The Untapped Potential of the Quadruple Aim of Primary Care to Foster a Culture of Health.

In 2015, the Robert Wood Johnson Foundation introduced the Culture of Health (CoH) action model to inform its grantmaking decisions in the United States. The essential principles of this model fall into four action dimensions: 1) making health a shared value, 2) fostering cross-sector collaboration, 3) creating more equitable communities, and 4) transforming healthcare systems. Although considerable success has been achieved since introduction of the CoH model, the pace of progress has been slower on the fourth dimension, since work in this area involves shifting mindsets from the acute care paradigm to one that focuses on prevention, by addressing the "upstream factors", including social and behavioral determinants impacting health. Moreover, despite its academic prominence, the CoH model remains restricted to the research realm, with limited translation to practice. By comparison, the Quadruple Aim (QA) is a four-dimensional framework that has been successfully translated into primary healthcare practice. Introduced in 2008, the QA entails the adoption of four principles in delivering healthcare: 1) improved patient experience, 2) population health, 3) lower costs, and 4) care team well-being, to achieve value in healthcare. The four principles of the QA could be viewed as analogous to the four principles of the CoH, given the inherent synergies in the underlying philosophy of the two frameworks. It is also noteworthy that both healthcare leadership (physician champions) and legislative reform had significant roles to play in the successful translation of the QA into mainstream practice. This in turn suggests that the primary healthcare system has potential to play an instrumental role in accelerating the pace of progress towards a culture of health by extending the scope of influence of the QA. This paper explores the inherent synergies between the QA and CoH models, and the untapped potential of the QA to foster a culture of health in the United States.