This paper is focused on the importance of recognizing staff in the healthcare industry through the development and implementation of an incentive bonus program. Beginning at childhood and continuing into work life as an adult, recognition and incentives play a crucial role to reinforcing desired behaviors. Recognition is important to build morale, professional relationships, and achieve consistent levels of growth in performance. The healthcare industry is undergoing constant change in the threat of disruption, which is compounded by staff shortages and turnover. Employees need to be recognized and rewarded for their role in the delivery of service and quality excellence. Financial incentives as recognition can help increase performance and motivation, improve patient safety and quality, and achieve greater financial sustainability. When financial incentives are not implemented correctly, it can lead to team disintegration, a magnified focus on monetary gain, and ultimate dependence for future performance. Taking these into account, developing an incentive program must be aligned with the goals of the organization, be grounded in reliable and objective data, be financially sustainable, and allow for individual impact, all while focusing on a collaborative team approach. If implemented correctly with clear communication and clarity, appropriate measurement and tracking along with action planning for future results, a staff incentive bonus program is a vital component to employee recognition to drive the performance goals of the organization. This will further the ultimate purpose in patient care; to ensure sustained improvement of both clinical and service quality excellence.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards & Recognition (Meaningful Recognition)
Development and Implementation of a Staff Incentive Bonus Program
BACKGROUND: Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts. METHODS: A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender. RESULTS: Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00). CONCLUSIONS: Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training
BACKGROUND: Research on the effects of increasing workplace diversity has grown substantially. Unfortunately, little is focused on the healthcare industry, leaving organizations to make decisions based on conflicting findings regarding the association of diversity with quality and financial outcomes. To help improve the evidence-based research, this umbrella review summarizes diversity research specific to healthcare. We also look at studies focused on professional skills relevant to healthcare. The goal is to assess the association between diversity, innovation, patient health outcomes, and financial performance. METHODS: Medical and business research indices were searched for diversity studies published since 1999. Only meta-analyses and large-scale studies relating diversity to a financial or quality outcome were included. The research also had to include the healthcare industry or involve a related skill, such as innovation, communication and risk assessment. RESULTS: Most of the sixteen reviews matching inclusion criteria demonstrated positive associations between diversity, quality and financial performance. Healthcare studies showed patients generally fare better when care was provided by more diverse teams. Professional skills-focused studies generally find improvements to innovation, team communications and improved risk assessment. Financial performance also improved with increased diversity. A diversity-friendly environment was often identified as a key to avoiding frictions that come with change. CONCLUSIONS: Diversity can help organizations improve both patient care quality and financial results. Return on investments in diversity can be maximized when guided deliberately by existing evidence. Future studies set in the healthcare industry, will help leaders better estimate diversity-related benefits in the context of improved health outcomes, productivity and revenue streams, as well as the most efficient paths to achieve these goals.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Diversity Improves Performance and Outcomes
OBJECTIVES: To investigate racial/ethnic and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15-per-hour minimum wage on their economic well-being. METHODS: Using the 2017 Annual Social and Economic Supplement to the Current Population Survey, we compared earnings, insurance coverage, public benefits usage, and occupational distribution of male and female health care workers of different races/ethnicities. We modeled the impact of raising the minimum wage to $15 per hour with different scenarios for labor demand. RESULTS: Of female health care workers, 34.9% of earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance. A total of 1.7 million female health care workers and their children lived in poverty. Raising the minimum wage to $15 per hour would reduce poverty rates among female health care workers by 27.1% to 50.3%. CONCLUSIONS: Many US female health care workers, particularly women of color, suffer economic privation and lack health insurance. Achieving economic, gender, and racial/ethnic justice will require significant changes to the compensation structure of health care.
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).
