Quadruple Aim In The Health System

Don Berwick and colleagues pioneered the Triple Aim paradigm in the health system, which emphasizes the pursuit of three dimensions of quality of care: improving population health, improving the patient experience, and reducing the per capita cost of care. The primary purpose of this approach is to improve the health of the target population, while the other two are secondary. The expansion of this paradigm to the Quadruple Aim is necessitated by the fact that a stressful work environment, combined with a stressful work environment, is undermining their capacity to meet the three dimensions of care metrics.

Presently, society keeps placing more demands on physicians and health systems at a time when a combination of the nursing shortage and increasing cost of care is reducing the available resources. From patients’ perspective, patient-centered care is conceptualized as an instant response to their care needs. This standard is difficult for caregivers to achieve in the present clinical environment. The severity of the challenges facing caregivers is evidenced by the fact that 46% have reported experiencing burnout (Bodenheimer & Sinsky, 2014). In particular, burnout is prevalent among physicians in the emergency department, neurologists, and family physicians. For instance, a 2014 survey revealed that 68% of family physicians and 73% of general internists would not choose the same career (Bodenheimer & Sinsky, 2014). This is a serious challenge because professional burnout translates into suicidal ideation, early retirement, and increased alcohol and substance abuse. The high levels of physician dissatisfaction must be interpreted as the rise of barriers to high-quality care in contemporary society.

Although the causes of burnout and stress are multifactorial, increased paperwork and administration activities are some of the leading causes. For example, a 2014 survey revealed that 43% of physicians are forced to spend about 30% of their day on administrative tasks (Bodenheimer & Sinsky, 2014). In addition, they are forced to spend a disproportionate amount of time away from face-to-face interactions with patients. The adoption of electronic health records, while integral in streamlining processes in a healthcare environment, has also contributed to physicians’ distractions. Emergency nurses have to spend 44% of their day doing data entry, so their day is spent on patients (Bodenheimer & Sinsky, 2014). Moreover, caregivers have observed that EHR has caused a tremendous increase in the time it takes to plan and review care plans.

Furthermore, burnout has been observed to affect other caregivers besides physicians. For instance, 34% of hospital and 37rsing home nurses have reported burnout (Bodenheimer & Sinsky, 2014). Those on the frontlines, such as receptionists, have not only decried long work hours, but also 68% of them have been victims of verbal abuse from their patients (Bodenheimer & Sinsky, 2014). They also feel they are trapped between the demands of their patients and those of their doctors. In a 2013 survey of 508 employees drawn from 243 healthcare employers, 60% of the healthcare providers reported experiencing burnout, while 34% voiced their desire to look for another job (Bodenheimer & Sinsky, 2014). Losing staff at a time when a rise in chronic illness and an aging population are increasing, the demands placed on the American health system could prove to be disastrous for population health outcomes. The fact that the cost of physician turnover is $250,000 highlights the significance of ensuring that appropriate efforts go into improving job satisfaction and commitment (Bodenheimer & Sinsky, 2014). The prevailing state of the health system leaves much to be desired and calls for urgent intervention measures to improve health outcomes.

Besides reducing empathy and causing compassion fatigue, burnout can cause a rise in medication administration errors. When nurses and medical assistants are worn out and dissatisfied, they will likely make human errors and fail to communicate or collaborate effectively with their colleagues. The fact that measures aimed at facilitating the attainment of Tripel Aim objectives are causing additional work and pressure for caregivers is unfortunate. It must be addressed to ensure quality care outcomes are maintained. In part, this is due to a need for more hiring of healthcare staff and the failure to design workflow in a way that the provision of care centers the interaction between the caregiver and the patient as opposed to compliance-related

In light of the sad state of affairs, it is evident that any progress that can be made about the Triple Aim requires a commitment to improving the well-being of care teams. Moving forward, stakeholders must appreciate that taking care of physicians and caregivers is the foundational step in creating an enabling environment for patients to be taken care of (Arnetz et al., 2020). Additionally, there is a need to ensure that more effort goes into meeting the needs and aspirations of the people.

