[This is an excerpt.] Although low Medicaid physician payment rates relative to those by Medicare have been well-documented, until now there has been little systematic information to characterize the level of Medicaid payments to hospitals. In this brief, we present findings from a first-ever study to construct a state-level payment index to compare fee-for-service (FFS) inpatient hospital payments across states and to benchmark Medicaidpayment to other payers such as Medicare. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
Medicaid Hospital Payment: A Comparison across States and to Medicare
OBJECTIVE: To determine whether state medical licensure application questions (MLAQs) about mental health are related to physicians' reluctance to seek help for a mental health condition because of concerns about repercussions to their medical licensure. METHODS: In 2016, we collected initial and renewal medical licensure application forms from 50 states and the District of Columbia. We coded MLAQs related to physicians' mental health as "consistent" if they inquired only about current impairment from a mental health condition or did not ask about mental health conditions. We obtained data on care-seeking attitudes for a mental health problem from a nationally representative convenience sample of 5829 physicians who completed a survey between August 28, 2014, and October 6, 2014. Analyses explored relationships between state of employment, MLAQs, and physicians' reluctance to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. RESULTS: We obtained initial licensure applications from 51 of 51 (100%) and renewal applications from 48 of 51 (94.1%) medical licensing boards. Only one-third of states currently have MLAQs about mental health on their initial and renewal application forms that are considered consistent. Nearly 40% of physicians (2325 of 5829) reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. Physicians working in a state in which neither the initial nor the renewal application was consistent were more likely to be reluctant to seek help (odds ratio, 1.21; 95% CI, 1.07-1.37; P=.002 vs both applications consistent). CONCLUSION: Our findings support that MLAQs regarding mental health conditions present a barrier to physicians seeking help.
Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions
What do we know about burnout, and what can we do about it? This article will provide an overview of what has been learned from current research on burnout, and what are the implications of the key themes that have emerged. One theme involves the critical significance of the social environment in health care settings. A second theme is the challenge of how to take what we know, and apply it to what we can do about burnout. What we need are new ideas about potential interventions, and clear evidence of their effectiveness. One example of this perspective addresses burnout by improving the balance of civil, respectful social encounters occurring during a workday. Research has demonstrated that not only can civility be increased at work but that doing so leads to an enduring reduction in burnout among health care providers. Lessons learned from this extensive research form the basis of recommendations for medical education. Specifically, the effectiveness of both the academic content and supervised practice would be enhanced by giving a greater emphasis to the social dynamics of healthcare teams. This perspective can help new physicians in avoiding potential pitfalls and recovering from unavoidable strains.
New Insights Into Burnout and Health Care: Strategies for Improving Civility and Alleviating Burnout
A collection of original content from NEJM Catalyst
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Physician Burnout: The Root of the Problem and the Path to Solutions
Objectives: To examine the impact of clerical support personnel for physician order entry on physician satisfaction, productivity, timeliness with electronic health record (EHR) documentation, and physician attitudes.
Methods: All seven part-time physicians at an academic general internal medicine practice were included in this quasi-experimental (single group, pre- and postintervention) mixed-methods study. One full-time clerical support staff member was trained and hired to enter physician orders in the EHR and conduct previsit planning. Physician satisfaction, productivity, timeliness with EHR documentation, and physician attitudes toward the intervention were measured.
Results: Four months after the intervention, physicians reported improvements in overall quality of life (good quality, 71%-100%), personal balance (43%-71%), and burnout (weekly, 43%-14%; callousness, 14%-0%). Matched for quarter, productivity increased: work relative value unit (wRVU) per session increased by 20.5% (before, April-June 2014; after, April-June 2015; range -9.2% to 27.5%). Physicians reported feeling more supported, more focused on patient care, and less stressed and fatigued after the intervention.
