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1 Introduction âBurnout comes from loss of connection to our patients, to ourselves, and to those we love. Too often in health care today we focus on tasksâon doing the appropriate tests and making the right diagnosis, when what our patients want and what we truly crave is to feel connected.â (She Knows You Are Coming, Jay Kaplan)1 In the 20 years since publication of the landmark Institute of Medicine (IOM) studies To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) many strategies have been employed to improve the safety and quality of health care in the United States. Improving the performance of the U.S. health care system to achieve the goals of better population health, enhanced patient care experiences, and lower health care costs (Berwick et al., 2008; Sikka et al., 2015; Whittington et al., 2015) depends in large part on clinicians, the health care professionals who provide direct patient care.2 Delivering safe, patient-centered, high-quality, and high-value health care requires a clinical workforce that is functioning at the highest level. However, there is growing recognition among health 1 Excerpted from the National Academy of Medicineâs Expressions of Clinician Well- Being: An Art Exhibition. To see the complete work by Jay Kaplan, visit https://nam.edu/Â expressclinicianwellbeing/#/artwork/257 (accessed January 30, 2019). 2 See Chapter 2 for a discussion of the target population of clinicians in the report. 21
22 TAKING ACTION AGAINST CLINICIAN BURNOUT care system experts that clinician well-being, so essential to the therapeutic alliance among clinicians, patients, and families, is eroding because of oc- cupational stress (Bodenheimer and Sinsky, 2014; Sikka et al., 2015; Street et al., 2009). The high rates of burnout reported among U.S. health care clinicians, and clinical students and trainees (âlearnersâ), are a strong indi- cation that the nationâs health care system is failing to achieve the aims for system-wide improvement. Although occupational stress can take multiple forms, professional burnout, a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accom- plishment from work, is the best-studied phenomenon (Bodenheimer and S Â insky, 2014; Schaufeli et al., 2009; Shanafelt et al., 2012, 2014). Exten- sive research has found that between 35 and 54 percent of U.S. nurses and physicians have substantial symptoms of burnout (Aiken et al., 2002b, 2012; McHugh et al., 2011; Moss et al., 2016; Shanafelt et al., 2009, 2012, 2015, 2019); similarly, the prevalence of burnout ranges between 45 and 60 percent for medical students and residents (Dyrbye et al., 2014; West et al., 2011). Burnout among health care clinicians and learners has been most studied in the medical and nursing professions; however, a growing understanding of the epidemiology and etiology of the syndrome suggests that burnout among all types of clinicians and learners is a growing public health concern (Jha et al., 2019). The high rate of clinician and learner burnout is a strong signal to health care leaders that major improvements in the clinical work and learning environments have to become a national and organizational priority. A growing body of research suggests that the changing landscape of the U.S. health care systemâhow care is provided, documented, and reimbursedâhas had profound effects on clinical practice and consequently on the experiences of clinicians, learners, patients, and their families. As the committee summarizes in the report, many mounting system pressures have contributed to overwhelming job demands for clinicians (e.g., workload, time pressures, technology challenges, moral and ethical dilemmas) and insufficient job resources and supports such as adequate job control, alignment of professional and personal values, and manageable workâlife integration. A chronic imbalance of high job demands and inadequate job resources can lead to burnout. The job demandâresources imbalance in health care is exacerbated by the increasing push for system performance improvement (which leads to greater administrative burden, production pressures, and shifts in financial incentives and payment structures); by technology implementation that hinders rather than supports patient care; by changing professional expectations; as well as by standards and regulatory policies that are insufficiently aligned with the delivery of high- quality patient care or professional values. Intensifying these and other