Healthcare organizations can operationalize the Quadruple Aim by adopting deliberate strategies to create an enabling environment for physicians and other caregivers to have a positive work environment. Implementing team documentation can enhance information-sharing and collaboration among the medical team while allowing them to serve more patients and go home earlier. In addition, using pre-visit planning and pre-appointment laboratory testing can reduce the time used in reviewing lab results. Also, improving delegation would allow nurses and medical assistants to provide more help to physicians. Adopting standardized workflows can translate into five hours being saved each week and improving patient care quality. Similarly, co-locating teams can be integral in operational efficiency and save physicians about thirty minutes. Ensuring that practice staff members are well-trained and understand their roles will empower them to contribute meaningfully to providing care.

However, barriers to implementing the Quadruple Aim must be overcome to achieve positive treatment outcomes. Besides rising healthcare costs and income inequalities, the rise of chronic illnesses is increasing the demand for care (Hsieh, 2019). For example, obesity and diabetes epidemics are increasing in society, creating additional challenges to health systems. An increasing gap between the available resources to healthcare providers and what they get is creating an undue burden for the caregivers. Nonetheless, there must be a balanced approach to addressing the needs of both patients and caregivers to avoid replacing one challenge with another.

To conclude, stakeholders must advocate for increased commitment to the Quadruple Aim approach to care because it emphasizes the healthcare team’s well-being, which is instrumental in creating an enabling environment for patient-centered care. Although many physicians, nurses, and other caregivers conceptualize their career as a call to serve, stressors and barriers in the work environment can dampen their enthusiasm, causing compassion fatigue and job dissatisfaction. When they are cared for and fulfilled in their work, they are less likely to make errors and more committed to providing the best quality of care to all their patients.


Arnetz, B. B., Goetz, C. M., Arnetz, J. E., Sudan, S., vanSchagen, J., Piersma, K., & Reyelts, F. (2020). Enhancing healthcare efficiency to achieve the Quadruple Aim: An exploratory study. BMC Research Notes, 13(1), 362-368.

https://doi: 10.1186/s13104-020-05199-8

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, 12(6), 573-577.

Hsieh, D. (2019). Achieving the Quadruple Aim: Treating Patients as People by Screening for and Addressing the Social Determinants of Health. Inventing Social Emergency Medicine, 74(55), 19–25. https://doi.org/10.1016/j.annemergmed.2019.08.436

Responsibility Center Management

Responsibility centers are essential for the management of an organization. A responsibility center is an operational unit or a part of the organization that fulfills the tasks within the given unit. A manager is responsible for a responsibility center and works to ensure that the responsibilities are fulfilled according to the unit’s structure. Different organizations have responsibility centers, and they use them to attain some goals and segment work (Responsibility Centre definition-AccountingTools, 2023). The said centers have goals, policies, objectives, financial reports, and procedures that outline their way of operations. There are four main types of responsibility centers: cost, revenue, profit, and investment. The use of them can benefit organizations, including those that provide human services like the Red Cross.

Types of Responsibility Centers and their Benefits

Cost Center

A cost center is essential for handling all issues related to the cost issues of the organization. Therefore, it supervises, allocates, eliminates, and segregates all costs of the organization. Its primary role is overseeing the organization’s costs, eliminating unnecessary budget costs, and ensuring that the company only executes the necessary expenditure measures (Responsibility Centre definition-AccountingTools, 2023). In other words, the center is beneficial since it helps handle the increment and management of the costs related to the company operations (Vaidya, n.d.). An organization can have different cost centers that touch on administrative, support, and service roles, which are necessary for smooth company operation and, therefore, cannot be eliminated.

Revenue Center

The revenue center handles the responsibility of monitoring and initiating revenue. It is a center that follows up on the budgeted revenue, marketing expenditures, and the actual revenue and compares them to understand the revenue generated and whether the company is making any progress (Responsibility Center definition-AccountingTools, 2023). The revenue center’s primary function is generating sales. It is judged according to the number of sales made and not the amount incurred, which is essential for outlining a human service organization’s revenue organization in a given period (Vaidya, n.d.). The center has managers responsible for generating revenue by setting targets and taking measures to achieve them; they work on maximizing the market share and minimizing expenses. Revenue centers are more pronounced and functional in sales-focused companies. It is essential for selling products and services from other internal units. It makes the decisions on the size of the marketing plan and strategy and sets the negotiation terms, payment plans, and delivery agendas for the products and services.

