1. Welcome to P REVENTING C LINICIAN B URNOUT : PERSONAL AND P ROFESSIONAL ISSUES AND P LANS Presented by: Mark Linzer, MD, FACP The presentation will begin shortly This webinar will be recorded and used for future presentations. Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative. This webinar is being offered by the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California Primary Care Office (PCO). Center for Patient and Provider Experience at

2. WELCOME EVERYONE! Thank you for joining us today

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6. Mark Linzer MD General Internal Medicine Center for Patient and Provider Experience Hennepin County Medical Center Center for Patient and Provider Experience at

7.  Research supported by Federal Agency for Healthcare Research and Quality (AHRQ) Center for Patient and Provider Experience at

8. 1. Identify features of a healthy work environment and how to create one. 2. Discuss ideas of self-care to protect against burnout. 3. Process collaborative approaches to develop and maintain a healthy workplace. Center for Patient and Provider Experience at

9. New York Times, 6-17-08 “It will take real structural change in the work environment for physician satisfaction to improve. Fortunately, the data show physicians are willing to put up with a lot before giving up.” Mark Linzer, Madison, WI

10.  Physician Worklife Study Funded by Robert Wood Johnson Foundation  1996-98: national survey of >5000 MDs  Findings: ◦ Satisfaction promoted by long term relationships with patients ◦ Time pressure diminished satisfaction ◦ Stress related to lack of work control ◦ Burnout predicted by work-home interference Linzer. J Gen Intern Med. 2000;15(7):441-50. Center for Patient and Provider Experience at

11. Sex Age Children Solo practice Academic practice Work hours Stress Satisfaction Work control Work-home interference Home support Background variables Mediating variables Variable outcomes Burnout From Linzer M. Am J Med 2001; 111:170-75. Center for Patient and Provider Experience at

12.  Funded by AHRQ; 2002-2006  119 PC clinics; 422 MDs; 1785 patients.  To determine relationships between work conditions, physician reactions (stress and burnout) and patient care (quality and errors). Linzer M, et al. Ann Intern Med 2009;151:28-36. Center for Patient and Provider Experience at

13. MEMO Study conceptual model Structure Culture Workflow Policies, processes Patient demands Satisfaction Trust Quality of care Medical errors Satisfaction Stress Burnout Intent to leave Workplace Characteristics Physician Reactions Patient Outcomes Center for Patient and Provider Experience at

14. Measuring Quality Up to 6 patients per primary care physician with diabetes and/or HTN Assess:  Patient satisfaction  Quality of life  Disease management Patient Survey Chart review Center for Patient and Provider Experience at

15.  Confidential chart reviews for errors in processes of care (e.g., wrong medications, missed preventive activities) Center for Patient and Provider Experience at

16.  50% need more time for visits  27% burning out or burned out  30% moderately likely to leave job in 2 years  Strong relationships between work conditions (time pressure, work control, chaos, organizational culture) and physician satisfaction, stress, burnout, intent to leave  Many patient care outcomes linked to work conditions Center for Patient and Provider Experience at

17. VariableOutcomep-value Moderate to high work control Higher diabetes care quality <0.05 Time pressureLower overall quality Poorer care for HTN patients <0.05 Linzer et al. Ann Intern Med 2009 Center for Patient and Provider Experience at

18. VariableOutcomep-value Information and communication emphasis Higher overall quality Better HTN quality care <0.05 <0.01 Values alignment Better diabetes care quality Fewer prevention errors <0.001 <0.01 Linzer et al. Ann Intern Med 2009 Center for Patient and Provider Experience at

19. Percent providers reporting... Your clinic (n= providers)Comparison (n=­ providers) Work control (high)25%68% Job satisfaction (high)37%68% Alignment of values with leadership (strong)42%70% Workplace chaos65%40% Time pressure ( high)65%30% Stress (high)80%39% Burnout (high)50%30% Intent to leave practice within 2 years65%15% The first column of numbers provides data specific to your clinic. The second column reports comparison data from __ primary care clinics from your site. Patients whose data are reported in this document have hypertension and/or diabetes. Office & Work Life Feedback W LW L Mock OWL (problematic setting). OWL construct discussed in Linzer M et al. Ann Intern Med. 2009;151:28-36.