INTRODUCTION 23 health system pressures on the clinical workforce is the explosive increase in the amount of medical information and data collected and the growing demand for health care as the U.S. population ages, including care and services for chronic conditions (Irving, 2017) and social care3 (NASEM, 2019a), in the face of an existing shortage of health professionals in many areas (Gruca et al., 2018; IHS Markit, 2017; Zhang et al., 2018). Burnout resulting from chronic workplace stress is not a new phenom- enon among clinicians or among other workers. However, the common perception that a job in the health care professions is generally associated with socioeconomic benefits may actually be a barrier to recognizing and ad- dressing the wide-ranging effects of clinician burnout. Several decades of re- search on the characteristics, the causes, and the outcomes of burnout clearly show that burnout has high personal costs for individual workers, but it also has high social and economic costs for their organizations (Maslach, 2018) and for society as a whole. For example, in health care, studies have found strong links between clinician burnout and unprofessional behavior lead- ing to undesirable patient experiences (Windover et al., 2018). Clinicians with burnout are at least twice as likely to report they have made a major medical error in the past 3 months as those without burnout, and they are also more likely to be involved in a malpractice litigation suit (Panagioti et al., 2018; Shanafelt et al., 2010; West et al., 2006, 2009). Physicians with Â burnout are more likely to reduce their clinical work hours, at least twice as likely to leave their job, and, worse yet, five times more likely to leave medicine altogetherÂ (Dyrbye et al., 2013; Hamidi et al., 2018; Linn et al., 1985; Shanafelt et al., 2009; Willard-Grace et al., 2019; Windover et al., 2018). Approximately 2,400 physicians leave the workforce each year, with professional burnout the largest factor influencing a decision to leave medi- cine early (Sinsky et al., 2017). Not only does this affect access to care, but an estimated $4.6 billion in societal costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States (Han et al., 2019). This figure does not account for the additional societal cost of burnout in other health care clinicians, which, to the com- mitteeâs knowledge, has not been estimated. These and other consequences of burnout are further discussed in Chapters 3 and 8. There is growing momentum for taking action to improve the qual- ity and safety of health care by addressing clinician and learner burnout (Aiken et al., 2002a; Dzau et al., 2018; Jha et al., 2019; Lake et al., 2019; Noseworthy et al., 2017; Perni, 2017; Shanafelt et al., 2017b). Catalyzing collective action to reduce burnout and improve clinician well-being is the core goal of the National Academy of Medicineâs (NAMâs) Action Col- laborative on Clinician Well-Being and Resilience, which was developed 3 Social care addresses health-related social risk factors and social needs (NASEM, 2019a).
24 TAKING ACTION AGAINST CLINICIAN BURNOUT in collaboration with the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges. The calls to accelerate progress toward improving professional well-being among clinicians build on the current focus of professionalism in health care. Clinicians are intrinsically motivated and committed to providing patients with high-Â uality, patient-centered care (Chassin and Baker, 2015; Madara q and Burkhart, 2015). It is when the health care system makes it difficult for clinicians to âfulfill their ethical commitments and deliver the best possible careâ that work takes a personal toll (Dzau et al., 2018, p. 312). Given the importance of burnout to health care quality and safety and the pervasiveness of burnout, there is a strong imperative to take a systemic approach to reduce it, focusing on the structure, organization, and culture of health care (Dzau et al., 2018; Shanafelt and Noseworthy, 2017; Shanafelt et al., 2017b). A systems approach incorporates thorough knowledge of several factors, including the stakeholders, their goals and activities, the technologies they use, and the environment in which they operate. In designing and implementing effective systems-focused interven- tions, it is crucial to consider the fact that health care is a âcomplex adap- tive systemâ in which the complex interplay of all of these factors affects system outcomes (NASEM, 2018; Plsek and Greenhalgh, 2001; Rouse, 2008). The Crossing the Global Quality Chasm: Improving Health Care Worldwide (NASEM, 2018) report provides general principles for building a new health care system that consider the complex adaptive nature of the health care system (see Box 1-1). A systems framework to improving health care more generally was the focus of a 2005 National Academy of Engineering and IOM report (NAE and IOM, 2005). The World Health Organization further advanced systems thinking as the standard in health system interventions and evaluation de- sign by providing tools and guidance (De Savigny and Adam, 2009). More recently, a 2014 Presidentâs Council of Advisors on Science and Technology report promoted the greater use of systems-engineering principles as a way of enhancing U.S. health care (PCAST, 2014). The subjects of recent systems- oriented approaches to complex public health issues have included dÂagnostic i error (NASEM, 2015), global health care quality (NASEM, 2018), tobacco use (IOM, 2015), obesity (IOM and NRC, 2015), cancer control (NASEM, 2019b), and a variety of case studies (Kaplan et al., 2013). Creating healthy and safe care systems for the nationâs patients and clinicians is a complex endeavor. Many factors over time have contributed to the current state. âFixingâ a single variable in the system, such as the electronic health record, will not solve the burnout problem by itself, nor will it be sufficient to gain the deep understanding necessary for a compre- hensive solution. Many different aspects of the health care environment have to work together in an integrated way to prevent, reduce, or mitigate