Profit Center

The profit center calculates the profits of the organization. An organization can have different profit centers with different managers who calculate the profit by comparing the expenses and the income (Responsibility center definition — AccountingTools, 2023). The profit center is keen on the goods and services being sold and their cost of production. The managers in this segment handle the increment of revenues and management of costs, which means the manager must monitor the segmental revenues and the related expenses. In the center, the manager controls the selling price and sales volume of the products and services and maintains the authority of all measured items (9.4 responsibility centers | Managerial accounting, n.d.). The managers at the profit center have all the necessary data to evaluate performance based on revenues and outline the acquisition cost and the business’s value within a given period.

Expense Center

The center handles investment and revenue by having an investment manager. The manager oversees the fund invested, the income, and expenses and forms a credit policy that impacts debt collection (Vaidya, n.d.). Examples of expense centers include the accounting department, which incurs expenses without producing direct revenue. In human service organizations, expense centers are responsible for outlining the efforts exerted to produce the services.

Application of Cost Center in Disaster Relief Program

Cost center as a responsibility center can be applied to the Disaster Relief Program in the Red Cross. The program is keen on the number of disasters that happen in a year and the nature of their occurrence (Disaster Relief, n.d.). Understanding the disaster and the needs of the affected population is vital for outlining a plan to support the community. The responsibility center of the cost center is used in the program to outline the cost of anticipating and responding to a disaster. The manager of the cost center in the Red Cross must follow the budget and ensure that all areas are included and the indicated expenditures are necessary and match (9.4 responsibility centers | Managerial accounting, n.d.). Calculating the cost ensures that our areas are covered and that the Disaster Relief Program has enough resources to respond to tragedies and save lives effectively.


Responsibility centers are segments with different goals and objectives but retain an interconnected function that works for the organization’s well-being. The four responsibility centers focus on the organization’s cost, revenue, expenses, and profit and are linked to the budget, costs, prices, and earnings from goods and services. Therefore, in most organizations, including the Red Cross, that provide human services, responsibility centers are necessary and used to provide different responsibilities related to the organization’s financial activities.


9.4 responsibility centers | Managerial accounting. (n.d.). Lumen Learning – Simple Book Production. https://courses.lumenlearning.com/suny-managacct/chapter/responsibility-accounting-in-business-environments/

Disaster relief. (n.d.). American Red Cross | Help Those Affected by Disasters. https://www.redcross.org/about-us/our-work/disaster-relief.html

Responsibility center definition — AccountingTools. (2023, December 4). AccountingTools. https://www.accountingtools.com/articles/what-is-a-responsibility-center.html

Vaidya, D. (n.d.). Responsibility Center. Wall Street Mojo. https://www.wallstreetmojo.com/responsibility-center/

Should Governments Everywhere Open Their Borders To All Individuals Who Wish To Move To Their Countries?


International migrants often move to developed countries, with the US, European countries, and the UAE being the top destinations. Notably, international migration entails entry (immigration) and exit (emigration) (Song, 2018, p.386). Public debate concerning the need for governments across the globe to open their borders to people who wish to move in their countries primarily focuses on immigration. Political theorists frame this issue using binary terms: you either support or oppose immigration (Song, 2018, p.386). One side is comprised of people who view borders as inefficient and unjust and challenge governments to open their borders to encourage the free circulation of people. On the other side are individuals who call for restrictive immigration measures to protect national and cultural identities. While these arguments are compelling, this paper argues that opening borders to all people promotes economic growth and moral equality and facilitates adaptation to climate change.

