Examining the Outpatient Wound Care Nurse’s Influence on the ‘Triple Aim’ Initiative

As quality assurance becomes more ingrained in today’s healthcare, a better understanding of outcomes measurement is needed to improve that care and lower overall costs.

With the continued increased attention to quality performance in healthcare, both from a clinical and financial perspective, practicing clinicians have likewise become more expected to possess specialized knowledge of their specific patient populations, more skillful in their application of best-evidence modalities as a means of improving outcomes and satisfaction scores, and more committed to providing care based upon standardized measures that meet national benchmarks as well as institutional policies that ensure patient and staff safety.

These responsibilities are certainly paramount in the wound care industry, which features a patient population that continues to live longer with difficult-to-heal chronic wounds that stem from serious comorbid conditions. In many of today’s inpatient units and outpatient clinics, the wound care nurse’s role has brought with it heightened expectations and responsibilities consistent with the changing culture of healthcare delivery. This article will discuss the evolving role of the nurse in outpatient wound clinics through the lens of the Institute for Healthcare Improvement’s (IHI’s) Triple Aim. 

Defining the “Triple Aim”

The term “Triple Aim” refers to a simultaneous pursuit of: 1) improving the patient experience of care, 2) improving the health of populations, and 3) reducing the per capita cost of healthcare. Note that the Triple Aim is a single idea with three dimensions. The framework for the Triple Aim was developed in 2007 by the IHI through a series of 90-day research-and-development projects. Although the IHI was founded in 1991, the roots of the organization are traced back to the late 1980s as part of the National Demonstration Project on Quality Improvement in Health Care. Dr. Don Berwick led a visionary group committed to redesigning healthcare into a system without errors, waste, delay, and unsustainable costs. Initially supported by a collection of grant-funded programs, the IHI is now a self-sustaining organization and collaborates globally. While the idea of achieving the goals of the Triple Aim simultaneously was once considered to be somewhat radical, in 2016 the concepts have become more mainstream in the healthcare lexicon. For instance, a recent online search of the term “Triple Aim” brought about some 46,400,000 results. However, the terms associated with the Triple Aim and its framework are often misused.¹ (Note that IHI officials prefer the term “framework” as opposed to “model” or “concept” because it’s considered to be more structured and more incorporating of the concepts of the Triple Aim as well as the resulting visual model developed by the IHI (see Figure 1). Thus, all involved, from individuals to the broad healthcare organizations/systems, are expected to use the framework to implement desired goals. 

For example, some initiatives undertaken by healthcare organizations in an attempt to emulate the Triple Aim have focused primarily on patient satisfaction, rather than the intended scope of the patient experience as defined by the Institute of Medicine’s six dimensions (safe, effective, patient-centered, timely, efficient, equitable). Additionally, some modifications omit the concept of population health altogether, focusing instead on quality, satisfaction, and costs (often in acute care settings). The Triple Aim is not intended to be realized by healthcare systems acting alone, nor by solely delivering high-quality care at lower costs. Improving health is a challenge that requires the engagement of partners across the community to address the broader determinants of health.¹ Additionally, some modifications made in the spirit of the Triple Aim tend to focus solely on reducing growth in healthcare costs when the goal should be to reduce costs per capita. Simply slowing unsustainable growth in costs is not good enough; the healthcare industry must find ways to reduce per capita costs and allow society to use these resources in other ways.¹

Awareness of the IHI’s Triple Aim is intended to provide registered nurses (RNs) and other clinicians who are practicing across the healthcare continuum with the knowledge of a national strategy being utilized to guide changes in healthcare while optimizing health system performance. A set of five healthcare system components, for which the goals of the Triple Aim are intended to assist, has also been established:

• individual patients and their families,
• redesign of primary care services and structures,
• prevention and health promotion,
• cost control, and
• system integration.

The Nurse's Role 

In general, the RN has the opportunity to influence all components of the Triple Aim by the very nature of his/her role — that being the responsibility for the care of patients and their families while assisting in education related to self-management, preventative measures, and promotion of overall health. As a member of the interprofessional healthcare team, the RN is also often tasked with finding ways to increase clinical efficiency and maintaining quality within the healthcare setting. The RN role is also often one in which the nurse educates colleagues on care practices and prevention along the continuum as a means of decreasing hospital admissions and readmissions, and thus costs to patients and facilities. The experienced wound care RN will likely also have the opportunity or responsibility to educate colleagues on best practices and evidence-based research as a means of providing standardized quality care.

