Hospitals successfully target the ‘triple aim’: quality, cost, and population health

In a study released by the American Hospital Association (AHA), investigators found that hospitals have made significant progress toward the “triple aims” for the improvement of health care in the United States: better care, better health, and lower costs. The study, submitted to the AHA by the Severyn Group, found that hospitals have made the greatest contribution in the area of patient safety, particularly the reduction of health care acquired conditions (HACs).

Three related goals

The triple aim was initially announced by the Institute for Health Care Improvement (IHCI) in 2007 and has been adopted by CMS, the AHA, and other organizations. CMS’ funding of the Partnership for Patients grants has been an important source of support, providing $218 million to 26 hospital engagement networks (HENs).

Reducing HACs

The AHA, CMS and other organizations, including the state of New York and Dignity Health, set goals to reduce several common risks that patients face during an episode of care, particularly inpatient care, including: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), adverse drug events (ADE),and ventilator-associated pneumonia (VAP). The study examined efforts by three HENs to reduce the incidence of specific HACs and “harm across the board,” an overall measure of HACs.


CLABSIs can arise when hospitals use central lines to deliver medication and other treatment to patients through a central vein leading to the heart, a practice often used in intensive care units (ICUs). The AHA’s Health Research and Educational Trust (HRET) worked with more than 1,500 hospitals in 44 states to implement specific measures to reduce CLABSIs. The Agency for Healthcare Research and Quality (AHRQ) supported a study of a comprehensive unit-wide safety program (CUSP), in which participants implemented five measures known to reduce the risk of infection: removing unnecessary central lines, washing the hands before inserting central lines, using maximum barrier precautions, cleaning the skin with chlorhexidine, and avoiding the femoral site.

The participating ICUs focused on implementing the five interventions over an 18-month period and reduced the incidence of CLABSIs by 40 percent, or 2,000 fewer CLABSIs per year. These results translate to 500 fewer deaths and $34 million in expenses avoided each year. Other HENs have implemented the same interventions since 2010, so that the national incidence of CLABSIs dropped by nearly half (49 percent), preventing more than 1,600 deaths and saving nearly $150 million.

Other infections

HENs have implemented similar measures to address CAUTIs, SSIs, and VAP with similar results. Hand washing and use of sterile technique have been important interventions to reduce all of these conditions.

Early elective deliveries

The American College of Obstetricians and Gynecologists (ACOG) opposes the practice of scheduling the induction of labor, which many physicians were doing frequently after 37 weeks gestation even if there were no medical issues requiring induction. The practice increases the risk of complications for both mother and baby. Hospitals began to use protocols under which induction of labor before 39 weeks was limited to specific medical issues. In one practice, physicians who violated the policy received warning letters, and after three warning letters, were required to appear before the board. Elective deliveries dropped dramatically.

Adverse drug events

HENs and hospitals implemented medication reconciliation, a procedure whereby practitioners from multiple disciplines, including physicians and pharmacists, review all the medications a patient was taking before admission to the hospital as well as those prescribed during the stay to prevent adverse reactions and avoidable side effects from combinations of drugs. Including a comprehensive list of medications in the physician’s discharge order was also helpful to reduce problems caused by miscommunication when patients leave the hospital for a nursing facility.

Comprehensive approaches

Some hospitals and HENs have directed their efforts to reduction of patient harm as a whole rather than focusing on one condition. These efforts also have significantly reduced the incidence of avoidable patient harm. The use of a “harm across the board” measure and regular feedback to hospitals led the AHA HRET HEN to report the prevention of more than 110,000 readmissions, 19,000 induced deliveries, and 8,500 HACs among its 1,500 hospitals over a 28-month period. In addition, they reduced pressure ulcers by 26 percent and saved an estimated $1.3 billion in avoidable costs. These programs help hospitals avoid penalties for excess readmissions under section 3025 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

The report also examined adherence to evidence-based practices for the treatment of particular conditions. The investigators noted that hospitals accredited by the Joint Commission significantly improved their application of evidence-based practices between 2002 and 2013. In 2002, about 82 percent of hospitals were found to adhere to 15 evidence-based practices. In contrast, in 2013, hospitals complied with 44 measures at 98 percent of the opportunities to do so.

Lower cost, healthier population

Other than the savings that were achieved by implementation of the safety and quality measures, the study did not present much data on cost reduction. However, the investigators noted that the rate of growth of health care expenditures dropped significantly in recent years.

Because many factors outside the control of hospitals affect the general health of a population, there was little data from which to measure the effects. Nevertheless, sec. 9007 of the ACA requires hospitals with charitable tax exemptions to perform assessments of the health care needs of their communities. Some hospitals introduced health education and exercise classes.