by David Ehrenberger, MD, Chief Medical Officer, HealthTeamWorks
Featured in the July-August 2019 Colorado Medicine Colorado Medicine.
“Houston, we’ve got a system problem”
A paraphrase of the profoundly understated quote from astronaut Jack Swigert of Apollo 13
It is an alarming paradox that as our health care system evolves and achieves higher quality, patient-centered care, there is a growing epidemic of physician and care team burnout. To many, this disconnect represents a “systems problem,” most notably at the frontlines of health care delivery: the community-based delivery of care. Scott Hammond, MD, a family physician leader and president of Westminster Medical Clinic, shares this insight: “Burnout is not [fundamentally] a ‘workload problem.’ It is a work distribution problem exacerbated by workflow inefficiencies, non-value-added work, and loss of autonomy and purpose.”
This article will explore a systems approach to understanding and addressing burnout, one that is designed to promote vitality in practice, helping physicians (and their care teams) improve the care they give and the lives they live. These practical tips, based on our experience working with practices across Colorado and nationally, are further illustrated by insights from a webinar panel discussion on burnout conducted in March 20191 that included three Colorado physician leaders: Debra Parsons, MD, an internist and president of the Colorado Medical Society; Corey Lyon, MD, a family physician, associate professor at the University of Colorado School of Medicine and associate program director for the family medicine residency; and Hammond.
Critical steps to building vitality in practice
1. Organizational commitment
Creating and formalizing organizational commitment to promoting physician (and team) wellbeing is the first step. This can begin modestly with a small group – or one or two physicians in a small practice – studying and sharing the national data on burnout (prevalence, etiology, impacts on engagement, productivity, suicide, etc.). To ensure a commitment to addressing burnout, however, requires sponsorship and championship by senior leadership and formalizing this commitment in the form of a policy or charter establishing, for instance, a “practice vitality committee.”
2. Make the diagnosis
Select and use a screening tool, such as the Mini-Z Burnout Survey2 and the Maslach Burnout Inventory HSS (MP), to quickly and easily assess the prevalence and severity of physician burnout at the practice or institution. This critical step can also be done across all staff and repeated periodically to monitor progress and to maintain focus and commitment to improvement.
Hammond and Lyon stress the importance of proactive engagement of staff and providers and recommend surveying attitudes, the experience of work, and burnout on a regular basis. Lyon uses the Mini Z survey to assess staff burnout, includes both providers and medical assistants, and notes that a meaningful interval for these surveys is approximately every six months.
3. Define the local “pathophysiology”
What are the major drivers of stress and burnout specific to your practice? Simple tools, such as staff surveys or focus groups, can be used to understand what is most stressful or frustrating in the experience of work and care delivery. From this, prioritize a short list focusing on the big impact – and the impactable – pain points. Examples may include non-clinical workload, staffing ratios, EHR workflow inefficiencies, panel mix, clinical workflow issues, or lack of voice.
4. Create an ongoing burnout treatment and prevention plan
With a clear idea of the degree of burnout and its drivers, develop your practice plan to address and test evidence-based “system changes” that promote provider and team engagement, top-of-license care, and workflow efficiencies. Here, it is useful to begin by studying Lencioni’s “5 dysfunctions of a team” to better understand the strengths and weaknesses of your team(s) and the profound roles high-functioning teams play in the healthy workplace.3 Common best-practice system changes include:
- Invest in and grow non-traditional skillsets across your staff. Examples include training physicians in leadership and management, MAs in population health management, and/or RNs in care management.
- Explore innovations in care team design and staffing including Bodenheimer’s Teamlet model,4 improved staffing ratios, the addition of new team members (e.g., care manager, behaviorist, clinical pharmacist) and the use of scribes. At CU’s AF Williams Family Medicine Center, the work, training and workflow of MAs is critical to the encounter. Lyon notes that their team-based care model, with an optimal MA:Provider ratio of ~2.5:1, has increased visit volume and patient access, improved clinical quality and decreased provider burnout by 50 percent.5
- Enlist the care team in improving the health IT experience. This could include exploring HIT workflows, looking for efficiencies and opportunities for team-based documentation, or investing in tools to mine and leverage clinical data used to excel in value-based care.
- Study and practice wellbeing skills and strategies. Parsons points to the “Work & Well-Being Toolkit for Physicians” as an excellent online resource from the Colorado Medical Society and the Colorado University Department of Behavioral Health.6 Christine Sinsky, MD, Tait Shanafelt, MD, and Mark Linzer, MD, all national experts in physician burnout, have built the Steps Forward Professional Well-Being website, a free seven-module resource out of the American Medical Association.7,8
5. Leverage human-centered design of the modern clinical office space
The traditional physical design of the office practice is based on a physician-centered workflow. Modern “human-centered design” can dramatically improve “top-of-license” care efficiency through principles of team member co-location and line-of-sight space workflows.9
6. Become a learning organization
Improving and sustaining vitality is an ongoing and collaborative learning process to promote meaning and purpose in the work of clinical care. This means baking the performance improvement and change management sciences into the practice’s routine:
- Create venues for sharing, studying and learning from performance data.
- Build and maintain safe venues to engage and give voice to staff in the improvement process.
- Embrace ongoing, proactive change as key to learning and staff engagement.
- Leverage the coaching resources of your local IPA or practice transformation organization.
7. Happy business is a happy practice
There is ample – though anecdotal – evidence that advanced primary care practices (e.g. PCMH) that translate their performance in patient-centered, team-based care into value-based remuneration are more fun, more engaging and better places to work. These practices tend to pursue every opportunity for non-fee-for-service payment. What are their secrets? These practices invest in, improve and transform their systems of team-based care, often with the support of a practice transformation coach, and demonstrate progressive improvement in market-relevant outcomes – quality, experience of care and cost efficiencies. They understand and make the connection between business vitality and physician (and team!) vitality.
HealthTeamWorks® helps medical practices, physician organizations and integrated delivery networks improve their performance in delivering value-based services. Our subject matter experts and solutions help providers improve clinical quality outcomes, patient experience, and provider vitality, while reducing the escalation in per capita cost of medical care.
- Burnout and Vitality in Practice: Expert Panel. HealthTeamWorks Webinar (March 13, 2019).
- Mini Z Burnout Survey. Preventing Physician Burnout: Step 3 https://edhub.ama-assn.org/steps-forward/module/2702509
- Lencioni, P. (2005). Overcoming the Five Dysfunctions of a Team. San Francisco, CA: Jossey-Bass
- Bodenheimer T, Willard-Grace R. Teamlets in Primary Care: Enhancing the Patient and Clinician Experience. J Am Board Fam Med 2016;29: 135-138
- Lyon C, English A, Smith PA. Team-Based Care Model Than Improves Job Satisfaction. Family Practice Management; March/April 2018;6-11
- Work & Well-Being Toolkit for Physicians (Colorado Medical Society).
- “Professional Well-Being”- AMA Steps Forward Learning Module
- “Creating the Organizational Foundation for Joy in Medicine” – AMA Steps Forward Learning Module
- McGough P, Jaffy M, et al. Redesigning Your Work Space to Support Team-Based Care. Fam Pract Manag. 2013 Mar-Apr;20(2):20-24