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Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and Accreditation Council for Graduate Medical Education, American College of Occupational and Environmental Medicine, American Hospital Association, Arnold P. Gold Foundation, Association of American Medical Colleges, BJC HealthCare, Cedars-Sinai Medical Center, The Doctors Company Foundation, Duke University Hospital, Gordon and Betty Moore Foundation, Johns Hopkins Health System, Josiah Macy Jr. Foundation, Keck School of Medicine of the University of Southern California, Medical College of Wisconsin, Montefiore Medicine, The Mont Fund, The Ohio State University, The State University of New York System, Tulane University, University of Florida, University of Illinois Hospital and Health Sciences System, University of Massachusetts Medical School, University of Michigan, University of New Mexico Health Sciences Center, University of North Carolina at Chapel Hill, University of Utah Health, University of Virginia Medical Center, University of Virginia School of Medicine, Vanderbilt University Medical Center, Washington University School of Medicine, Yale New Haven Health System, and Yale School of Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25521 Library of Congress Control Number: Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2019 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Taking action against clinician burnout: A systems approach to professional well-being. Washington, DC: The National Academies Press. https://doi. org/10.17226/25521. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE ON SYSTEMS APPROACHES TO IMPROVE PATIENT CARE BY SUPPORTING CLINICIAN WELL-BEING PASCALE CARAYON (Co-Chair), Leon and Elizabeth Janssen Professor, Director of the Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin–Madison CHRISTINE CASSEL (Co-Chair), Senior Advisor on Strategy and Policy, Professor of Medicine, University of California, San Francisco ELISABETH BELMONT, Corporate Counsel, MaineHealth NEIL BUSIS, Director, Community Neurology, and Director, General Teleneurology Program, University of Pittsburgh Medical Center M. LYNN CRISMON, Dean, James T. Doluisio Regents Chair and Behrens Professor of Pharmacy, College of Pharmacy, and Professor, Department of Psychiatry, Dell Medical School, The University of Texas at Austin LISELOTTE DYRBYE, Professor of Medicine and Medical Education, Co-Director, Program on Physician Well-Being, Mayo Clinic POOJA KINKHABWALA, Endocrinology Fellow, Larkin Community Hospital WANDA LIPSCOMB, Senior Associate Dean for Diversity and Inclusion, Associate Dean for Student Affairs, Associate Professor of Psychiatry, College of Human Medicine, Michigan State University SARANYA LOEHRER, Head of Innovation, Institute for Healthcare Improvement M. A. J. LEX MacNEIL, Founding Dean and Professor, College of Dental Medicine-Illinois, Midwestern University (retired) JOSÉ PAGÁN, Chair and Professor, Department of Public Health Policy and Management, College of Global Public Health, New York University SHARON PAPPAS, Chief Nurse Executive, Emory Healthcare and Professor, Nell Hodgson Woodruff School of Nursing, Emory University CYNDA RUSHTON, Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics and School of Nursing, Johns Hopkins University TAIT SHANAFELT, Associate Dean, Chief Wellness Officer, and Jeanie and Stew Ritchie Professor of Medicine, Stanford Medicine GEORGE THIBAULT, Former President, Josiah Macy Jr. Foundation, and Daniel D. Federman Professor of Medicine and Medical Education Emeritus, Harvard Medical School VINDELL WASHINGTON, Chief Medical Officer, Blue Cross and Blue Shield of Louisiana v PREPUBLICATION COPY—Uncorrected Proofs

MATTHEW WEINGER, Director, Center for Research and Innovation in Systems Safety, Professor, Vanderbilt University Schools of Medicine and Engineering, Staff Physician, Veterans Affairs Tennessee Valley Healthcare System Study Staff Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine LAURA AIUPPA DENNING, Study Director MARC MEISNERE, Associate Program Officer RAJBIR KAUR, Senior Program Assistant (until October 2019) SHARYL NASS, Board Director Board on Human-Systems Integration, Division of Behavioral and Social Sciences and Education, National Academies of Sciences, Engineering, and Medicine HEATHER KREIDLER, Associate Program Officer (until July 2019) TOBY WARDEN, Board Director vi PREPUBLICATION COPY—Uncorrected Proofs