Economic Vulnerability Among US Female Health Care Workers: Potential Impact of a $15-per-Hour Minimum Wage
IMPORTANCE: Burnout symptoms among physicians are common and have potentially serious ramifications for physicians and their patients. Randomized studies testing interventions to address burnout have been uncommon. OBJECTIVE: To explore the effect of individualized coaching on the well-being of physicians. DESIGN, SETTING, AND PARTICIPANTS: A pilot randomized clinical trial involving 88 practicing physicians in the departments of medicine, family medicine, and pediatrics who volunteered for coaching was conducted between October 9, 2017, and March 27, 2018, at Mayo Clinic sites in Arizona, Florida, Minnesota, and Wisconsin. Statistical analysis was conducted from August 24, 2018, to March 25, 2019. INTERVENTIONS: A total of 6 coaching sessions facilitated by a professional coach. MAIN OUTCOMES AND MEASURES: Burnout, quality of life, resilience, job satisfaction, engagement, and meaning at work using established metrics. Analysis was performed on an intent-to-treat basis. RESULTS: Among the 88 physicians in the study (48 women and 40 men), after 6 months of professional coaching, emotional exhaustion decreased by a mean (SD) of 5.2 (8.7) points in the intervention group compared with an increase of 1.5 (7.7) points in the control group by the end of the study (P < .001). Absolute rates of high emotional exhaustion at 5 months decreased by 19.5% in the intervention group and increased by 9.8% in the control group (−29.3% [95% CI, −34.0% to −24.6%]) (P < .001). Absolute rates of overall burnout at 5 months also decreased by 17.1% in the intervention group and increased by 4.9% in the control group (−22.0% [95% CI, −25.2% to −18.7%]) (P < .001). Quality of life improved by a mean (SD) of 1.2 (2.5) points in the intervention group compared with 0.1 (1.7) points in the control group (1.1 points [95% CI, 0.04-2.1 points]) (P = .005), and resilience scores improved by a mean (SD) of 1.3 (5.2) points in the intervention group compared with 0.6 (4.0) points in the control group (0.7 points [95% CI, 0.0-3.0 points]) (P = .04). No statistically significant differences in depersonalization, job satisfaction, engagement, or meaning in work were observed. CONCLUSIONS AND RELEVANCE: Professional coaching may be an effective way to reduce emotional exhaustion and overall burnout as well as improve quality of life and resilience for some physicians.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)
Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial
To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.
Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review
Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios—five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis
[This is an excerpt.] Employers shape the work conditions that parents face, and they play a central role in policy debates about how to address work-family pressures. To better understand employer perspectives on these issues, this report presents findings from interviews with 16 organizations that represent or directly work with employers. Focusing on three policy areas central to parents’ ability to manage work and family—paid leave, workplace flexibility and control, and child care—the report explores three research questions:
- What are employers’ perceived motivations and barriers for providing work-family supports to low-wage workers?
- What role do employers see for public policy or employer policy in each area?
- How do employers think about relationships between different work-family supports and other benefits they might provide low-wage workers?
[To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards & Recognition (Adequate Compensation)
Employers, Work-Family Supports, and Low-Wage Workers
Background: Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout.
Objective: To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels.
Design: Cost-consequence analysis using a mathematical model.Setting: United States.Participants: Simulated population of U.S. physicians.
Measurements: Model inputs were estimated by using the results of contemporary published research findings and industry reports.
Results: On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.
Limitations: Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated.
Conclusion: Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.