The Concept of Open Borders

Due to globalisation, calls for unrestricted movement of people have increased in recent years. Historical and political accounts indicate territorial demarcations or national borders are consequences of warfare invasions and conquests (Castañeda, 2020, p.3). However, the unintended impacts of these boundaries have led to calls for open borders from political leaders and scholars. The concept of open borders implies that governments should remove restrictions that inhibit the movement of people in and out of their countries (Weiner, 1996, p.172). Niño Arnaiz (2022) affirms that open borders mean “unrestricted freedom of movement between countries” but not a relaxation of immigration policies (p.59). Therefore, open borders demand the right to immigrate. This raises the question of whether governments everywhere should open their borders to people wishing to move to their countries.

Evidence Supporting Open Borders

The overarching limitation to the free mobility of people is the selective permeability of international political borders. Scholarship advocating for no borders and open borders highlights arguments that portray border controls and human migration controls as problematic (Baudr, 2014, p.78). Studies have shown that border controls cause countless injuries and deaths, separation of families, mass detention and deportation of migrants, and restrict the freedom of movement (Chamberlain, 2019, p.2). As such, political theorists have identified why governments everywhere should open their borders to everyone.

Moral Equality and Freedom

The proponents of open borders assume either materialist or liberal positions. Liberal political theory advocates for open borders, holding that migration controls violate liberal principles like moral equality (Bauder, 2014, p.79). From a liberal utilitarian perspective, government policies that restrict the movement of people are unjustifiable because their benefits outweigh the limitations. According to Chamberlain (2019, p. 3), Joseph Carens presents the most influential case supporting open borders based on moral equality and freedom. Carens’ feudalism analogy highlights the unfairness of being born in a wealthy country. His arguments are based on utilitarianism, liberal egalitarianism, and libertarianism. Based on these theories, open borders allow free migration, enabling people born in developing countries to move to developed nations to harness more excellent opportunities (Weiner, 1996, p.174). This implies that all humans have equal moral worth.

Academicians have provided more arguments supporting open borders. First, political theorists appeal to liberal egalitarian principles of equal opportunity and moral equality. This claim contends that respecting people’s moral equality demands a global commitment to equal opportunities (Song, 2018, p.389). Equality of opportunity implies that a person’s capacities and talents should determine access to various social positions. This moral argument supporting open borders is attributable to gross economic inequalities among countries (Weiner, 1996, p.174; Carens, 2015; Bartram, 2010, p.342). As a result, immigration controls contribute to unjust discrimination. Achieving equality of opportunity across the globe requires unrestricted movement of people facilitated by open borders.

Second, the proponents of open borders cite the value of freedom. Jean-Luc Nancy, a French philosopher, argued that community and freedom are mutually constitutive (Chamberlain, 2019, p.14). In other words, freedom of community demands openness to the outside. Several freedom-based arguments support the need for global open borders. First, political theorists argue that freedom of movement is a human right (Song, 2018, p.389). Velasco (2016) shared similar thoughts, noting that freedom of residence and the free circulation of people are critical human rights. Secondly, unrestricted international movement extends rights people consider fundamental: “the right to leave a country and the right of domestic free movement” (Song, 2018, p.390). Third, libertarians believe that open borders facilitate optimal utilisation of human resources, contributing to growth and happiness (Bartram, 2010, p.343). As such, when governments open their borders to all people, they stimulate economic growth and prosperity.

Economic Growth

Neoclassical and neoliberal economists critique migration restrictions and border controls due to associated economic losses. In 2020, Basboga investigated the economic implications of open borders in Europe. The findings indicated that opening national borders facilitated the free movement of people, increasing regional gross value added (GVA) by 2.7% per capita in Europe (p.540). Caplan and Naik (2015, p.233) identify labour as the most valuable commodity globally – yet due to harsh immigration laws, most human capital is underutilised. Border controls and immigration restrictions artificially interfere with the self-regulating labour market since they selectively allow some immigrants to partake in national labour markets while preventing competition from foreign workers (Bauder, 2014, p.79). On the contrary, open borders allow free-cross-border movement of labour, increasing labour competition, removing privileges associated with protected labour, and eventually adding productivity and efficiency. As such, governments everywhere should open their borders to tap the value of people intending to move to their countries.

