BACKGROUND: Awareness of the economic cost of physician attrition due to burnout in academic medical centers may help motivate organizational level efforts to improve physician wellbeing and reduce turnover. Our objectives are: 1) to use a recent longitudinal data as a case example to examine the associations between physician self-reported burnout, intent to leave (ITL) and actual turnover within two years, and 2) to estimate the cost of physician turnover attributable to burnout. METHODS: We used de-identified data from 472 physicians who completed a quality improvement survey conducted in 2013 at two Stanford University affiliated hospitals to assess physician wellness. To maintain the confidentially of survey responders, potentially identifiable demographic variables were not used in this analysis. A third party custodian of the data compiled turnover data in 2015 using medical staff roster. We used logistic regression to adjust for potentially confounding factors. RESULTS: At baseline, 26% of physicians reported experiencing burnout and 28% reported ITL within the next 2 years. Two years later, 13% of surveyed physicians had actually left. Those who reported ITL were more than three times as likely to have left. Physicians who reported experiencing burnout were more than twice as likely to have left the institution within the two-year period (Relative Risk (RR) = 2.1; 95% CI = 1.3–3.3). After adjusting for surgical specialty, work hour categories, sleep-related impairment, anxiety, and depression in a logistic regression model, physicians who experienced burnout in 2013 had 168% higher odds (Odds Ratio = 2.68, 95% CI: 1.34–5.38) of leaving Stanford by 2015 compared to those who did not experience burnout. The estimated two-year recruitment cost incurred due to departure attributable to burnout was between $15,544,000 and $55,506,000. Risk of ITL attributable to burnout was 3.7 times risk of actual turnover attributable to burnout. CONCLUSIONS: Institutions interested in the economic cost of turnover attributable to burnout can readily calculate this parameter using survey data linked to a subsequent indicator of departure from the institution. ITL data in cross-sectional studies can also be used with an adjustment factor to correct for overestimation of risk of intent to leave attributable to burnout.
Estimating Institutional Physician Turnover Attributable to Self-Reported Burnout and Associated Financial Burden: A Case Study
BACKGROUND: Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers.
METHODS: We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers.
RESULTS: For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists).
CONCLUSIONS: Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network
[This is an excerpt.] This is the fourth and final report evaluating the four-year Comprehensive Primary Care (CPC) initiative, which was launched by the Center for Medicare & Medicaid Innovation (CMMI) of the Centers for Medicare & Medicaid Services (CMS) to improve primary care delivery, health care quality, and patient experience, and lower costs. This fourth and final report to CMS covers the full CPC intervention period (October 2012 through December 2016). The report examines: (1) who participated in CPC; (2) the supports practices received; (3) how practices implemented CPC and changed the way they delivered health care; (4) the impacts of CPC on clinicians’ and staff members’ experience; and (5) the impacts of CPC on patient experience, cost, service use, and quality-of-care outcomes for attributed Medicare fee-for-service (FFS) beneficiaries. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).
Evaluation of the Comprehensive Primary Care Initiative: Fourth Annual Report
BACKGROUND: Little is known about possible experiences of burnout among drug counselors in opioid treatment programs that are scaling up capacity to address the current opioid treatment gap. METHODS: Participants in this quality improvement study were 31 drug counselors employed by large opioid treatment programs whose treatment capacities were expanding. Experiences of burnout and approaches for managing and/or preventing burnout were examined using individual semi-structured interviews, which were audiotaped, transcribed, and systematically coded by a multidisciplinary team using grounded theory. RESULTS: Rates of reported burnout (in response to an open-ended question) were lower than expected, with approximately 26% of participants reporting burnout. Counselor descriptions of burnout included cognitive, affective, behavioral, and physiological symptoms; and job-related demands were identified as a frequent cause. Participants described both self-initiated (e.g., engaging in pleasurable activities, exercising, taking breaks during workday) and system-supported strategies for managing or preventing burnout (e.g., availing of supervision and paid time off). Counselors provided recommendations for system-level changes to attenuate counselor risk of burnout (e.g., increased staff-wide encounters, improved communication, accessible paid time off, and increased clinical supervision). CONCLUSIONS: Findings suggest that drug counselor burnout is not inevitable, even in opioid treatment program settings whose treatment capacities are expanding. Organizations might benefit from routinely assessing counselor feedback about burnout and implementing feasible recommendations to attenuate burnout and promote work engagement.
