

the “knowledge and skills to avoid power struggles, broker, and lead

interdisciplinary communication and facilitate consensus among team

members in ethically difficult situations.”33

Ethical decision‐making is such an important skill for APRNs that

it is included in the core competencies outlined by the National

Organization of Nurse Practitioner Faculties.27 Nurses and APRNs

must be aware of ethical guidelines and available resources, such as

ethics committees, that will offer support in solving ethical dilemmas.

8.2 | Critical communication filters

Communication is the central tenet of nurses’ effectiveness in patient

care and interprofessional collaboration. It is necessary to carefully

consider how verbal, non‐verbal, and written communication are

interpreted by patients and healthcare team members. In the past,

healthcare professionals were academically prepared to work with

individuals within their professions, often using vocabulary and

acronyms not familiar to the other professions. In addition,

healthcare professionals were trained to use different approaches

to problem‐solving and lacked an understanding of the values, role,

and scope of practice of members of other professions.24 Advanced

communication skills likely contribute to the success of APRNs and

executive leaders through coaching patients and collaborating with

colleagues from nursing and other professions.33 Engaging in

transparent communication, where the views of the patient and

other team members are valued, fosters collaborative processes that

will eventually benefit everyone involved.

8.3 | Effective collaboration filters

When interprofessional healthcare teams possess mutual trust and

employ shared‐decision‐making strategies, team members, patients,

62 | BACHYNSKY

families, and communities benefit. It takes time to establish the trust

that leads to effective collaboration, and there are wide ranges of

human dynamics that need to be developed within a team.

“Collaboration needs to be understood not only as a professional

endeavor but also as a human process.”12 Team members must see

collaboration as beneficial to establish the buy‐in that is necessary to

be actively engaged on an interprofessional team.

RNs and APRNs possess the knowledge, skills, and fortitude to

advance both the Triple and Quadruple Aim Goals, through

participation on interprofessional healthcare teams. Structural

changes in the health delivery system have positioned APRNs to

function in a manner that will reduce disparities and address health

issues that are common among vulnerable populations. Although the

policy implications must be considered to facilitate comprehensive

health care, APRNs have irrevocably demonstrated their capacity to

lead patients to health and wellness.

8.4 | Conflict filters

In recent years, a shift has occurred to a more holistic focus on health and

wellness. This is in contrast to the healthcare model which “defines health

as the absence of illness or disease (implying) that optimum health exists

when a person is free of symptoms and does not require healthcare

treatment,”4 excluding preventive health measures.

Another issue that has the potential to cause substantial conflict

is the autonomy that nursing has achieved. Clearly, nurses (especially

APRNs) have evolved as independent healthcare professionals in

recent years. The expanded role of APRNs, which includes diagnosing

healthcare conditions, prescribing medications, and performing

traditionally healthcare procedures, openly challenges the authority

and boundaries of medicine.37

Within interprofessional healthcare collaboration, the hierarchies

are flattened; and all healthcare providers must be willing to

collectively problem‐solve and share decision‐making with the other

team members and the patient.21 The implementation of this type of

collaboration takes time to implement and strategizing to achieve

buy‐in from key players and stakeholders. This new paradigm

challenges/health care/delivery in the Unites States, as most

“healthcare professionals have traditionally been socialized to have

the answers themselves,”21(p23), and interprofessional care can

cause uneasiness.

The increased proportion of patients with healthcare insurance is

increasing the demand for APRNs, which could also give rise to

resentment from other health professions that are not receiving as

much encouragement to fill the healthcare‐provider gap. To resolve

these interpersonal conflicts, open communication, and trust must

be established.

9 | SUMMARY

Healthcare delivery in the Unites States is changing at a rapid pace.

The Patient Protection and Affordable Care Act31 was intended to

provide policy implications that expand access to care and ultimately

improve the health of Americans. The Triple Aim, created by The

Institute for Healthcare Improvement, delineates a structure for

improving population health and the healthcare experience and

reducing per capita cost.2 The Quadruple Aim adds an element

designed to focus on policy implications of meeting the needs of the

healthcare provider. Advanced Practice Registered Nurses (APRNs)

are key in carrying out the goals of the Affordable Care Act, Triple

Aim, and Quadruple Aim, especially when actively engaged within

interprofessional teams. This chapter offers insight into the implica-

tions of interprofessional nursing and APRN leadership and outlines

filters affecting implications for nursing policy.

ORCID

Natalie Bachynsky http://orcid.org/0000-0001-9577-6335

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AUTHOR BIOGRAPHY

Natalie Bachynsky received her PhD in Nursing Science and

post‐masters Family Nurse Practitioner certificate from Texas

Woman's University (TWU) in Houston, TX. She received her

Bachelor of Nursing Science and Master of Nursing Education

from the University of Texas Medical Branch (UTMB) School of

Nursing in Galveston, TX. Dr. Bachynsky was a faculty member at

UTMB School of Nursing for many years before returning to full‐time practice in rural East Texas. While at UTMB, Dr. Bachynsky

developed several “service‐learning” projects where health

professions students provided free medical services to vulnerable

populations, such as the federally‐funded "Interprofessional

Pediatric Advocacy Program" through which nursing, medical

and allied health students provided collaborative home health

care to medically‐fragile children being monitored by Child

Protective Services from 2012‐2015. Dr. Bachynsky's research

interests include interprofessional care and health promotion for

vulnerable populations.

How to cite this article: Bachynsky N. Implications for policy:

The triple aim, quadruple aim, and interprofessional

collaboration. Nurs Forum. 2020;55:54‐64.https://doi.org/10.1111/nuf.12382

64 | BACHYNSKY

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