INTRODUCTION 25 BOX 1-1 Proposed New Design Principles to Guide Health Care Developed by the Committee on Improving the Quality of Health Care Globally â1. Systems thinking drives the transformation and continual improvement of care delivery. â2. Care delivery prioritizes the needs of patients, health care staff, and the larger community. â 3. Decision making is evidence based and context specific. â 4. Trade-offs in health care reflect societal values and priorities. â 5. Care is integrated and coordinated across the patient journey. â 6. Care makes optimal use of technologies to be anticipatory and predictive at all system levels. â 7. Leadership, policy, culture, and incentives are aligned at all system levels to achieve quality aims and promote integrity, stewardship, and accountability. â 8. Navigating the care delivery system is transparent and easy. â 9. Problems are addressed at the source, and patients and health care staff are empowered to solve them. 10. Patients and health care staff co-design the transformation of care delivery and engage together in continual improvement. 11. The transformation of care delivery is driven by continuous feedback, learn- ing, and improvement. 12. The transformation of care delivery is a multidisciplinary process with adeÂ quate resources and support. 13. The transformation of care delivery is supported by invested leaders. SOURCE: NASEM, 2018. burnout and improve professional well-being (Shanafelt and Noseworthy, 2017; Shanafelt et al., 2017b). Systems-oriented strategies will need to in- clude making improvements in clinician workload and clinical workflow, providing more usable technologies that are focused on cliniciansâ needs, and developing organizational structures and processes that better support clinicians and the interdisciplinary care teams in which they work (Andela et al., 2017; Bodenheimer and Willard-Grace, 2016; Catt et al., 2005). IndiÂ vidually focused interventions, such as group discussions and mindfulness education, can be complementary to system interventions (Krasner et al., 2009; Panagioti et al., 2017; West et al., 2014). There is a serious problem of burnout among health care professionals in this country, with consequences for both clinicians and patients (e.g., safety), health care organizations (e.g., productivity), and society (e.g., cost of care) (Panagioti et al., 2018; Shanafelt et al., 2017a; West et al., 2018). This report by the Committee on Systems Approaches to Improve Patient
26 TAKING ACTION AGAINST CLINICIAN BURNOUT Care by Supporting Clinician Well-Being synthesizes current knowledge about the prevalence, causes, and consequences of clinician burnout and makes recommendations on how best to design systems approaches to re- duce clinician burnout and support professional well-being. ORIGIN OF THE TASK AND COMMITTEE CHARGE The NAMâs Action Collaborative on Clinician Well-Being and Resil- ience (Action Collaborative) was launched in January 2017 in response to alarming rates of stress, burnout, and suicide among U.S. clinicians. The Action Collaborative is a network of more than 190 organizations com- mitted to reversing these trends and improving clinician well-being. The leadership of the Action Collaborative requested that the Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine undertake a consensus study that would serve as one approach to achieving the Action Collaborativeâs goals for addressing clinician burnout and well-being. The Action Collaborative has three goals: (1) to raise the visibility of clinician stress, burnout, depression, moral injury, and suicide; (2) to improve the baseline understanding of the challenges to clinician well-being; and (3) to advance evidence-based, multidisciplinary approaches to improving patient care by caring for the caregiver. The Action Collab- orativeâs working groups meet regularly to identify strategies for improving clinician well-being at both the individual and systems levels.4 With support from a broad coalition of sponsors (see Box 1-2), the study was launched in June 2018. The charge to the committee was to examine the scientific evidence on clinician burnout and well-being and to make recommendations about systems approaches to reduce burnout and improve well-being, including providing a research agenda to address areas of uncertainty (see Box 1-3). An independent committee was appointed with a broad range of ex- pertise, including in clinical care, health care systems and administration, health information technology, health care quality, health professional edu- cation, systems engineering/organizational science, human-systems inte- gration, human factors and ergonomics, health care policy and financing, oversight of clinical documentation, burnout, research methodology, imple- mentation science, and medical ethics. Brief biographies of the 17 members of this Committee on Systems Approaches to Improve Patient Care by Sup- porting Clinician Well-Being are presented in Appendix A. 4 For more information about the Action Collaborative and to view the many resources developed on the topic of clinician well-being, please visit https://nam.edu/initiatives/clinician- resilience-and-well-being (accessed October 1, 2018).