Experiences of Burnout Among Drug Counselors in a Large Opioid Treatment Program: A Qualitative Investigation
The COMmunity of Practice And Safety Support (COMPASS) program was developed to prevent injuries and advance the health and well-being of home care workers. The program integrates elements of peer-led social support groups with scripted team-based programs to help workers learn together, solve problems, set goals, make changes, and enrich their supportive professional network. After a successful pilot study and randomized controlled trial, COMPASS was adapted for the Oregon Home Care Commission’s training system for statewide dissemination. The adapted program included fewer total meetings (7 versus 13), an accelerated meeting schedule (every two weeks versus monthly), and a range of other adjustments. The revised approach was piloted with five groups of workers (total n = 42) and evaluated with pre- and post-program outcome measures. After further adjustments and planning, the statewide rollout is now in progress. In the adaptation pilot several psychosocial, safety, and health outcomes changed by a similar magnitude relative to the prior randomized controlled trial. Preliminary training evaluation data (n = 265) show high mean ratings indicating that workers like the program, find the content useful, and intend to make changes after meetings. Facilitating factors and lessons learned from the project may inform future similar efforts to translate research into practice.
From Research-to-Practice: An Adaptation and Dissemination of the COMPASS Program for Home Care Workers
INTRODUCTION: Access to quality primary care is challenging for rural populations and individuals residing in primary care health professional shortage areas (HPSAs). The ability of nurse practitioners (NPs) to provide full care is governed by state scope-of-practice (SOP) regulation, which is classified into three types: full SOP, reduced SOP, and restricted SOP. Understanding how legislative and regulatory decisions can influence supply of NPs in underserved areas can help guide effective health policies to reduce disparities in access to care. OBJECTIVE: To investigate the trends in NP supply in rural and primary care HPSA counties and their relationship with SOP regulation. METHODS: The authors conducted longitudinal data analyses using an integrated county-level national data set from 2009 to 2013. A hierarchical mixed-effects model was performed to assess the relationship between state SOP regulation and NP supply in rural and primary care HPSA counties. RESULTS: The number of NPs per 100,000 population increased in rural and primary care HPSA counties across states with various types of SOP regulation between 2009 and 2013. Compared with the NP supply in rural or primary care HPSA counties in states with reduced or restricted SOP regulation, NP supply in those counties in states with full SOP regulation was statistically significantly higher. CONCLUSION: State full SOP regulation was associated with higher NP supply in rural and primary care HPSA counties. Regulation plays a role in maximizing capacity of the NP workforce in these underserved areas, which are most in need for improvement in access to care. This information may help inform state regulatory policies on NP supply, especially in underserved areas.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Advance Team-Based Care).
Full Scope-of-Practice Regulation Is Associated With Higher Supply of Nurse Practitioners in Rural and Primary Care Health Professional Shortage Counties
Team-based health care has been linked to improved patient outcomes and may also be a means to improve clinician well-being. The increasingly fragmented and complex health care landscape adds urgency to the need to foster effective team-based care to improve both the patient and team’s experience of care delivery. This paper describes key features of successful health care teams, reviews existing evidence that links high-functioning teams to increased clinician well-being, and recommends strategies to overcome key environmental and organizational barriers to optimal team-based care in order to promote clinician and patient well-being.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Optimizing Teams).
Implementing Optimal Team-Based Care to Reduce Clinician Burnout
BACKGROUND: Physician utilization of well-being resources remains low despite efforts to promote use of these resources. Objective: We implemented a well-being assessment for internal medicine residents to improve access and use of mental health services. METHODS: We scheduled all postgraduate year 1 (PGY-1) and PGY-2 residents at West Virginia University for the assessment at our faculty and staff assistance program (FSAP). While the assessment was intended to be universal (all residents), we allowed residents to "opt out." The assessment visit consisted of an evaluation by a licensed therapist, who assisted residents with a wellness plan. Anonymous surveys were distributed to all residents, and means were compared by Student's t test. RESULTS: Thirty-eight of 41 PGY-1 and PGY-2 residents (93%) attended the scheduled appointments. Forty-two of 58 residents (72%, including PGY-3s) completed the survey. Of 42 respondents, 28 (67%) attended the assessment sessions, and 14 (33%) did not. Residents who attended the sessions gave mean ratings of 7.8 for convenience (1, not convenient, to 9, very convenient), and 7.9 for feeling embarrassed if colleagues knew they attended (1, very embarrassed, to 9, not embarrassed). Residents who attended the assessment sessions reported they were more likely to use FSAP services in the future, compared with those who did not attend (P<.001). CONCLUSIONS: Offering residents a well-being assessment may have mitigated barriers to using counseling resources. The majority of residents who participated had a positive view of the program and indicated they would return to FSAP if they felt they needed counseling.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Mental Health).