Estimating the Attributable Cost of Physician Burnout in the United States
Canadian Public Safety Personnel (e.g., correctional workers, dispatchers, firefighters, paramedics, and police) are regularly exposed to potentially traumatic events, some of which are highlighted as critical incidents warranting additional resources. Unfortunately, available Canadian public safety personnel data measuring associations between potentially traumatic events and mental health remains sparse. The current research quantifies estimates for diverse event exposures within and between several categories of public safety personnel. Participants were 4,441 public safety personnel (31.7% women) in 1 of 6 categories (i.e., dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, and Royal Canadian Mounted Police). Participants reported exposures to diverse events including sudden violent (93.8%) or accidental deaths (93.7%), serious transportation accidents(93.2%), and physical assaults (90.6%), often 11+ times per event. There were significant relationships between potentially traumatic event exposures and all mental disorders. Sudden violent death and severe human suffering appeared particularly related to mental disorder symptoms, and therein potentially defensible as critical incidents. The current results offer initial evidence that (a) potentially traumatic event exposures are diverse and frequent among diverse Canadian public safety personnel; (b) many different types of exposure can be associated with mental disorders; (c) event exposures are associated with diverse mental disorders, including but not limited to posttraumatic stress disorder, and mental disorder screens would be substantially reduced in the absence of exposures; and (d) population attributable fractions indicated a substantial reduction in positive mental disorder screens (i.e., between 29.0 and 79.5%) if all traumatic event exposures were eliminated among Canadian public safety personnel.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)
Exposures to Potentially Traumatic Events Among Public Safety Personnel in Canada
BACKGROUND: The unique characteristics of each emergency situation and the necessity to make prompt decisions cause emergency medical services (EMS) staff's ethical conflicts and moral distress. OBJECTIVES: This study aimed to explore EMS staff's experiences of the factors behind their moral distress. METHODS: This qualitative study was conducted on 14 EMS staff using the conventional content analysis. Data were collected through unstructured and semi-structured interviews. Each interview was started using general questions about moral issues at workplace and barriers to professional practice. The five-step content analysis approach proposed by Graneheim and Lundman was used for data analysis. RESULTS: The factors behind EMS staff's moral distress were categorized into 13 subcategories and 5 main categories. The main categories were staff's lack of knowledge and competence, inability to adhere to EMS protocols, restraints on care provision, ineffective interprofessional communications, and conflicts in value systems. The subcategories were, respectively, inadequate knowledge and experience, working with incompetent colleagues, artificial services, working in unpredictable situations, lay people's interference in care provision, resource and equipment shortages, barriers to early arrival at the scene, obligatory obedience to the system, poor interprofessional interactions, inadequate interprofessional trust, refusal of care, challenges in obtaining consent, and challenges in telling the truth. CONCLUSION: EMS staff experience moral distress at work due to a wide range of factors. Given the negative effects of moral distress on EMS staff's physical and mental health and the quality of their care services, strategies are needed to prevent or reduce it through managing its contributing factors.
This resource is found in our Actionable Strategies for Public Safety Organizations: Drivers (Relational Breakdown) AND Drivers (Operational Breakdown)
Factors Behind Moral Distress among Iranian Emergency Medical Services Staff: A Qualitative Study into their Experiences
Individual, institutional, and societal risk factors for the development of burnout can differ for women and men physicians. While some studies on physician burnout report an increased prevalence among women, this finding may be due to actual differences in prevalence, the assessment tools used, or differences between/among the genders in how burnout manifests. In the following discussion paper, we review the prevalence of burnout in women physicians and contributing factors to burnout that are specific for women physicians. Understanding, preventing, and mitigating burnout among all physicians is critical, but such actions are particularly important for the retention of women physicians, given the increasing numbers of women in medicine and in light of the predicted exacerbation of physician shortages.
Gender-Based Differences in Burnout: Issues Faced by Women Physicians
This toolkit will help your practice identify and eliminate the “stupid stuff” that adds unnecessary burden to the daily workload and contributes to clinician burnout. The toolkit provides a structured process for recognizing wasteful tasks, particularly within EHR systems, and includes real-world examples and actionable STEPS.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens) AND Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).
Getting Rid of Stupid Stuff: Reduce the Unnecessary Daily Burdens for Clinicians
[This is an excerpt.] The greatest asset of any EMS agency is its people – the EMS practitioners and other personnel who are there for members of the community during their worst moments,and who ensure their patients receive high-quality, compassionate and life-saving care. However, “being there” for patients and their family members and friends during medical emergencies is inherently stressful. EMS practitioners often work under difficult, unpredictable and rapidly changing circumstances. They may work in harsh environments, with limited information, assistance and resources. In the course of their work, they may be exposed to risks such as infectious disease, physical violence,occupational injury, vehicle crashes and death. They may be called on to help the victims of traumatic events, such as those who have experienced a natural disaster,serious motor vehicle collision, abuse or violence. EMS practitioners also run the risk of becoming victims of violence at the hands of patients who are inebriated or having a mental health crisis. To be able to effectively handle the stress associated with working in EMS, EMS personnel benefit from having good physical, mental and emotional health. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Ensuring Physical & Mental Health).