INTRODUCTION 27 BOX 1-2 Sponsors of Taking Action Against Clinician Burnout: A Systems Approach to Improving Professional Well-Being Accreditation Council for Graduate Tulane University ââMedical Education University of Florida American College of Occupational and University of Illinois Hospital ââEnvironmental Medicine â â and Health Sciences System American Hospital Associationâ University of Massachusetts Arnold P. Gold Foundation â â Medical School Association of American Medical Colleges University of Michigan BJC HealthCare University of New Mexico Health CedarsâSinai Medical Center ââ Sciences Center Doctors Company Foundation, The University of North Carolina Duke University Hospital ââ at Chapel Hill Gordon and Betty Moore Foundation University of Utah Health Johns Hopkins Health System University of Virginia Medical Josiah Macy Jr. Foundation ââ Center Keck School of Medicine of the University University of Virginia School ââof Southern California ââof Medicine Medical College of Wisconsin Vanderbilt University Medical Montefiore Medicine ââCenter Mont Fund, The Washington University Schoolâ Ohio State University, The ââof Medicine State University of New York Yale New Haven Health System ââSystem, The Yale School of Medicine METHODS OF THE STUDY The committee deliberated during four 2-day, in-person meetings and many conference calls that took place between October 1, 2018, and May 31, 2019. At two of the meetings speakers were invited to inform deliberations and members of the public were given the opportunity to offer comments and suggestions. The speakers provided valuable input to the committee on a broad range of topics, including burnout, moral distress, resilience, work- place health and safety, the nursing work environment, patient safety, tech- nology in health care, clinical documentation requirements, administrative burden, and the usability of electronic health records. A number of experts and organizations provided written input to the committee on an array of topics. In addition, the committee completed an extensive search of the peer- reviewed literature, ultimately considering more than 4,000 articles. The search targeted English-language articles published since 2000 concerning
28 TAKING ACTION AGAINST CLINICIAN BURNOUT BOX 1-3 Charge to the Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being An ad hoc committee under the auspices of the National Academies of Sci- ences, Engineering, and Medicine will examine the scientific evidence regarding the causes of clinician burnout as well as the consequences for both clinicians and patients and interventions to support clinician well-being and resilience. The committee will examine components of the clinical training and work environment that can contribute to clinician burnout in a variety of care settings as well as potential systems interventions to mitigate those outcomes. The committee will identify promising tools and approaches to support clinician well-being, identify gaps in the evidence base, and propose a research agenda to address areas of uncertainty. In developing its report, the committee will consider key components of the health care system, including â¢ factors that influence clinical workflow, workload, and humanâsystems interactions; â¢ the training, composition, and function of interdisciplinary care teams; â¢ the ongoing movement toward outcomes-based payment and quality improvement programs; â¢ current and potential use and impact of technologies and tools such as electronic health records and other informatics applications; and â¢ regulations, guidance, policies, and accreditation standards that define clinical documentation and coding requirements, as well as institutional expectations and interpretations of those requirements. The committee may develop a conceptual framework that encapsulates its findings and will issue a report with recommendations for system changes to streamline processes and manage complexity, minimize the burden of documentation requirements, and enhance workflow and teamwork to support the well-being of all clinicians and trainees on the care team, prevent clinician burnout, and facilitate high-quality patient care. U.S. and international health care professionals. International papers about physicians and nurses were referenced in some instances when the data were particularly strong or filled a void. In particular, because there were limited data on dentists and pharmacists, the committee had to rely more on research conducted in settings outside of the United States. The committee also re- viewed grey literature, including publications by professional associations, government agencies, and business and industry. See Chapter 9 for a discus- sion about the gaps in the literature and the areas needing further research.