Economic growth is also stimulated by innovation. Migration makes people more productive and innovative (Caplan. and Naik, 2015, p.236). As Savic (n.d.) writes, collaboration between people from diverse cultures brings unique ideas and perspectives that contribute to innovation. For example, Silicon Valley, a well-known technological hub as well as home to the world’s prominent technological companies like Google, Apple, and Facebook, is an excellent example of the value of open borders in fostering creativity and innovation (Savic, n.d.; Caplan. and Naik, 2015, p.236). The success of these technological firms is mainly attributable to the continuous influx of immigrants – those from within America and those from other nations. The innovative ideas, talents, and skills of immigrants have transformed Silicon Valley into an international centre of excellence.

Economic growth fuelled by migration has steadily lowered global inequality. Data collected between 1970 and 200 revealed a decline in inequality (Caplan. and Naik, 2015, p.237). From an economic point of view, open borders allow people to move from areas with low productivity to those with high productivity. This enriches the world as people escape poverty, equalising income distribution. Open borders lead to quicker and larger progress by addressing international gaps (Caplan. and Naik, 2015, p.237). While international inequality cannot vanish overnight, governments everywhere should consider opening their doors to achieve equal or even income distribution.

Global Justice

The free movement of people by encouraging open borders catalyses global redistribution of resources, increasing the possibility of improving the welfare of underprivileged communities and countries. The policing of national borders is becoming unacceptable politically and socially because of its significant cost to human lives and materials (Velasco, 2016). The defence for free circulation and open borders as a solution to global justice is hinged on the following three premises (Niño Arnaiz, 2022, p.55). First, the world is unjust, as millions of individuals lack the basic resources to sustain a decent life. Secondly, open borders worldwide would alleviate global injustices by allowing individuals to seek better opportunities elsewhere. Finally, borders reproduce injustice by partially delimiting opportunities and preventing people from relocating to developed nations. Thus, the solution to poverty and other global injustices lies in lifting immigration restrictions and permitting the free movement of people across borders.

Adaptation to Climate Change

Migration can be increasingly employed as an adaptive strategy to minimise populations’ vulnerability and expire to the effects of climate change. Benveniste, Oppenheimer, and Fleurbaey (2020) researched the impact of restrictive border policies on vulnerability and exposure to climate change effects for host communities and migrants. The results suggested that restrictive border policies increase vulnerability and exposure to the effects of climate change by trapping individuals in countries where they find themselves (p.6). Further, the study confirmed the role remittances and migration play in positively contributing to climate change adaptation. Opening borders allows countries to get additional income through remittances that can be invested in reducing susceptibility to the effects of climate change. Therefore, opening borders can increase awareness about the effects of climate change.

Arguments Against Open Borders

Despite the many arguments favouring open borders, numerous political theorists have opposed the idea of governments allowing free movement in and out of their borders. Although open borders take a high moral ground, the move can jeopardise the welfare of the host counter and threaten its politicide (Weiner, 1996, p.173). A prosperous and safe country that opens its doors to foreigners risks overwhelming its welfare and social services. Many migrants can seek to transform the host country’s political system (Weiner, 1996, p.173). Nonetheless, border policy evidence is counterintuitive, implying border openings and lifting movement restrictions do not automatically increase immigration and emigration (Vezzoli, 2021, p.3). Also, border closures do not end migration.

Michael Walzer (1998) provides a notable view explaining why governments should restrict the movement of people in and out of their borders. Political theorists use the concept of political membership, which is perceived as a fundamental social good (Song, 2018, p.387). Walzer compared political communities to neighbourhoods, families, and clubs. He noted that, unlike families, clubs, and neighbourhoods, governments have the obligation/right to regulate the physical movement and location of nonmembers and members on their territories (Song, 2018, p.388). This is because political communities must safeguard their people’s welfare, culture, and security. Hence, restrictive border policies are instrumental in preserving and maintaining distinctive cultures. The cultural imperative shows governments everywhere should control immigration to protect the welfare, liberty, culture, and politics of their political communities.