Conclusions: This study supports the use of physician order entry clerical personnel as a simple, cost-effective intervention to improve the work lives of primary care physicians.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Physician Order Entry Clerical Support Improves Physician Satisfaction and Productivity
OBJECTIVE: To determine the prevalence of burnout (based on the Maslach Burnout Inventory on the 3 dimensions of high Emotional Exhaustion, high Depersonalization, and low Personal Accomplishment) among emergency nurses. METHOD: A search of the terms “emergency AND nurs* AND burnout” was conducted using the following databases: CINAHL, Cochrane, CUIDEN, IBECS, LILACS, PubMed, ProQuest, PsycINFO, SciELO, and Scopus. RESULTS: Thirteen studies were included for the Maslach Burnout Inventory subscales of Emotional Exhaustion and Depersonalization and 11 studies for the subscale of low Personal Accomplishment. The total sample of nurses was 1566. The estimated prevalence of each subscale was 31% (95% CI, 20–44) for Emotional Exhaustion, 36% (95% CI, 23–51) for Depersonalization, and 29% (95% CI, 15–44) for low Personal Accomplishment. CONCLUSIONS: The prevalence of burnout syndrome in emergency nurses is high; about 30% of the sample was affected with at least 1 of the 3 Maslach Burnout Inventory subscales. Working conditions and personal factors should be taken into account when assessing burnout risk profiles of emergency nurses.
Prevalence of Burnout Syndrome in Emergency Nurses: A Meta-Analysis
OBJECTIVE: To evaluate the effects of a randomized controlled intervention on the incidence of patient-to-worker (Type II) violence and related injury in hospitals. METHODS: Forty-one units across seven hospitals were randomized into intervention (n = 21) and control (n = 20) groups. Intervention units received unit-level violence data to facilitate development of an action plan for violence prevention; no data were presented to control units. Main outcomes were rates of violent events and injuries across study groups over time. RESULTS: Six months post-intervention, incident rate ratios of violent events were significantly lower on intervention units compared with controls (incident rate ratio [IRR] 0.48, 95% confidence interval [CI] 0.29 to 0.80). At 24 months, the risk for violence-related injury was lower on intervention units, compared with controls (IRR 0.37, 95% CI 0.17 to 0.83). CONCLUSIONS: This data-driven, worksite-based intervention was effective in decreasing risks of patient-to-worker violence and related injury.
This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).
Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention
BACKGROUND: Hospitals are experiencing an estimated 16.5% turnover rate of registered nurses costing from $44,380 - $63,400 per nurse—an estimated $4.21 to $6.02 million financial loss annually for hospitals in the United States of America. Attrition of all nurses is costly. Most past research has focused on the new graduate nurse with little focus on the mid-career nurse. Attrition of mid-career nurses is a loss for the profession now and into the future. RESEARCH OBJECTIVE: The purpose of the study was to explore relationships of professional values orientation, career development, job satisfaction, and intent to stay in recently hired mid-career and early-career nurses in a large hospital system. RESEARCH DESIGN: A descriptive correlational study of personal and professional factors on job satisfaction and retention was conducted. PARTICIPANTS AND RESEARCH CONTEXT: A convenience sample of nurses from a mid-sized hospital in a metropolitan area in the Southwestern United States was recruited via in-house email. Sixty-seven nurses met the eligibility criteria and completed survey documents. ETHICAL CONSIDERATIONS: Institutional Review Board approval was obtained from both the university and hospital system. FINDINGS: Findings indicated a strong correlation between professional values and career development and that both job satisfaction and career development correlated positively with retention. DISCUSSION: Newly hired mid-career nurses scored higher on job satisfaction and planned to remain in their jobs. This is important because their expertise and leadership are necessary to sustain the profession into the future. CONCLUSION: Nurse managers should be aware that when nurses perceive value conflicts, retention might be adversely affected. The practice environment stimulates nurses to consider whether to remain on the job or look for other opportunities.