Implementing a Universal Well-Being Assessment to Mitigate Barriers to Resident Utilization of Mental Health Resources
The aim of this study was to systematically review the range, nature, and extent of current research activity exploring the influence of innovative health-related technologies on social inequalities in health, with specific focus on a deeper understanding of the variables used to measure this connection and the pathways leading to the (re)production of inequalities. A review process was conducted, based on scoping review techniques, searching literature published from January 1, 1996 to November 25, 2016 using MEDLINE, Scopus, and ISI web of science. Search, sorting, and data extraction processes were conducted by a team of researchers and experts using a dynamic, reflexive examination process. Of 4139 studies collected from the search process, a total of 33 were included in the final analysis. Results of this study include the classification of technologies based on how these technologies are accessed and used by end users. In addition to the factors and mechanisms that influence unequal access to technologies, the results of this study highlight the importance of variations in use that importantly shape social inequalities in health. Additionally, focus on health care services technologies must be accompanied by investigating emerging technologies influencing healthy lifestyle, genomics, and personalized devices in health. Findings also suggest that choosing one measure of social position over another has important implications for the interpretation of research results. Furthermore, understanding the pathways through which various innovative health technologies reduce or (re)produce social inequalities in health is context dependent. In order to better understand social inequalities in health, these contextual variations draw attention to the need for critical distinctions between technologies based on how these various technologies are accessed and used. The results of this study provide a comprehensive starting point for future research to further investigate how innovative technologies may influence the unequal distribution of health as a human right.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Using Technology to Improve Workflows)
Innovative Technologies and Social Inequalities in Health: A Scoping Review of the Literature
[This is an excerpt.] "Shared governance (SG) is an organizational model that provides a structure for shared decision-making among professionals about practice and clinical outcomes. With successful implementation, shared governance legitimizes [professionals'] decision making control over their practice while extending their influence to some administrative areas previously controlled by managers." Recently, the shared governance (SG) structure underwent extensive redesign at our organization, a large, free-standing children's hospital in the Midwest. Our new, Interprofessional Shared Governance model is grounded in 2 fundamental premises: one, for the best decision making to occur, those directly involved in that area of practice must be involved in decision making about that practice; and two, the majority of decision making about practice should be occurring at the point of care (POC). By actualizing these 2 premises, nurses and allied health professionals from all settings and roles are empowered to actively and meaningfully participate in all levels of organizational decision making. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Worker & Learner Engagement).
Meaningful Participation and Effective Communication in Shared Governance
[This is an excerpt.] A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits. An MAO that inappropriately denies authorization of services for beneficiaries, or payments to health care providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS paid for beneficiary healthcare. Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Reduce Administrative Burden).
Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials
BACKGROUND: Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP. METHODS: An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures. RESULTS: There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure. INTERPRETATION: The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)
Mental Disorder Symptoms among Public Safety Personnel in Canada
OBJECTIVE: To characterize how black, Hispanic, and Native American resident physicians experience race/ethnicity in the workplace. DESIGN, SETTING, AND PARTICIPANTS: Semistructured, in-depth qualitative interviews of black, Hispanic, and Native American residents were performed in this qualitative study. Interviews took place at the 2017 Annual Medical Education Conference (April 12-17, 2017, in Atlanta, Georgia), sponsored by the Student National Medical Association. Interviews were conducted with 27 residents from 21 residency programs representing a diverse range of medical specialties and geographic locations. MAIN OUTCOMES AND MEASURES: The workplace experiences of black, Hispanic, and Native American resident physicians in graduate medical education. RESULTS: Among 27 participants, races/ethnicities were 19 (70%) black, 3 (11%) Hispanic, 1 (4%) Native American, and 4 (15%) mixed race/ethnicity; 15 (56%) were female. Participants described the following 3 major themes in their training experiences in the workplace: a daily barrage of microaggressions and bias, minority residents tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identity while seen as "other." CONCLUSIONS AND RELEVANCE: Graduate medical education is an emotionally and physically demanding period for all physicians. Black, Hispanic, and Native American residents experience additional burdens secondary to race/ethnicity. Addressing these unique challenges related to race/ ethnicity is crucial to creating a diverse and inclusive work environment.
This resource is found in our Actionable Strategies for Health Organizations: Promoting Diversity, Equity, & Inclusion.
Minority Resident Physicians' Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace
BACKGROUND: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. OBJECTIVES: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. REVIEW METHODS: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. RESULTS: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. CONCLUSION: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended.
Moral Distress in Critical Care Nursing: The State of the Science
A novel approach to advanced electronic health record (EHR) skills training was developed in a large healthcare organization to improve high-quality EHR documentation, while reducing stressors linked to physician burnout.
