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2 A Framework for a Systems Approach to Clinician Burnout and Professional Well-Being âThere is hope that we can change this culture and not drive [clinicians] to extremes in which they cause harm to them- selves or inadvertently cause harm to patients as a result of a system that is making it harder for them to do what drove them to medicine in the first placeâto heal.â (Bridging the Gap, Zohal Ghulam-Jelani)1 To consider approaches for improving patient care by supporting the professional well-being of clinicians, the committee developed a conceptual framework that clarifies the structure and dynamics of the system in which clinicians work and reveals potential levers for change. The committeeâs framework for a systems approach to clinician burnout and professional well-being is based on theories and principles from the fields of human factors and systems engineering, job and organizational design, and occu- pational safety and health. Throughout the report, the committee applies this framework to examine many important aspects of the current system and to identify strategies that will foster healthy and safe care systems for the nationâs patients and clinicians. To set the context for the rest of the report, this chapter presents the definitions of burnout, professional well- being, and resilience; gives an overview of systems approaches informing 1 Excerpted from the National Academy of Medicineâs Expressions of Clinician Well-Being: An Art Exhibition. To see the complete work by Zohal Ghulam-Jelani, visit https://nam.edu/ expressclinicianwellbeing/#/artwork/347 (accessed January 30, 2019). 37
38 TAKING ACTION AGAINST CLINICIAN BURNOUT the committeeâs framework; and presents the committeeâs systems model of burnout and professional well-being. DEFINITIONS OF BURNOUT, PROFESSIONAL WELL-BEING, AND RESILIENCE âBurnout,â âwell-being,â and âresilienceâ are three distinct terms used in the Statement of Task and, more broadly, in the scientific and popular lit- erature about issues in the work environment for clinicians. Fundamentally, burnout is an obstacle to professional well-being. That said, the absence of burnout does not necessarily indicate the presence of overall well-being. The World Health Organization (WHO) declared that âhealth is a state of complete physical, mental, and social well-being and not merely the ab- sence of disease or infirmityâ (WHO, 2006, p. 1). Well-being is a function of complex interplay of physical, emotional, mental, social, and spiritual factors that interact with the ecosystem within which the person resides. In psychology and related fields there is no agreement about the number of factors that constitute well-being (Gander et al., 2016). Many of the same factors that contribute to burnout in some clinicians may lead to other forms of diminished well-being in others (Chari et al., 2018). In this report, the committee focuses on burnout as a barrier to profes- sional well-being (defined further below). The committee acknowledges that the absence of burnout does not by itself result in a state of professional well-being. However, the committee believes that addressing the drivers of burnout (as well as barriers to well-being and optimal performance) is critical to assisting clinicians reach the goal of professional well-being and will also help health systems in which clinicians work or train reach their maximum potential. The committee acknowledges that there are significant differences in how vulnerable individual clinicians are to burnout because personal resilience and other individual and contextual factors influence each individualâs capacity and approaches to dealing with work-related stress (discussed further in Chapter 4). Below, the committee defines the concepts of burnout, professional well-being, and resilience in relation to the study approach.
A FRAMEWORK FOR A SYSTEMS APPROACH 39 Connections Heal Patients and Clinicians a We choose medicine as a profession in order to help other human beings. It is the connection between practitioner and patient that becomes the foundation of the healing relation- ship and it is exactly that bond which has inherent in it both the possibility of clinician and patient well-being and the risk of burnout. Too often we think of the doctor-patient relation- ship as a one-way street. The truth is that we receive as much from our patients as we give to them. a 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/ expressclinicianwellbeing/#/artwork/257 (accessed January 30, 2019). SOURCE: She Knows You Are Coming (poetry), Jay Kaplan, New Orleans, LA. Burnout Burnout is a work-related phenomenon studied since at least the 1970s (Schaufeli et al., 2009). It is a well-established construct that has been the subject of thousands of publications, most focused on professionals who directly serve other individuals (e.g., human service workers, also referred to as the âhelping professionsâ). In 1976 Christina Maslach, a social psy- chology researcher, further developed the concept after conducting a series of interviews of human service workers (Maslach, 1976), leading ultimately to the definition that burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach et al.,
40 TAKING ACTION AGAINST CLINICIAN BURNOUT 1996) (see Box 2-1). Although Maslachâs definition of burnout and the accompanying measurement tool, the Maslach Burnout Inventory (MBI), are the most widely used approaches (Schaufeli et al., 2009), researchers have conceptualized and defined burnout in various other ways as well. All of these approaches agree on at least one thing, howeverâthat the key feature of burnout is mental exhaustion due to occupation-related factors (Salvagioni et al., 2017). Consistent with these previous definitions, WHO recently updated its definition of burnout to this: Burn-out is a syndrome conceptualized as resulting from chronic work- place stress that has not been successfully managed. It is characterized by three dimensions: (1) feelings of energy depletion or exhaustion; (2) in- creased mental distance from oneâs job, or feelings of negativism or cyni- cism related to oneâs job; and (3) reduced professional efficacy. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. Burnout has an ICD-11 (International Classification of Diseases, Elev- enth Revision) code of QD85. It should be noted that WHO defines burn- out as a problem associated with employment rather than as an individual mental health diagnosis and that it is considered to be distinct from mood disorders (WHO, 2019). BOX 2-1 Key Dimensions of Burnout The three key dimensions of burnout are overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. Exhaustion is the physical and emotional response of stress. Emotions associated with exhaustion include feeling overextended by work demands and depleted of emotional and physical resources that support replenishment and recovery. Cynicism represents the interpersonal aspect of burnout and refers to a negative, callous, or excessively detached response to various aspects of the job, usually resulting in a negative reaction to people, loss of idealism, and the dehumanization of others. Inefficacy refers to feelings of incompetence and a lack of achievement and productivity in work and represents the self-evaluation aspect of burnout. SOURCE: Maslach and Leiter, 2017.
