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Reaching for the Quadruple Aim – How to design effective whole system health service improvement?


Gro Karine Rosvold Berntsen

Norwegian center for ehealthresearch, NO
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In this workshop we will present ideas and discuss how to make health service improvements that reach for the Quadruple Aim.


Despite large efforts and many studies, the research community still does not understand how to reach Berwick's and Bodenheimer’s quadruple aims for care (better patient experience, health and function, cost-benefit ratio and professional experience), with any degree of predictability (1). In a recent review on this topic, we found that interventions tend to reflect a reductionist paradigm, which forces care workers into standardized and narrowly focused interventions also for complex problems (2). There was a lack of studies that build on theoretical models for health care, complexity theory and change management set in complex adaptive systems.

We, the authors, build on decades of experience in large scale care transformation processes in health care. We have combined technical and social work practice innovation. Our efforts include close collaboration with patient partners, front line health professionals, decision makers and e-health service providers.

Our current working hypothesis is that complex health service improvements will yield predictable outcomes, when researchers 1) fully understand the nature of synergistic digitally supported, person-centered, integrated and proactive care 2) tailor interventions to local strengths and weaknesses, 3) add a continuous formative evaluation which is fed back into the process, and 4) include all the areas of the quadruple aim in the final summative evaluation.

Target audience:

Stakeholders of health service improvement like patients, practitioners, researcher and others interested in diving into the complexity of health service improvement.

 Take away:

Insights into the structuring and practical implementation of health service improvements towards the quadruple aim.

Format 90 min workshop:

30 min: Berntsen GKR: A brief overview of the literature of studies reaching for the Quadruple Aim, with emphasis on :

•              The active ingredients: Digitally supported Person-centered, integrated and proactive care

•              The design of the implementation process in a local context

•              The possible role of evaluation in change management.

30 min: Cafe dialogue in breakout sessions

Each group will discuss all the questions below. However, the four groups will start with “their” question, and then move on to the other questions in the session.

•              Host: Gro Berntsen: What do the active ingredients person-centered, integrated and proactive care really mean?

•              Host: Aslak Steinsbekk and Anders Grimsmo- How do we design locally tailored implementation processes?

•              Host: Berglind Smaradottir and Espen Nordheim : What kind of digital tools are essential to support the active ingredients?

•              Host: Line Silsand and Gro Hilde Severinsen: What is the role of evaluation in innovation?

20 min summary , max 5 min from each group host on their primary topic

10 min plenary dialogue facilitated by Berntsen and Steinsbekk

1.            Bodenheimer T, Sinsky CJTAoFM. From triple to quadruple aim: care of the patient requires care of the provider. 2014;12(6):573-6.

2.            Berntsen GKR, Strisland F, Malm-Nicolaisen K, Smaradottir B, Fensli R, Røhne M. The evidence base for an ideal care pathway for frail and multi-morbid elderly: A combined scoping review and systematic intervention review.  J Med Internet Res. 2019.


How to Cite: Berntsen GKR. Reaching for the Quadruple Aim – How to design effective whole system health service improvement?. International Journal of Integrated Care. 2021;21(S1):358. DOI:
Published on 01 Sep 2021.
Peer Reviewed


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