Another objection to open borders is based on the liberal nationalistic model of self-determination. Miller (2016) advanced Walzer’s cultural argument by pointing out that governments should control migration based on self-determination rights (Song, 2018, p.392). In this case, citizens are interested in the preservation and character of their respective national culture. Immigration produces ethnic and racial diversity, affecting the pace at which national culture changes. In countries with high immigration rates, there is insufficient time to adjust to cultural change. Notably, ethnic and racial diversity caused by immigration reduces belief in political institutions and social trust (Song, 2018, p.392). If immigration levels negatively affect social trust, democratic participation, and social welfare delivery, governments should not open their borders. The nationalistic account suggests immigration control helps preserve national identity.

Finally, scholars have refuted the claim that open borders are necessary for achieving global justice. Niño Arnaiz (2022) challenges this assumption, holding that global justice and open borders are incompatible principles. Open borders only remove free transit barriers, allowing people to move freely to other countries. By contrast, distributive justice requires government intervention to allocate social cooperation burdens and benefits fairly (Niño Arnaiz, 2022, p.59). Thus, advocating for open borders to promote global justice seems unjustifiable.


The question of whether governments everywhere should open their doors to people who wish to move into their countries demands a critical review of possible cons and pros. This paper argues that governments should embrace an open border policy to enjoy the benefits of economic and moral equality. Open border proponents cite the value achieved through equal global opportunities and the extension of freedoms people enjoy today. Again, open borders generate economic gains, contribute to global justice, and help adapt to the effects of climate change. However, open border critics cite the need to protect national cultures and identities as a sufficient ground to restrict immigration. While these arguments are compelling, governments should establish frameworks that allow people to move across borders more freely. Open borders can address global inefficiencies caused by strict immigration policies.


Bartram, D., 2010. International migration, open borders debates, and happiness. International Studies Review12(3), pp.339-361.

Basboga, K., 2020. The role of open borders and cross-border cooperation in regional growth across Europe. Regional Studies, Regional Science7(1), pp.532-549.

Bauder, H., 2014. The possibilities of open and no borders. Social Justice, pp.76-96.

Benveniste, H., Oppenheimer, M. and Fleurbaey, M., 2020. Effect of border policy on exposure and vulnerability to climate change. Proceedings of the National Academy of Sciences117(43), pp.26692-26702.

Caplan, B. and Naik, V., 2015. A radical case for open borders. The Economics of Immigration: Market-Based Approaches, Social Science, and Public Policy, pp.180-209. https://doi.org/10.1093/acprof:oso/9780190258788.003.0008

Carens, J. 2015. The case for open borders. [online] OpenDemocracy. Available at: https://www.opendemocracy.net/en/beyond-trafficking-and-slavery/case-for-open-borders/.

Castañeda, E., 2020. Introduction to “reshaping the world: Rethinking borders”. Social Sciences9(11), p.214. http://dx.doi.org/10.3390/socsci9110214

Chamberlain, J. A. 2019. Challenging borders: The case for open borders with Joseph Carens and Jean-Luc Nancy. Journal of International Political Theory, 175508821985991. https://doi.org/10.1177/1755088219859919

Niño Arnaiz, B., 2022. Should we open borders? Yes, but not in the name of global justice. Ethics & Global Politics15(2), pp.55-68. https://doi.org/10.1080/16544951.2022.208139

Savic, T. n.d. Global Insights | Report 2023 Q3. [online] Available at: https://www.henleyglobal.com/publications/global-mobility-report/2023-q3/global-insights/how-open-borders-enhance-economic-opportunities-for-countries.

Song, S., 2018. Political theories of migration. Annual review of political science21, pp.385-402. https://doi.org/10.1146/annurev-polisci-082317-093019

Velasco, J.C., 2016. Open-Border immigration policy: A step towards global justice. Migraciones internacionales8(4), pp.41-72.

Weiner, M. 1996. Ethics, national sovereignty and the control of immigration. International Migration Review, 30(1), 171–197. https://doi.org/10.1177/019791839603000114

Vezzoli, S., 2021. How do borders influence migration? Insights from open and closed border regimes in the three Guianas. Comparative Migration Studies9(1), pp.1-23. https://doi.org/10.1186/s40878-020-00213-1