Guide to Building an Effective EMS Wellness and Resilience Program
The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Establish a Culture of Shared Commitment).
Healing the Professional Culture of Medicine
Employees can provide invaluable input to organizations when they can freely express their opinions at work. Employees, however, may not believe that it is safe or efficacious to voice their concerns. How features of communication channels affect employees' safety and efficacy perceptions is largely ignored in existing voice models. Therefore, this study seeks to understand how the anonymity and visibility affordances of a communication channel influence employees' safety and efficacy perceptions, and, thus, their intention to engage in prohibitive voice at work. Two between-subjects experiments were conducted to test how these channel affordances affect voicing behavior in organizations. The results indicate that the more anonymous and less visible participants perceive a voicing channel to be, the safer and the more efficacious they evaluate the channel. Theoretical and practical implications, limitations, and future research directions are discussed.
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Psychological Safety).
How Anonymity and Visibility Affordances Influence Employees' Decisions About Voicing Workplace Concerns
High rates of provider turnover are problematic for our mental health system. Research indicates that supervisory support could alleviate some turnover intention by decreasing emotional exhaustion (a key component of burnout) as well as by increasing job satisfaction. However, the potential mediation mechanisms have not been rigorously tested. Longitudinal data collected from 195 direct clinical care providers at two community mental health centers identified positive effects of supervisory support on reduced turnover intention through reduced emotional exhaustion. Job satisfaction was not a significant mediator. Supervisory support may help mitigate turnover intention through work-related stress reduction.
Impact of Supervisory Support on Turnover Intention: The Mediating Role of Burnout and Job Satisfaction in a Longitudinal Study
This paper develops a model of the nursing home industry to investigate the quality effects of policies that either raise regulated reimbursement rates or increase local competition. Using data from Pennsylvania, I estimate the parameters of the model. The findings indicate that nursing homes increase the quality of care, measured by the number of skilled nurses per resident, by 8.7 percent following a universal 10 percent increase in Medicaid reimbursement rates. In contrast, I find that pro-competitive policies lead to only small increases in skilled nurse staffing ratios, suggesting that Medicaid increases are more cost effective in raising the quality of care.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Incentivizing Better Quality of Care: The Role of Medicaid and Competition in the Nursing Home Industry
BACKGROUND AND OBJECTIVES: Several factors can compromise patient safety, such as ineffective teamwork, failed organizational processes, and the physical and psychological overload of health professionals. Studies about associations between burn out and patient safety have shown different outcomes. OBJECTIVE: To analyze the relationship between burnout and patient safety. MATERIALS AND METHODS: A systematic review with a meta-analysis performed using PubMed and Web of Science databases during January 2018. Two searches were conducted with the following descriptors: (i) patient safety AND burnout professional safety AND organizational culture, and (ii) patient safety AND burnout professional safety AND safety management. RESULTS: Twenty-one studies were analyzed, most of them demonstrating an association between the existence of burnout and the worsening of patient safety. High levels of burnout is more common among physicians and nurses, and it is associated with external factors such as: high workload, long journeys, and ineffective interpersonal relationships. Good patient safety practices are influenced by organized workflows that generate autonomy for health professionals. Through meta-analysis, we found a relationship between the development of burnout and patient safety actions with a probability of superiority of 66.4%. CONCLUSION: There is a relationship between high levels of burnout and worsening patient safety.
Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis
[This is an excerpt.] Only four years into practice, AMA member Kevin Hopkins, MD, was struggling with the clerical burdens of contemporary medicine. He was not a good typist, and he was not particularly good with using electronic devices. Every day was difficult. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Optimizing Teams).