INTRODUCTION 29 CONCEPTUAL FRAMEWORK The studyâs Statement of Task (see Box 1-3) places emphasis on âsys- tems approachesâ to achieve the dual objective of improving patient care and addressing clinician burnout and well-being. To help orient and or- ganize its work, the committee developed a conceptual framework that harnesses systems thinking and design principles with the goal of fostering healthy and safe care systems for the nationâs clinicians and patients. In Chapter 2 the committee describes this framework and presents a systems model of clinician burnout and professional well-being, which is discussed and elaborated on throughout the report. Target Population, Health Care Organizations, and Educational Institutions Clinicians and Learners The Statement of Task refers to âall clinicians and trainees on the care team.â In the committeeâs framework, the term âcliniciansâ is used to refer to health care professionals who provide direct patient care. The term âlearnersâ includes students and trainees, who learn and work within various and diverse settings, including classrooms, laboratories, and clini- cal settings. After reviewing the literature, the committee found that much of the evidence is related to physicians and nurses. Although physicians and nurses are the focus of most of the available published research, there is limited but consistent evidence that burnout is also a significant problem among phar- macists, dentists, nurse practitioners, and physician assistants. Furthermore, the available evidence suggests that burnout is present to varying degrees in other health care professionals and clinicians (e.g., genetic and mental health counselors, perfusionists, respiratory therapists). The evidence provided in the literature about burnout informed the development of the committeeâs framework. On the basis of this evidence, the committee determined it was important to develop a framework that shines a light on many fundamental aspects of the health care system that are barriers to healthy work and learning environments. The prin- ciples that define the committeeâs framework are based on theories and constructs from systems science (see Chapter 2, Box 2-2) that are appli- cable to various types of workers and workplaces. Based on the available literature the committee believes that many evidence-based approaches used by high-functioning systems and healthy work environments in other domains are relevant to health care inclusive of all clinicians. Because the factors contributing to burnout or affecting well-being will vary by clinical
30 TAKING ACTION AGAINST CLINICIAN BURNOUT profession, organization, and even by individuals in the same work envi- ronment, the committeeâs report does not provide a prescriptive approach, but rather offers health care leaders and other stakeholders guidance to improve the well-being of clinicians in all disciplines to the extent they are relevant and meaningful to the local context. The committeeâs framework is intended to be dynamicâit includes a learning feedback loop, by which the system can adapt to new or different inputs. These inputs can include new information and data about clinician characteristics or other vari- ables that future research studies suggest are important. The next steps in understanding and acting on clinician burnout more broadly is to use the framework as a platform for expanding research and pilot projects relating to other disciplines and a myriad of other areas, as discussed in Chapter 9, A Research Agenda to Advance Clinician Well-Being. Like the early IOM studies about safety and quality (IOM, 2000, 2001), this report sets the stage for much subsequent work. Health Care Organizations and Educational Institutions In the report, the term âhealth care organizationâ (HCO) broadly ap- plies to all types of care-providing entitiesâfrom single clinician offices to large, integrated health systems. All HCOs comprise people, processes, and resources that are part of a system that delivers care services to meet the health needs of patients. âHealth professions educational institutionsâ refers to organizations that provide health care professional education and training (e.g., professional schools, undergraduate and graduate programs, sponsoring health care organizations). These organizations are a system comprising people, processes, and resources that provide structure, guid- ance, and support for learning.
