Despite substantial evidence documenting the social patterning of disease, relatively little information is available on how the health care system can best intervene on social determinants to impact individual and population health. Announced in January 2016, the Centers for Medicare and Medicaid Innovation's (CMMI) Accountable Health Communities (AHC) initiative provides an important opportunity to improve the evidence base around integrated social and medical care delivery. To maximize learning from this large-scale demonstration, comprehensive evaluation efforts should focus on effectiveness and implementation research by supporting local, regional, and national studies across a range of outcomes. Findings from this demonstration could transform how, when, and which patients' health-related social needs are addressed within the health care delivery system. Such findings would strongly complement other initiatives to address social factors outside of health care.
Evaluating the Accountable Health Communities Demonstration Project
First responders are often exposed to multiple potentially traumatic incidents over the course of their career. However,scientific research showed that first responders are more resilient compared with the general population. In addition, experience of life-threatening situations and acute stress may lead first responders to the development of posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms. Current clinical research and practice has developed evidence-based treatments shown to be effective in helping first responders ameliorate their PTSD symptoms and perform their duties effectively. Literature showed that cognitive–behavioral therapy (CBT) entails multiple evidence-based techniques that lead those suffering from PTSD toward symptom improvement and trauma recovery. The current article aims to (a) provide readers with rigorous information about stress and trauma experienced by first responders, (b) present PTSD symptomatology as well as risk and protective PTSD factors prevalent among first responders, (c) provide information about the psychophysiology of PTSD, and (d) explore the efficacy of CBT treatment for first responders diagnosed with PTSD. The author highlights the necessity for psychophysiological measurement of CBT treatment efficacy for first responders diagnosed with PTSD; also, potential gaps in the current scientific literature regarding this issue are highlighted. Recommendations for future research and clinical practice are discussed so that health professionals and researchers continue to serve those who serve our communities.
This resource is found in our Actionable Strategies for Public Safety Organizations: Actionable Strategies (Mental Health & Stress/Trauma Supports)
Examining the Psychophysiological Efficacy of CBT Treatment for First Responders Diagnosed With PTSD: An Understudied Topic
These are challenging times for health care executives. The health care field is experiencing unprecedented changes that threaten the survival of many health care organizations. To successfully navigate these challenges, health care executives need committed and productive physicians working in collaboration with organization leaders. Unfortunately, national studies suggest that at least 50% of US physicians are experiencing professional burnout, indicating that most executives face this challenge with a disillusioned physician workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work. There is a strong business case for organizations to invest in efforts to reduce physician burnout and promote engagement. Herein, we summarize 9 organizational strategies to promote physician engagement and describe how we have operationalized some of these approaches at Mayo Clinic. Our experience demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Leadership and sustained attention from the highest level of the organization are the keys to making progress.
This resource is found in our Actionable Strategies for Health Organizations: Strengthening Leadership.
Executive Leadership and Physician Well-being
BACKGROUND: In health care, burnout has been defined as a psychological process whereby human service professionals attempting to positively impact the lives of others become overwhelmed and frustrated by unforeseen job stressors. Burnout among various physician groups who primarily practice in the hospital setting has been extensively studied; however, no evidence exists regarding burnout among hospital clinical pharmacists. OBJECTIVE: The aim of this study was to characterize the level of and identify factors independently associated with burnout among clinical pharmacists practicing in an inpatient hospital setting within the United States. METHODS: We conducted a prospective, cross-sectional pilot study utilizing an online, Qualtrics survey. Univariate analysis related to burnout was conducted, with multivariable logistic regression analysis used to identify factors independently associated with the burnout. RESULTS: A total of 974 responses were analyzed (11.4% response rate). The majority were females who had practiced pharmacy for a median of 8 years. The burnout rate was high (61.2%) and largely driven by high emotional exhaustion. On multivariable analysis, we identified several subjective factors as being predictors of burnout, including inadequate administrative and teaching time, uncertainty of health care reform, too many nonclinical duties, difficult pharmacist colleagues, and feeling that contributions are underappreciated. CONCLUSIONS: The burnout rate of hospital clinical pharmacy providers was very high in this pilot survey. However, the overall response rate was low at 11.4%. The negative effects of burnout require further study and intervention to determine the influence of burnout on the lives of clinical pharmacists and on other health care-related outcomes.
Factors Associated with Burnout Among US Hospital Clinical Pharmacy Practitioners: Results of a Nationwide Pilot Survey
Private industry hospital workers exhibit a higher incidence of injury and illness—6.0 cases per 100 full-time workers— than employees working in other industries traditionally considered dangerous, such as manufacturing and construction. Hospital workers routinely face hazards related to lifting, moving, or otherwise physically interacting with patients. Workplace injuries and illnesses among hospital workers reflect common risks of hospital jobs and differ by type of hospital.
Hospital Workers: An Assessment of Occupational Injuries and Illnesses
OBJECTIVE: In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality. RESEARCH DESIGN AND SUBJECTS: Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality. PRINCIPAL FINDINGS: Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement. CONCLUSION: Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.
This resource is found in our Actionable Strategies for Government: Optimizing Workload & Workflows (Support & Ensure Safe Staffing).
How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes
Little research has explored burnout and its causes in the American fire service. Data were collected from career firefighters in the southeastern United States (n = 208) to explore these relationships. A hierarchical regression model was tested to examine predictors of burnout including sociodemographic characteristics (model 1), work pressure (model 2), work stress and work–family conflict (model 3) and interaction terms (model 4). The main findings suggest that perceived work stress and work–family conflict emerged as the significant predictors of burnout (both p< .001). Interventions and programs aimed at these predictors could potentially curtail burnout among firefighters.
Impact of Work Pressure, Work Stress and Work–Family Conflict on Firefighter Burnout
[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.