20. Mock OWL (problematic setting). OWL construct discussed in Linzer M et al. Ann Intern Med. 2009;151:28-36. Practice data… Your clinic (y/n)Comparison clinics (n=­­) Technology Electronic medical record100%75% Computerized lab results 75% Computerized patient notes 75% 90% Computerized medication lists 50% 85% Computerized problem lists 50% 85% Patient communication via email/MyChart 100%75% Resources Staffing ratio (RN+LPN+MA / MD+NP+PA) 1.21.7 Exam rooms per physician2.22.7 Bottlenecks _X_ Yes __ No Phone access _X_ Yes __ No Exam room wait (your clinic only) _X_Yes __No Follow-up appointments _X_ Yes __ No Interpreter access _X_Yes __No Patient check-in/check-out __ Yes _X_ No Insurance approvals/pre-authorizations _X_Yes ­__No Scheduling tests __ Yes _X_ No Pharmacy services The first column of numbers provides data specific to your clinic. The second column reports comparison data from __ primary care clinics from your site. Patients whose data are reported in this document have hypertension and/or diabetes. Office & Work Life Feedback W LW L

21.  Randomized trial of QI interventions to improve work conditions and care quality  34 clinics in Rural WI; Chicago; NYC  Use OWL to measure work environment and patient outcomes at baseline and after 6-12 months in intervention and control sites Center for Patient and Provider Experience at

22.  Clinics shown their OWL data and comparison clinics data  Data spurred meaningful conversations and movement towards solutions  Activated managers may be key link to clinic transformation Center for Patient and Provider Experience at

23.  Harvard Business School: stocks rose 147% when employee satisfaction rose  In 7900 businesses: productivity and income tied to employee satisfaction  Sears: when employee satisfaction rose 4%, sales increased by $200 million, with a rise in customer satisfaction Center for Patient and Provider Experience at (Brown & Gunderman. Acad Med 2006;81:577-82)

24. Burnout Linzer et al. Am J Med 2001;111:170-75. Turnover: $250,000/departing physician Buchbinder et al. Am J Manag Care 1999;5:1431-8 Instability (larger patient load for remaining providers) Brown & Gunderman. Acad Med 2006;81:577-82 Reduced patient: 1) access to care, 2) satisfaction, 3) medication adherence Linn et al. Med Care 1985; 23:1171-78; DiMatteo. Health Psychol 1993;12: 93-102 Increased patient disenrollment Brown & Gunderman. Acad Med 2006;81:577-82 Center for Patient and Provider Experience at

25.  Prevalent (20-40%) in practicing physicians (Linzer. Am J Med. 2001;111:170-75), higher in medical students (Dyrbye L. Ann Intern Med 2008;149:334-41).  Associated with perceived errors by medical housestaff (West C. JAMA. 2009;296:1071-78)  1.6 x higher in women physicians than men  Mediated by home support, work control, and work-home balance (Linzer et al. Am J Med 2001;111:170-5)  Present in 46% of US MDs (Shanafelt T. Arch Intern Med 2012) Center for Patient and Provider Experience at

26.  Demands balanced by control  Stress increases if demands rise or control diminishes  Support can facilitate impact of control: more support, less stress  Bottom line… support and work control prevent stress (Karasek et al. Am J Public Health 1981;71:694-705) Demands ControlSupport Center for Patient and Provider Experience at

27.  US vs Netherlands: Less gender difference in burnout in Netherlands due to a) fewer work hours and b) better work control in women vs men MDs (Linzer et al. J Am Med Women’s Assoc 2002;57:191-3)  More burnout in US women MDs due to gendered expectations for listening  US women MDs describe faster pace, less values alignment with leadership (Horner-Ibler et al. J Gen Intern Med 2005; 20(s1):194) Center for Patient and Provider Experience at

28.  MEMO study looked at relationship between EMR functionality and stress, burnout and dissatisfaction.  Two findings: ◦ Burnout and dissatisfaction increased as EMR functions increased; then decreased as EMR became fully functional – but not to original levels. ◦ In fully functional EMRs, shorter visits associated with more dissatisfaction, burnout, intent to leave. (Babbott. JGIM, abstract, 2011) Center for Patient and Provider Experience at