INTRODUCTION 31 Connections Heal Patients and Clinicians a We have experienced firsthand the extraordinary pressures facing students, clinicians, patients, and families surround- ing health care delivery. We were immersed at two ends of the health care spectrumâour daughterâs last year of medi- cal school, and my motherâs struggle with lung cancer. We couldnât help but notice the â¦ medical students and resi- dents were under pressure to learn and perform, magnified by daunting hours and exhaustion. We watched the pressures on my motherâs care team, as they searched for ways to manage her disease while giving her hope â¦ and patiently listening to anxious loved ones as they tried to cope. I witnessed my daughterâs 3-day vigil at her grandmotherâs bedside â¦ know- ing that as a physician she would face this scene hundreds of times again. Ironically, she missed her final class on death and dying â¦ living it instead. And though we often wilted under the pressure we felt, we were awed by the compassion and resilience of the clinicians. They âmanagedâ the pressure, even embraced it. It gave us strength. For clinicians, â¦ my hope would be that they can find both strength and balance in their role, knowing the value they bring to the patients they care for and the lives they touch. a Excerpted from the National Academy of Medicineâs Expressions of Clinician Well- Being: An Art Exhibition. To see the complete work by Angela Sanders, visit https://nam. edu/expressclinicianwellbeing/#/artwork/214 (accessed January 30, 2019). SOURCE: Under Pressure, Angela Sanders.
32 TAKING ACTION AGAINST CLINICIAN BURNOUT ORGANIZATION OF THE REPORT The committee organized this report into 10 chapters. Chapter 2 de- fines the concepts of burnout, professional well-being, and resilience. It further describes the committeeâs systems approach and conceptual frame- work for addressing clinician burnout and professional well-being, which are grounded in the theories and principles of human factors and systems engineering, job and organizational design, and occupational safety and health. Chapter 3 discusses the prevalence and consequences of clinician burnout. Chapter 4 describes the contributing factors of clinician burnout and professional well-being in terms of job demands and job resources as well as the individual clinician factors that mediate burnout. Chapter 5 focuses on health care organizations, interventions that target burnout in the workplace, and the principles with which health care organizations can design well-being systems. Chapter 6 describes how the external environ- ment (including the health care industry, laws, regulations, standards, and societal values) can contribute to workplace stress. Chapter 7 discusses cur- rent and future health information technology, how stakeholders across all levels can work to improve it, and the potential of emerging technologies to reduce some of the burdens that contribute to burnout. Chapter 8 discusses the prevalence and consequencesâas well as the contributing factorsâof burnout among students and trainees of the health professions. Chapter 9 discusses the gaps in the current research on burnout and well-being and proposes a research agenda to advance the field. Chapter 10 details the committeeâs main conclusions and recommendations for reducing clinician burnout and improving professional well-being. REFERENCES AHA (American Hospital Association). 2018. Clinician well-being. https://www.aha.org/ topics/clinician-well-being (accessed July 3, 2018). Aiken, L. H., S. P. Clarke, and D. M. Sloane. 2002a. Hospital staffing, organization, and quality of care: Cross-national findings. International Journal for Quality in Health Care 14(1):5â13. Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, and J. H. Silber. 2002b. Hospi- tal nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288(16):1987â1993. Aiken, L. H., W. Sermeus, K. Van Den Heede, D. M. Sloane, R. Busse, M. McKee, L. Bruyneel, A. M. Rafferty, P. Griffiths, M. T. Moreno-Casbas, C. Tishelman, A. Scott, T. Brzostek, J. Kinnunen, R. Schwendimann, M. Heinen, D. Zikos, I. S. Sjetne, H. L. Smith, and A. Kutney-Lee. 2012. Patient safety, satisfaction, and quality of hospital care: Cross sec- tional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ (Online) 344:e1717. Andela, M., and D. J. S. Truchot. 2017. Emotional dissonance and burnout: The moderating role of team reflexivity and re-evaluation. Stress and Health 33(3):179â189.
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