As the patient advocate and coordinator of care in many clinical settings, the RN often has the opportunity to insure the success of each aspect of the Triple Aim. “How much” influence the nurse may have directly relates to the area in which the RN practices, for example, an outpatient wound care clinic.

By following the steps of the nursing process,² the RN has the distinct advantage of being able to incorporate the goals of the Triple Aim and its corresponding components into decision-making. The challenge for the RN is to determine a standardized method and timing of obtaining current evidence. Consider the following examples of how Triple Aim goals can be attained through the framework of the nursing process:

Assessment: While performing the standardized wound care assessment, the RN modifies the assessment to include questions specific to the patient’s age, for example, as it relates to nutrition and dietary considerations.³ 

Diagnosis: Upon admission, the RN notes the intact skin over several bony prominences is reddened and nonblanchable. The RN documents these areas as pressure ulcer stage I,⁴ thus providing the basis for a nutritional consult and nursing skills such as turning a minimum of every two hours (regardless of the patient’s physical location), etc. 

Outcomes/Planning: In designing the care plan for the patient, the RN contributes to the Triple Aim by taking into consideration what has previously worked for the individual, evidence-based care planning for the population the individual is in, and knowledge of available resources for the individual patient. The RN’s partnering role with the physician in determining the rationale for choosing an approach to care versus another is also a benefit. 

Implementation: The implementation of a care plan relates to the Triple Aim as the RN works with the patient to insure adherence to an established regimen. This includes having knowledge of the patient’s current level of health literacy. One way to insure the patient will be able to perform the required skills at home to remain healthy and foster prevention, such as dressing changes, is to require return demonstration during clinic visits (ie, adherence⁵). In doing so, the number of calls/visits to the clinic may decrease, thus decreasing overall costs and improving results related to quality assurance. 

Evaluation: It’s incumbent upon the RN in any practice setting to educate himself/herself on documentation requirements from a national perspective. As more electronic health records (EHRs) are linked to each other and “big data” is generated, the evidence collected drives the health of the patient population living with chronic wounds. In the specific outpatient setting, the wound clinic program manager will be responsible for insuring the staff RNs are knowledgeable of the data generated from standardized assessments. For example, based on the data generated from the EHR, does the prognosis of patients who are living with chronic, nonhealing wounds who also smoke demonstrate the need for additional nutritional counseling?⁶

Conclusion 

The daily work of the RN is inherently focused on implementing the Triple Aim framework by providing care to a specific patient population (those requiring the expertise of a trained wound care clinician), improving the patient experience (by educating patients at their level of health literacy), and working toward reducing cost (by insuring patients are capable of caring for themselves between visits by requiring return demonstration of a procedure). It is the RN working in conjunction with physicians and the interprofessional healthcare team that insures the patient receives organized care for wounds along the continuum. 

M. Anne Longo is a registered nurse licensed in Ohio and is the former senior director of the center for professional excellence/education at Cincinnati Children’s Hospital Medical Center. She is one of three authors of the Sigma Theta Tau International book, Staff Educator’s Guide to Professional Development: Assessing and Enhancing Nurse Competency.

References 

1. Case J. A Primer on Defining the Triple Aim. Institute for Healthcare Improvement. Accessed online: www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=63

2. The Nursing Process. American Nurses Association. Accessed online: www.nursingworld.org/especiallyforyou/studentnurses/thenursingprocess.aspx

3. Friedrich L, Collins N. Nutrition & wound healing in the older adult: considerations for wound clinics. TWC. 2013;7(9):20-30.

4. Bergquist-Beringer S, Davidson J. Pressure Ulcer Training. National Database of Nursing Quality Indicators. Press Ganey. 2016. Accessed online: https://members.nursingquality.org/ndnqipressureulcertraining/default.aspx

5. Hurlow J, Hensley L. Achieving patient adherence in the wound care clinic. TWC. 2015;9(9):14-32.

6. Schaum K. Business briefs: smoking cessation counseling: coding, payment, & coverage. TWC. 2016;10(5)8-11.