Title: Woven Artist: Tia Calvert (Rochester, MN) Artist Statement: Working at a health care organization, I see the effects of burnout, but I also see resiliency in our providers. Woven represents the intricacies, layers, and com- plexities of feeling burnt out while serving patients. It doesn’t happen all at once, but builds over time. The shimmering threads represent life and hope that is e ­ mbedded in each provider; the spirit of serving; and the belief that you will make a difference. All of these aspects woven together are the essence of the provider. This artwork was submitted as part of the National Academy of Medicine’s E ­ xpressions of Clinician Well-Being, an art exhibition that collected insights ­ irectly d from clinicians, patients, loved ones, and organizations working to prevent burn- out and promote well-being. For more information on the exhibition, please visit nam.edu/expressclinicianwellbeing. PREPUBLICATION COPY—Uncorrected Proofs

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Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: PATTI ABBOTT, University of Michigan School of Nursing MOHAMMED ALI, Rollins School of Public Health, Emory University ALAN BALCH, National Patient Advocate Foundation DAVID W. BATES, Brigham and Women’s Hospital and Partners Healthcare System CARLOS DEL RIO, Rollins School of Public Health, Emory University CASWELL A. EVANS, JR., College of Dentistry, University of Illinois at Chicago (Retired) EVE KERR, Veterans Affairs Ann Arbor Healthcare System and University of Michigan EILEEN LAKE, University of Pennsylvania CATHERINE LUCEY, University of California, San Francisco ix PREPUBLICATION COPY—Uncorrected Proofs

x REVIEWERS NAJM MESHKATI, Viterbi School of Engineering, University of Southern California WILLIAM M. SAGE, The University of Texas at Austin School of Law and Dell Medical School THOMAS SCHWENK, University of Nevada, Reno CHRISTINE SINSKY, American Medical Association PAUL C. TANG, IBM Watson Health Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by MARLA E. SALMON, University of Washington, and DON EUGENE DETMER, University of Virginia School of Medicine. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments We, the members of the National Academies of Sciences, Engineering, and Medicine’s Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, wish to express our sincere gratitude to the many individuals and groups who helped with this report. The committee appreciates the generous funding support extended by these sponsors: Accreditation Council for Graduate Medical Education, American College of Occupational and Environmental Medicine, American Hospital Association, Arnold P. Gold Foundation, Association of American Medical Colleges, BJC HealthCare, Cedars-Sinai Medical Center, The Doc- tors Company Foundation, Duke University Hospital, Gordon and Betty Moore Foundation, Johns Hopkins Health System, Josiah Macy Jr. Foun- dation, Keck School of Medicine of USC, Medical College of Wisconsin, Montefiore Medicine, The Mont Fund, The Ohio State University, The State University of New York System, Tulane University, University of Florida, University of Illinois Hospital and Health Sciences System, University of Massachusetts Medical School, University of Michigan, University of New Mexico Health Sciences Center, University of North Carolina at Chapel Hill, University of Utah Health, University of Virginia Medical Center, University of Virginia School of Medicine, Vanderbilt University Medical Center, Washington University School of Medicine, Yale New Haven Health System, and Yale School of Medicine. Over the course of the study, we received valuable information and in- sight from a number of individuals with expertise in fields related to systems approaches to clinician burnout and professional well-being. Thank you to the presenters at our public meetings: xi PREPUBLICATION COPY—Uncorrected Proofs

xii ACKNOWLEDGMENTS David Bates, Brigham and Women’s Hospital and Partners HealthCare System Jay Bhatt, American Hospital Association Molly Coye, AVIA Andy Gettinger, The Office of the National Coordinator for Health Information Technology Mira Irons, American Board of Medical Specialties Darrell G. Kirch, Association of American Medical Colleges Richard I. Levin, Arnold P. Gold Foundation Barry Marx, Centers for Medicare & Medicaid Services Matthew McHugh, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania Robert McLellan, Dartmouth-Hitchcock Medical Center Marc Moss, University of Colorado School of Medicine Thomas J. Nasca, Accreditation Council for Graduate Medical Education Marc Overhage, Cerner Corporation Laura Punnett, University of Massachusetts at Lowell William C. Rupp, The Doctors Company Foundation Stephen C. Schoenbaum, Josiah Macy Jr. Foundation Kelley Skeff, Stanford University School of Medicine Emily Yoder, Centers for Medicare & Medicaid Services Many within the National Academies were helpful to study staff. We would like to thank Lauren Shern (Health and Medicine Division Executive Office); Greta Gorman, Nicole Joy, and Tina Seliber (communications and report production). We also appreciate the valuable assistance from Rebecca Morgan (National Academies Research Center); Dana Korsen and Stephanie Miceli (Office of News and Public Information). This report was also made possible by the leadership and support of the staff of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, including Victor Dzau, Michael McGinnis, Charlee Alexander, Kyra Cappelucci, Ivory Clarke, Laura DeStefano, Imani Rickerby, Samantha Phillips, and Mariana Zindel. PREPUBLICATION COPY—Uncorrected Proofs

