Evaluating Health Care Innovation with Triple Aim

The health care needs of Canadians are changing. Our population is aging, and rates of chronic and complex disease are on the rise. To tackle these challenges, health care leaders are exploring innovative solutions.

While many of these solutions are promising, they can’t be implemented haphazardly. The outcomes of new models of care and efficiency-enhancing technologies need to be tracked. To determine what works, evaluation should happen on a continuous basis.

But evaluation comes with its own challenges. Most health care initiatives have so many dimensions, it’s hard to create a comprehensive criteria.

The answer, in many cases, is to start with an overarching framework. Triple Aim – an approach pioneered by the American Institute for Healthcare Improvement – can provide a great starting point.

Why Evaluation is Important

In 2012, the Conference Board of Canada presented the Summit on Sustainable Health and Health Care. One of its major findings surprised many Canadians, and even some health care providers. To put it plainly, there’s little agreement on what we want most from our health care system.

Should providers be most focused on improving acute care? Should policymakers be most concerned with reducing wait times for medical appointments and procedures? Such questions are plagued by uncertainty. And that uncertainty can hinder our attempts to evaluate health care progress.

Measuring outcomes is important. But an increase in measurement doesn’t necessarily lead to better understanding. Decision makers and frontline workers aren’t always clear on the goals they’re working towards. How can they know when they’ve achieved them? What constitutes success?

When it comes to health care, Canadians are demanding greater accountability. That’s something that most sector leaders, providers, and frontline workers want, too.

Consider a provincial example. A 2012 report from Alberta’s auditor general found that the province’s Primary Care Networks were largely deficient. And one of the biggest problems identified was a failure to “define clear objectives, performance measures or targets.”

Who wants to be part of an initiative that isn’t serving patients as well it could be?

Evaluation can help. Once a government body commits to ongoing assessment, it’s forced to come up with a criteria for success. It’s forced to test its assumptions. And above all, it’s forced to identify areas in need of change.

Decision makers need to develop evaluative frameworks for all initiatives, complete with agreed-upon values and specific goals.

The Triple Aim Approach

Triple Aim is a framework developed by an American organization known as the Institute for Healthcare Improvement. It outlines three major goals that decision makers should use to optimize heath care performance.

• Improving the patient experience of care
• Improving the health of populations; and
Reducing the per capita cost of health care.

Many health care initiatives are successful at meeting one or two of these aims, to some degree. But in order for users to get the most from their health care dollars, projects must simultaneously succeed at all three.

Before we go any further, let’s address one major potential criticism of Triple Aim. The goals it sets forth are very broad. Can they actually lead to specific, beneficial action?
We believe the answer is yes.

Let’s not forget how much is required from most health care initiatives. When the list of desired outcomes is long, it can be hard to stay on track.

Starting with three key areas of focus – patient experience, population health, and cost containment – leads to more effective planning and implementation. Decision makers who are guided by Triple Aim’s overarching goals are more likely to address the most essential challenges in their regions.

When designing a new initiative, system, or project, policymakers must find more project-specific objectives within the three aims. From there, the framework provides advice on how to go about creating change. Unsurprisingly, this process includes defining system aims and measures, and rapidly testing and scaling up initiatives that work.

It’s important to remember that the same goals used to build a sustainable initiative or system should be used to evaluate it. But the Triple Aim framework can also be used to assess initiatives developed outside of it.

Evaluating Health Care Innovation with Triple Aim

Triple Aim has been a guiding framework for many health care initiatives in several countries. Participating organizations have been part of an international collaborative known as the Triple Aim Improvement Community (TAIC).

In 2014, the Canadian Foundation for Health Care Improvement (CFHI) supported the nine Canadian groups that belonged to the TAIC. The Ontario organizations involved included Women’s College Hospital, the Canadian Mental Health Association, Grey Bruce Health Services, and Peel Public Health.

Due to its comprehensiveness, the Triple Aim is good for building and evaluating projects that tackle new and growing challenges. These problems need to be viewed from all angles; partial solutions could yield unexpected consequences.

This strength was highly relevant to Women’s College, where one of the main focuses is a modern problem – chronic and complex disease. As the rates of these conditions grow, leaders need to find more efficient and cost effective solutions.

New technologies and innovative delivery models can help. By providing an infrastructure that allows more patients to live at home, innovation allows policymakers to make strides toward the big three goals.

Consider the possibilities of virtual care. At the Women’s College Hospital Institute for Health Systems Solutions and Virtual Care (WIHV), new solutions are guided by the Triple Aim. They’re also focused on ensuring that patients are the greatest beneficiaries of a given solution.

Patient independence often results in better quality of life. It can lead to ongoing care for more people (who needn’t be in hospital beds). And of course, by supporting home and community care, it can also lower costs.

Within the Triple Aim framework, every piece of a solution should be evaluated. Does it meet the criteria by helping to improve patient experience, improve population health, and reduce per capita health care costs? Perhaps it contributes significantly to the larger vision of a project or system by helping to achieve one or two of these aims.

The Bottom Line

The Triple Aim is a bold approach. It’s ambitious. Targeting the big three goals facing the health care system is no easy task. As policymakers implement increasingly innovative solutions, they must also find ways of evaluating them. For decision makers, not to mention those on the frontline, it’s important to remember the big picture.

Feature image courtesy of Bruce Guenter

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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