This resource is found in our Actionable Strategies for Health Organizations: Meaningful Rewards& Recognition (Career Supports and Development)
Professional Values, Job Satisfaction, Career Development, and Intent to Stay
This American College of Physicians (ACP) position paper, initiated and written by ACP's Medical Practice and Quality Committee and approved by the Board of Regents on 21 January 2017, reports policy recommendations to address the issue of administrative tasks to mitigate or eliminate their adverse effects on physicians, their patients, and the health care system as a whole. The paper outlines a cohesive framework for analyzing administrative tasks through several lenses to better understand any given task that a clinician and his or her staff may be required to perform. In addition, a scoping literature review and environmental scan were done to assess the effects on physician time, practice and system cost, and patient care due to the increase in administrative tasks. The findings from the scoping review, in addition to the framework, provide the backbone of detailed policy recommendations from the ACP to external stakeholders (such as payers, governmental oversight organizations, and vendors) regarding how any given administrative requirement, regulation, or program should be assessed, then potentially revised or removed entirely.
This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).
Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians
[This is an excerpt.] This set of recommendations is intended to assist employers in creating workplaces that are free of retaliation, including retaliation against employees who engage in activity protected under the 22 whistleblower laws that the Occupational Safety and Health Administration (OSHA) enforces. This document is advisory in nature and informational in content. It is not mandatory for employers, and does not interpret or create legal obligations. These recommendations are intended to be broadly applicable to all public and private sector employers that may be covered by any of the whistleblower protection provisions enforced by OSHA. This recommended framework can be used to create and implement a new program, or to enhance an existing program. While the concepts outlined here are adaptable to most workplaces, employers may adjust these guidelines for such variables as employer size, the makeup of the workforce, and the type of work performed. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Health Organizations: Empowering Worker & Learner Voice (Psychological Safety).
Recommended Practices for Anti-Retaliation Programs
First responders are exposed to critical incidents and chronic stressors that contribute to a higher prevalence of negative health outcomes compared to other occupations. Psychological resilience, a learnable process of positive adaptation to stress, has been identified as a protective factor against the negative impact of burnout. Mindfulness-Based Resilience Training (MBRT) is a preventive intervention tailored for first responders to reduce negative health outcomes, such as burnout. This study is a secondary analysis of law enforcement and firefighters samples to examine the mechanistic role of psychological resilience on burnout. Results indicated that changes in resilience partially mediated the relationship between mindfulness and burnout, and that increased mindfulness was related to increased resilience (b = .41, SE = .11, p< .01), which in turn was related to decreased burnout (b = −.25, SE = .12, p = .03). The bootstrapped confidence interval of the indirect effect did not contain zero [95% CI; −.27, −.01], providing evidence for mediation. Limitations and implications are discussed.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)
Role of Resilience in Mindfullness Training for First Responders
[This is an excerpt.] In 2007, the Mayo Clinic Department of Medicine created the Program on Physician Well-Being (PPWB) to better understand the entire spectrum of personal, professional, and organizational factors that influence physician well-being. This effort was led by Tait Shanafelt, MD, Lotte Dyrbye, MD, and Colin West, MD, PhD. The program spanned across disciplines, including medicine, psychology, and health science research. In the first few years, the focus of the PPWB was on establishing the epidemiology of burnout and distress. Based on institutional and national survey studies, it became evident that burnout is highly prevalent among physicians across all specialties. The drivers vary from practice to practice, but include excessive workload, inadequate support at work, work-home conflicts, loss of control, and diminished meaning and purpose from work. [To read more, click View Resource.]
Success Story: COMPASS Groups Rejuvenate Relationships and Reduce Burnout
Widespread burnout among physicians has been recognized for more than 2 decades. Extensive evidence indicates that physician burnout has important personal and professional consequences.A lack of awareness regarding the economic costs of physician burnout and uncertainty regarding what organizations can do to address the problem have been barriers to many organizations taking action. Although there is a strong moral and ethical case for organizations to address physician burnout, financial principles (eg, return on investment) can also be applied to determine the economic cost of burnout and guide appropriate investment to address the problem. The business case to address physician burnout is multifaceted and includes costs associated with turnover, lost revenue associated with decreased productivity, as well as financial risk and threats to the organization’s long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety. Nearly all US health care organizations have used similar evidence to justify their investments in safety and quality. Herein, we provide conservative formulas based on readily available organizational characteristics to determine the financial return on organizational investments to reduce physician burnout. A model outlining the steps of the typical organization’s journey to address this issue is presented. Critical ingredients to making progress include prioritization by leadership, physician involvement, organizational science/learning, metrics, structured interventions, open communication, and promoting culture change at the work unit, leader, and organization level.Understanding the business case to reduce burnout and promote engagement as well as overcoming the misperception that nothing meaningful can be done are key steps for organizations to begin to take action. Evidence suggests that improvement is possible, investment is justified, and return on investment measurable. Addressing this issue is not only the organization’s ethical responsibility, it is also the fiscally responsible one.