Preface Twenty years ago, in its two landmark reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine (IOM) called for dramatic attention to the issue of patient safety and more broadly qual- ity of care. The reports led to major changes in the design of health care work systems and processes to improve quality of care, and reduce prevent- able patient harm. This report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, is a critical follow-up to these major reports and other reports in the IOM’s Quality Chasm Series, as it calls attention to the safety, health, and well-being of health care clinicians. We were pleased to co-chair the work of this consensus study committee, as our respective areas of expertise—bioethics, professionalism, and quality of care and human factors and systems engineering in health care—are both essential to understanding this complex phenomenon. The report has two major overarching themes. First, clinician burnout is a major problem; the report calls for immediate action. Health care is going through many dramatic changes (related to technology, regulation, policy, societal trends) that have profound impact on health care delivery and consequently the organizations that deliver care and the people who work within them to care for patients. In this rapidly changing and stressful environment, the rates of burnout among clinicians are alarming. Clinicians are motivated and guided by professional oaths and values that are chal- lenged by these profound changes in the external environment, in health care organizations and in learning and work environments. This creates real or perceived dissonance of values and mismatch of resources with xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv PREFACE job demands experienced by clinicians. Clinician burnout is bad for both clinicians and patients. Emotional exhaustion, depersonalization, and loss of sense of professional efficacy—the three dimensions of burnout—are detrimental to quality of care. Clinician burnout is also costly for organiza- tions experiencing workforce shortages and difficulty retaining high-quality clinicians. Clinicians suffering burnout are poor teachers and role models for students and trainees, extending these concerns throughout the learning environment. The report calls for immediate action by health care organi- zations, health professions educational institutions, and health care policy, regulatory, and standards-setting entities. Second, clinician burnout is a complex multi-factorial problem that is not easily solved; the report recommends a systems approach to reducing clini- cian burnout and fostering professional well-being. Multiple work system factors contribute to clinician burnout (e.g., high workload, administrative burden, poorly designed technologies) and stem from decisions or actions taken at various levels in health care: the local frontline care delivery level, health care organizations, and multiple policy and regulatory actors in the external environment. The report shows that multiple interacting factors pro- duce imbalances in job demands and resources experienced by clinicians at all stages of their professional development and career. Humanism and pro- fessionalism are two major motivating factors for most clinicians, and many aspects of the modern work environment conflict with these fundamental ethical norms. Regulatory and institutional policies, payer requirements, and intrusive, difficult technologies all challenge the basic ethical motivations that are essential to professional fulfillment of the human beings who are central to high-quality patient care. Therefore, work system transformation with meaningful, effective involvement of clinicians is necessary at multiple levels to tackle the critical problem of burnout. Health care organizations have a key role in this transformation; they need to adopt systems design principles to reduce clinician burnout and foster professional well-being. In the context of these overarching themes, the report highlights specific key issues of clinician burnout that need to be addressed: • Clinician burnout needs to be tackled early in professional develop- ment, and special stressors in the learning environment need to be recognized. • Stakeholders in the external environment have an important role to play in preventing clinician burnout as their decisions can result in increased burden and other demands that affect clinician burn- out. Every attempt at alignment and reduction of requirements to reduce redundancy is essential. • Technology can either contribute to clinician burnout (e.g., poorly designed electronic health record technologies) or potentially reduce clinician burnout (e.g., well-functioning patient communications, PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xv clinical decision support) if it is well designed, implemented, and integrated into clinical workflow. The report reiterates several rec- ommendations of previous IOM and National Academies of Sci- ences, Engineering, and Medicine reports to improve usability, workflow integration, and inter-operability of health information technology. • Medical societies, state licensing boards, specialty certification boards, medical education and health care delivery organizations all need to take concrete steps to reduce the stigma for clinicians of seeking help for psychological distress, and make assistance more easily available. There were areas where the study committee wished we could go fur- ther but found insufficient evidence to support strong recommendations. One of those areas is interventions. The evidence for system interventions that significantly address clinician burnout is limited. Some organizational interventions (e.g., changes to clinical work processes) can reduce clinician burnout, and individual interventions (e.g. stress management) may also be effective, but they do not address some of the core work system factors that contribute to clinician burnout. In light of the limited evidence base, the study committee was not able to provide specific recommendations for system interventions. The report strongly recommends that health care or- ganizations create, implement and evaluate their own interventions by using a systematic approach to reducing clinician burnout, use rigorous methods of evaluating burnout and burnout risk, and do so while openly sharing their lessons learned with other health care organizations. The report also calls for investment in research on organizational interventions. As co-chairs of the study committee, we thank all the members of the committee for their individual and group contributions. In our experience, neither of us has seen such intense dedication and level of contribution of volunteer committee members. We learned a great deal from this diverse group, and are extremely grateful for the opportunity to work with them. None of the work of the committee would have been possible without the professional staff of the National Academies, led by the study director, Laura Aiuppa, in collaboration with Marc Meisnere, Rajbir Kaur, Heather Kreidler, and other National Academies staff. Both personally and on behalf of the study committee, we thank them for a truly collaborative, incredibly effective, and productive process. Christine Cassel and Pascale Carayon,   Co-Chairs Committee on Systems Approaches to    Improve Patient Care by Supporting   Clinician Well-Being PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xix SUMMARY 1 1 INTRODUCTION 21 2 A FRAMEWORK FOR A SYSTEMS APPROACH TO CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING 37 3 EXTENT AND CONSEQUENCES OF CLINICIAN BURNOUT 63 4 FACTORS CONTRIBUTING TO CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING 81 5 HEALTHY AND SAFE HEALTH CARE ORGANIZATIONS 127 6 THE INFLUENCE OF THE EXTERNAL ENVIRONMENT ON CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING 167 7 HEALTH INFORMATION TECHNOLOGY 199 xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii CONTENTS 8 STUDENT AND TRAINEE BURNOUT AND PROFESSIONAL WELL-BEING 235 9 A RESEARCH AGENDA TO ADVANCE CLINICIAN WELL-BEING 273 10 CONCLUSIONS AND RECOMMENDATIONS 285 APPENDIXES A COMMITTEE AND STAFF BIOGRAPHIES 297 B MEDICARE PROGRAM, THE JOINT COMMISSION, AND INTERNATIONAL CLASSIFICATION OF DISEASES, TENTH REVISION, CLINICAL DOCUMENTATION AND CODING REQUIREMENTS 309 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations AACN American Association of Critical-Care Nurses AAMC Association of American Medical Colleges ABMS American Board of Medical Specialties ACA Patient Protection and Affordable Care Act of 2010 ACGME Accreditation Council for Graduate Medical Education ACP American College of Physicians ADA American with Disabilities Act AI artificial intelligence AMA American Medical Association AMIA American Medical Informatics Association ANCC American Nurses Credentialing Center APM Alternative Payment Model APN advanced practice nurse AUC Appropriate Use Criteria CMA certified medical assistant CME continuing medical education CMS Centers for Medicare & Medicaid Services CPOE computerized physician order entry EHR electronic health record FDA U.S. Food and Drug Administration FSMB Federation of State Medical Boards xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACRONYMS AND ABBREVIATIONS HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCD human-centered design HCO health care organization HCP health care professional HF/SE human factors and systems engineering HFE human factors engineering HFE human factors or ergonomics HHS U.S. Department of Health and Human Services HIE health information exchange HITECH Health Information Technology for Economic and Clinical Health Act HIPAA Health Insurance Portability and Accountability Act of 1996 HWE healthy work environment IM-ITE Internal Medicine In-Training Examination IOM Institute of Medicine IT information technology MACRA Medicare Access and CHIP Reauthorization Act of 2015 MBI Maslach Burnout Inventory MIPS merit-based Incentive Payment System MOC maintenance of certification NAM National Academy of Medicine ONC The Office of the National Coordinator for Health ­Information Technology PACT Patient Aligned Care Team PCMH patient-centered medical home PDMP Prescription Drug Monitoring Program PES-NWI Practice Environment Scale of the Nursing Work Index PHW Physician Worklife Study SaMD software as a medical device SAMHSA Substance Abuse and Mental Health Services Administration USMLE United States Medical Licensing Examination VA U.S. Department of Veterans Affairs WHO World Health Organization PREPUBLICATION COPY—Uncorrected Proofs

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Patient-centered, high-quality health care relies on the well-being, health, and safety of health care clinicians. However, alarmingly high rates of clinician burnout in the United States are detrimental to the quality of care being provided, harmful to individuals in the workforce, and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organization, and culture of health care.

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being builds upon two groundbreaking reports from the past twenty years, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, which both called attention to the issues around patient safety and quality of care. This report explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.

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