29. Career fit:  If % time clinicians are able to do what they are most passionate about falls below 10%, burnout rises dramatically (>50%).  Thus, be sure clinicians have time (at least 10%) to devote to what they care most about (“career fit”) (Shanafelt T. Arch Intern Med. 2009;169(10):990-995.) Center for Patient and Provider Experience at

30.  Flexible/part-time work (Linzer. Acad Med 2009;84:1395-1400)  Leaders model work-home balance; value well-being (Saleh. Clin Orthop Relat Res 2009;467:558-65; Dunn. J Gen Intern Med 2007;22:1544-52)  Promote work control; limit EMR time outside office; provide sufficient time to use it inside  Alter our “culture of endurance” (Viviers. Can J Ophthalmol 2008;43:535-46) Center for Patient and Provider Experience at

31.  Less time pressure, more control  Extend appt times, or offload non-clinician work  “Desk top” slots during sessions  Time to catch up (2 hrs?) after vacation/leave  More order, less chaos  Maximally utilize space  Pilot unique schedules: “7 on, 7 off”  Support for work-home balance  Support part-time practice and practice styles supportive of parents of young children Center for Patient and Provider Experience at

32. Build forms work into practice flow Don’t wait until the end of the day Respect the lifecycle Hire float clinicians to cover parental/ sick leaves Build workplace teams Address work flow and quality measures MDs, APPs, MAs, RNs, Pharm Ds Supportive Culture Be sure values are aligned (between clinicians and leaders) Take time to listen Action often not needed Kenny C. Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience, CRC Press; 1 edition (November 8, 2010). Linzer M, Respecting the lifecycle: rational workforce planning in a section of general internal medicine. Am J Med. 2002;113: 443-48.

33.  Time to: ◦ Reflect together on challenging cases ◦ Exercise 3-4 x per wk ◦ Eat all meals ◦ Complete work at work ◦ See a patient, listen, provide empathy, attend to quality measures, and use the EMR ◦ Huddle with your team (who can help with all of the above) ◦ Meet with leaders and discuss values, direction and purpose Center for Patient and Provider Experience at

34.  Hard workers; usually at more than their FTE  Loyal, connected, good morale  Patient satisfaction is high  Full time clinicians may wish to go part time (e.g. for children, end of career)! Mechaber H et al. J Gen Intern Med. 2008;23(3):300-3. Center for Patient and Provider Experience at

35. 1. Overall, I am satisfied with my current job: Strongly disagree DisagreeNeither agree nor disagreeAgreeAgree strongly 2. I feel a great deal of stress because of my job Strongly disagreeDisagreeNeither agree nor disagreeAgreeAgree strongly 3. Using your own definition of “burnout”, please circle one of the answers below: 1. I enjoy my work. I have no symptoms of burnout. 2. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. 3. I am definitely burning out and have one or more symptoms of burnout, ex. emotional exhaustion. 4. The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. 5. I feel completely burned out and often wonder if I can go on. I am at the point where I may need to seek help. 4. My control over my workload is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal 5. Sufficiency of time for documentation is: 1 – Poor2 – Marginal3 – Satisfactory4 – Good5 – Optimal 6. Which number best describes the atmosphere in your primary work area? Calm Busy, but reasonable Hectic, chaotic 12345 7. My professional values are well aligned with those of my department leaders: Strongly disagreeDisagreeNeither agree nor disagreeAgreeAgree strongly 8. My professional values are well aligned with those of our organizational leaders: Strongly disagreeDisagreeNeither agree nor disagreeAgreeAgree strongly *This survey was developed by Dr. Mark Linzer (Division Director, General Internal Medicine) and his team at Hennepin County Medical Center in Minneapolis MN as part of his ongoing research in Clinician Worklife and Satisfaction. Disclaimer-this is adapted from the OWL (Office and Work Life™ measure); more detailed surveys are often needed for second stage work. Center for Patient and Provider Experience at

36. 1. Visible site for clinician wellness 2. Wellness Champions in each setting 3. Periodic, brief surveys of stress, burnout and remediable predictors 4. Focused action plans to promote wellness 5. Role for managers – oversee the wellness focus and transformation Center for Patient and Provider Experience at

37. Been a privilege to share our research with you. Thank you for listening and participating! Center for Patient and Provider Experience at