The Business Case for Investing in Physician Well-being
[This is an excerpt.] Direct care workers—nursing assistants, home health aides, and personal care aides who support older Americans and people with disabilities—are among America’s lowest paid workers, often struggling to access health coverage. However, new coverage numbers show that this workforce benefited substantially from the Affordable Care Act (ACA). Between 2010 and 2014, half a million direct care workers gained coverage. At the same time, the uninsured rate across this workforce decreased by 26 percent. As the Trump administration and the new Congress consider the future of the Affordable Care Act (ACA) and Medicaid, itis important to consider the impact of these changes on this critical U.S. workforce. [To read more, click View Resource.]
This resource is found in our Actionable Strategies for Government: Fair and Meaningful Reward & Recognition (Strengthen Worker Compensation and Benefits).
The Impact of the Affordable Care Act on Health Coverage for Direct Care Workers
In recent years, policy developments in the United States have dramatically changed how nonprofit hospitals interact with surrounding communities. However, despite the importance of these changes encoded in Internal Revenue Service regulations, little is known about how these requirements have affected how nonprofit hospitals are approaching community health evaluation. We present qualitative findings from interviews with hospital employees and consultants overseeing preliminary rounds of community health needs assessments, as required by the Affordable Care Act. The sample comes from the Appalachian region of Ohio, an area targeted because of significant health challenges. Our findings suggest that the Affordable Care Act has led hospitals to formalize their processes, focus on developing an evidence base, cultivate local partnerships, and reflect on the role of the hospital in public health.
This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Invest/Advocate for Patients, Communities, & Workers).
The Impact of the Affordable Care Act on Hospital-Led Community Health Evaluation in The U.S. Appalachian Ohio Region
OBJECTIVES: This study reviews the current state of the published peer-reviewed literature related to physician burnout and two quality of care dimensions. The purpose of this systematic literature review is to address the question, ‘How does physician burnout affect the quality of healthcare related to the dimensions of acceptability and safety?’ DESIGN: Using a multiphase screening process, this systematic literature review is based on publically available peer-reviewed studies published between 2002 and 2017. Six electronic databases were searched: (1) MEDLINE Current, (2) MEDLINE In-process, (3) MEDLINE Epub Ahead of Print, (4) PsycINFO, (5) Embase and (6) Web of Science. SETTING: Physicians practicing in civilian settings. PARTICIPANTS: Practicing physicians who have completed training. Primary and secondary outcome measures Quality of healthcare related to acceptability (ie, patient satisfaction, physician communication and physician attitudes) and safety (ie, minimising risks or harm to patients). RESULTS: 4114 unique citations were identified. Of these, 12 articles were included in the review. Two studies were rated as having high risk of bias and 10 as having moderate risk. Four studies were conducted in North America, four in Europe, one in the Middle East and three in East Asia. Results of this systematic literature review suggest there is moderate evidence that burnout is associated with safety-related quality of care. Because of the variability in the way patient acceptability-related quality of care was measured and the inconsistency in study findings, the evidence supporting the relationship between burnout and patient acceptability-related quality of care is less strong. CONCLUSIONS: The focus on direct care-related quality highlights additional ways that physician burnout affects the healthcare system. These studies can help to inform decisions about how to improve patient care by addressing physician burnout. Continued work looking at the relationship between dimensions of acceptability-related quality of care measures and burnout is needed to advance the field.