The 3-day intensive EHR education intervention covered best practices in EHR documentation and physician well-being. The specialty physician faculty used interactive teaching including demonstration, facilitation, and individual coaching. Laptops were provided for hands-on practice. Mixed-method evaluation included real-time feedback, daily surveys, and post-activity surveys to measure participant learning and satisfaction, and also collection of performance data from the EHR to measure use of order sets designed to improve quality of care.
Since 2014, 46 trainings were held with 3500 physicians. Most physicians (85%–98% across all programs) reported improved quality, readability, and clinical accuracy of documentation; fewer medical errors; and increased efficiency in chart review and data retrieval due to the training. Seventy-eight per cent estimated a time savings of 4 to 5 minutes or more per hour. Physician performance data from the EHR showed significant improvement in use of order sets for several critical health conditions such as sepsis, stroke, and chest pain of possible cardiac cause.
This advanced EHR training for physicians was well-received and improved physicians’ use of several order sets designed to improve quality of care. EHR training programs such as this may have impact on the safety, quality, accuracy, and timeliness of care and may also help reduce physician burnout by improving critical skills and reducing time interfacing with all aspects of a patient's health record.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Novel Electronic Health Record (EHR) Education Intervention in Large Healthcare Organization Improves Quality, Efficiency, Time, and Impact on Burnout
The purpose of this paper is to raise awareness of and begin to build an open dialogue regarding nurse suicide. Recent exposure to nurse suicide raised our awareness and concern, but it was disarming to find no organization-specific, local, state, or national mechanisms in place to track and report the number or context of nurse suicides in the United States. This paper describes our initial exploration as we attempted to uncover what is known about the prevalence of nurse suicide in the United States. Our goal is to break through the culture of silence regarding suicide among nurses so that realistic and accurate appraisals of risk can be established and preventive measures can be developed.
Nurse Suicide: Breaking the Silence
Nurses have been required to provide more patient-centered, efficient, and cost effective care. In order to do so, they need to work at the top of their license. We conducted a time motion study to document nursing activities on communication, hands-on tasks, and locations (where activities occurred), and compared differences between different time blocks (7am-11am, 11am-3pm, and 3pm-7pm). We found that nurses spent most of their time communicating with patients and in patient rooms. Nurses also spent most of their time charting and reviewing information in EHR, mostly at the nursing station. Nurses’ work was not distributed equally across a 12-hour shift. We found that greater frequency and duration in hands-on tasks occurred between 7am-11am. In addition, nurses spent approximately 10% of their time on delegable and non-nursing activities, which could be used more effectively for patient care. The study results provide evidence to assist nursing leaders to develop strategies for transforming nursing practice through re-examination of nursing work and activities, and to promote nurses working at top of license for high quality care and best outcomes. Our research also presents a novel and quantifiable method to capture data on multidimensional levels of nursing activities.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Nurses’ Time Allocation and Multitasking of Nursing Activities: A Time Motion Study
[This is an excerpt.] Projected cost of physician burnout in terms of turnover. (Other costs of burnout, in terms of medical errors, malpractice liability, patient satisfaction, productivity and organizational reputation, are not included.) [To read more, click View Resource.]
Organizational Cost of Physician Burnout
[This is an excerpt.] Maintaining meaningful relationships between patients and physicians is the foundation of primary care. A patient panel is a group of patients assigned to one specific physician or clinical team. The team is dedicated to the care of those within that panel. The ability of a physician to build and sustain these meaningful relationships depends on their panel size. But what is the right panel size for a primary care physician (PCP)? How many patients can a family physician, pediatrician, or internist manage while still providing sufficient same-day access for their patients' acute needs, planned care appointments for chronic care and prevention, and between-visit care and population management? How does a practice manage access for both new and established patients while also ensuring asynchronous access to care, such as after-hours care, email follow-up, and communication through online patient portals? There is not yet an exact science for determining the ideal patient panel size; in the meantime, this toolkit presents current panel size determination and optimization approaches. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
Panel Sizes for Primary Care Physicians: Optimize Based on Both Patient and Practice Variables
[This is an excerpt.] Patient assignments can lead to dissatisfaction among nursing staff, especially when they're not consistent, objective, and quantifiable. This dissatisfaction can create barriers to the adaptability and teamwork that are so critical to good patient care. In 2016, three RNs on a complex 23-bed medical-surgical unit at Durham VA Health Care System identified a recurring complaint by nursing staff that patient assignments were inconsistent and unequal. An average of five RNs and one charge nurse were assigned five patients per nurse per shift. The nursing assignment system included placing patients in one of two categories: "standard patient" or "involved care" patient. The problem was the subjectivity of these terms; they had no supporting evidence. The result was frustrated nurses, which prompted the unit to develop a process improvement project. [To read more, follow this link.]
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Safe & Appropriate Staffing).
