by Lucy Loomis, MD, MSPH, family physician, Denver Health
Featured in the July-August 2019 Colorado Medicine Colorado Medicine.
In the past five years, there has been increasing recognition of the importance of an engaged medical team for the delivery of high-quality medical care. The concept of the “Triple Aim,” conceptualized by Don Berwick, MD, of the Institute for Healthcare Improvement, encourages focus on simultaneously improving population health and patient experience, while also reducing costs. It was updated in 2014 by Thomas Bodenheimer, MD, and Christine Sinsky, MD,1 to the “quadruple aim,” including joy in practice. This concept recognized that if the workforce develops burnout while striving to achieve the triple aim, progress will be difficult to sustain.
A high-functioning medical team is a key component to reducing burnout and improving engagement. Team-based care addresses many of the components of modern medical care that drive burnout including reducing administrative burden and workplace chaos, and increasing autonomy and camaraderie.
There have been multiple studies of the impact of team care on improving joy in practice. In their review of 23 practices, Sinsky and Bodenheimer2 also recognized that “team-based care is shown to make primary care more feasible and enjoyable.” The IHI3 has also described “joy in practice” as a “fundamental redesign of the medical encounter to restore the health relationship of patients with a physician and health care systems.”
In the primary care setting, there are numerous examples2 of key components of practice redesign that can improve physician satisfaction. The majority of the innovations are built on enhancement of the practice team, both through expanded team member roles, and efforts to build camaraderie, communication and teamwork. Improved communication and team cohesiveness through co-location, pre-clinic huddles, regular meetings, and real-time communication in the visit support team function and reduce rework. Enhanced team roles such as scribing, or medical assistants (MAs) assisting with order entry or inbox management, reduce documentation time. MAs can also assist with coaching and agenda setting, allowing for better focused visits. A lot of the routine work of prevention and chronic disease management is easily delegated to non-provider staff, freeing up physician time for patient interaction and relationship. For example, with additional rooming time, MAs can review medications, help set agendas, close gaps in care or complete forms, preserving time in the encounter for the provider to focus on the patient and his or her health concerns. These changes can also help improve satisfaction of other team members, and increase their sense of engagement with the patients.
Here in Colorado, the University of Colorado Department of Family Medicine set out to test the effects of expanding the MA role.4,5 Starting in 2015 they increased their ratio of MAs to providers to 2.5:1, based on the University of Utah’s “Care by Design” model. MAs went through rigorous training and used structured protocols to function semi-independently. Each MA stayed with a single patient throughout the visit, and had more time to assist in documentation, as well as provide pre- and post-visit assistance. The additional MA assisted with in-basket management. Within six months after implementation, the burnout rates among providers dropped significantly, from 53 percent to 13 percent.
Staff satisfaction also improved, demonstrating the benefits of the team-based model for all members of the team. Practice performance metrics for preventive and chronic disease care indicators also improved. With the gains in efficiency and performance, the practice was able to increase visits enough to offset the costs of the additional staff, without affecting provider satisfaction. Since 2016, the model has been adopted by many other sites in the UCH system.
- Thomas Bodenheimer, MD and Christine Sinsky, MD, From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Ann Fam Med November/December 2014 vol. 12 no. 6 573-576.
- Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3): 272–278.
- Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org.)
- Wright A, Katz I, Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. NEJM 378:4 Jan 25, 2018.
- Lyon C, English AF, Chabot Smith P, A Team-Based Care Model That Improves Job Satisfaction, Fam Pract Manag. 2018 Mar/Apr;25(2):6-11.