The Relationship Between Physician Burnout and Quality of Healthcare in Terms of Safety and Acceptability: A Systematic Review
BACKGROUND: Healthcare provider burnout is considered a factor in quality of care, yet little is known about the consistency and magnitude of this relationship. This meta-analysis examined relationships between provider burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and the quality (perceived quality, patient satisfaction) and safety of healthcare. METHODS: Publications were identified through targeted literature searches in Ovid MEDLINE, PsycINFO, Web of Science, CINAHL, and ProQuest Dissertations & Theses through March of 2015. Two coders extracted data to calculate effect sizes and potential moderators. We calculated Pearson’s r for all independent relationships between burnout and quality measures, using a random effects model. Data were assessed for potential impact of study rigor, outliers, and publication bias. RESULTS: Eighty-two studies including 210,669 healthcare providers were included. Statistically significant negative relationships emerged between burnout and quality (r = −0.26, 95 % CI [−0.29, −0.23]) and safety (r = −0.23, 95 % CI [−0.28, −0.17]). In both cases, the negative relationship implied that greater burnout among healthcare providers was associated with poorer-quality healthcare and reduced safety for patients. Moderators for the quality relationship included dimension of burnout, unit of analysis, and quality data source. Moderators for the relationship between burnout and safety were safety indicator type, population, and country. Rigor of the study was not a significant moderator. DISCUSSION: This is the first study to systematically, quantitatively analyze the links between healthcare provider burnout and healthcare quality and safety across disciplines. Provider burnout shows consistent negative relationships with perceived quality (including patient satisfaction), quality indicators, and perceptions of safety. Though the effects are small to medium, the findings highlight the importance of effective burnout interventions for healthcare providers. Moderator analyses suggest contextual factors to consider for future study.
The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis
Professional burnout and mental health vulnerabilities, like depression and suicidal ideation, are significant concerns affecting practicing physicians and trainees. Professional burnout can impact a physician’s health and quality of life, the quality of care they provide, and their productivity and workforce participation. Although psychiatrists appear to be less affected by burnout than physicians from many other specialties, research shows they are at higher risk for depression and suicide. However, opportunities exist to enhance psychiatrist well-being through further research, increased education and providing evidence-based interventions. Moreover, psychiatrists are in an ideal position to provide expertise and knowledge to others in the health care profession, especially in distinguishing between burnout and depression and the best approaches to both conditions. The APA convened the Ad-hoc Workgroup on Physician Well-being and Burnout to make recommendations on the development of activities and products to facilitate APA’s focus on well-being and burnout.
Toolkit for Wellbeing Ambassadors: A Manual
Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians’ wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.
When Healthcare Professionals Cannot Do the Right Thing: A Systematic Review of Moral Distress and Its Correlates
Depression is common among training physicians and may disproportionately affect women. The identification of modifiable risk factors is key to reducing this disease burden and its negative impact on patient care and physician career attrition. To determine the presence and magnitude of a sex difference in depressive symptoms and work-family conflict among training physicians; and if work-family conflict impacts the sex difference in depressive symptoms among training physicians. A prospective longitudinal cohort study of medical internship in the United States during the 2015 to 2016 academic year in which 3121 interns were recruited across all specialties from 44 medical institutions. Prior to and during their internship year, participants reported the degree to which work responsibilities interfered with family life using the Work Family Conflict Scale and depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9). Mean (SD) participant age was 27.5 (2.7) years, and 1571 participants (49.7%) were women. Both men and women experienced a marked increase in depressive symptoms during their internship year, with the increase being statistically significantly greater for women (men: mean increase in PHQ-9, 2.50; 95% CI, 2.26-2.73 vs women: mean increase, 3.20; 95% CI, 2.97-3.43). When work-family conflict was accounted for, the sex disparity in the increase in depressive symptoms decreased by 36%. Our study demonstrates that depressive symptoms increase substantially during the internship year for men and women, but that this increase is greater for women. The study also identifies work-family conflict as an important potentially modifiable factor that is associated with elevated depressive symptoms in training physicians. Systemic modifications to alleviate conflict between work and family life may improve physician mental health and reduce the disproportionate depression disease burden for female physicians. Given that depression among physicians is associated with poor patient care and career attrition, efforts to alleviate depression among physicians has the potential to reduce the negative consequences associated with this disease.