A FRAMEWORK FOR A SYSTEMS APPROACH 41 Burnout is generally considered to be a context-dependent phenom- enon that is due to work-related stressors and that primarily affects pro- fessional attitudes and behaviors, although it can have ramifications on the personal front as well. It differs from depression, which is a mental health diagnosis that has well-defined diagnostic criteria and is context- independent (Melnick et al., 2017). In North America, burnout is consid- ered to be a work-related syndrome, whereas in Europe it is thought of more as a medical diagnosisâa situation that results in the availability of occupational resources and access to paid work leave for those who have high degrees of burnout (Schaufeli et al., 2009). Philosophically, since the d Â rivers of burnout originate in the work environment, the committee favors the occuÂ ational framework that views and addresses burnout as a system p issue rather than as a personal mental health diagnosis. While individually targeted interventions may help individual clinicians, they will not address the systemic issues that drive the burnout problem in the first place. The evidence indicates that burnout is best thought of as a continuous variable, rather than as a dichotomous one; that is, there are âdegreesâ of burnout with severity in the various dimensionsâemotional exhaustion, depersonalization, and loss of personal accomplishmentâmanifesting dif- ferently in different individuals (Maslach et al., 1997). Greater severity across these dimensions has been shown to relate to multiple negative professional and personal outcomes among clinicians (see Chapter 3). Al- though it may be more accurate to consider burnout as a continuous vari- able, research studies often treat it as a dichotomous variable; approaches to dichotomizing burnout, as well as commonly used measurement tools for burnout, are discussed in Chapter 3. The dichotomous-versus-continuous- variable issue for burnout is analogous to the situation with hypertension (Palamara et al., 2018). Blood pressure is a continuous variable for which higher numbers are associated with a greater risk of adverse consequences. Nonetheless, thresholds are set to dichotomize individuals as having or not having âhypertension,â even though it is recognized that not all individuals thus characterized as hypertensive have an equally severe condition. All of these features of blood pressure characteristics (i.e., continuous variable, higher scores associated with greater risk, and thresholds identified as as- sociated with an increased risk of adverse outcomes) are consistent with the construct and data on burnout. As with hypertension, any thresholds set to dichotomize burnout should be based on objective data indicating a relationship between the threshold and adverse or undesirable outcomes. Professional Well-Being Professional well-being is related to the broader concept of psycho- logical well-being, or subjective well-being, which stems from various life
42 TAKING ACTION AGAINST CLINICIAN BURNOUT and non-work sources of satisfaction enjoyed by individuals (Diener, 2000). Worker well-being (which in this report applies to clinicians) is defined âas an integrative concept that characterizes quality of life with respect to an indi- vidualâs health and work-related environmental, organizational, and psychoÂ social factors. Well-being is the experience of positive perceptions and the presence of constructive conditions at work and beyond that enables workers to thrive and achieve their full potentialâ (Chari et al., 2018, p. 590). Profes- sional well-being is further conceptualized as job-related and is a function of being satisfied with oneâs job, finding meaning in oneâs work, feeling engaged while at work, having a high-quality working life, and finding professional fulfillment in oneâs work (Danna and Griffin, 1999; Doble and Santha, 2008). Although professional well-being can be measured by a variety indicators (Chari et al., 2018), work engagement, linked to the motivational aspects of work, has been a common proxy for professional well-being. Work engage- ment is a positive, fulfilling state of mind characterized by âvigor, dedication, and absorptionâ with work (Schaufeli and Bakker, 2010, p. 2). Although research suggests that professional well-being can be influ- enced by both the physical and the psychological aspects of work (Chari et al., 2018), little is known about how to best measure professional well- being, what contributes to professional well-being, and which benefits are derived from the professional well-being of clinicians (Brady et al., 2018; Diener et al., 2015). Resilience While there is no generally agreed-upon definition of resilience (Aburn et al., 2016), the term generally reflects the ability of a person, community, or sys- tem to withstand, adapt, recover, rebound, or even grow from adversity, stress, or trauma (IOM, 2012b; Luthar et al., 2000; Szanton and Gill, 2010). Resil- ience is something that emerges (or not) as a sum of an individualâs or systemâs traits, states, external stimuli, mediators, and prior responses. Resilience can be viewed as a kind of âdynamic adaptive capacityâ to support the ability to rebound and to ultimately improve the function of an individual, community, or system (Szanton and Gill, 2010). All entities, including health care systems and the clinicians who work in these systems, have limits to the magnitude of changes, disturbances, or stressors they can absorb before their structures, pro- cesses, and relationships begin to degrade. When stress overpowers resilience, performance and, in the case of individuals, health can degrade. In this report the term âresilienceâ is used to refer both to individual clinicians and to the clinical systems in which they work. The former usage, individual resilience, is discussed in Chapter 4, under individual mediating factors.
A FRAMEWORK FOR A SYSTEMS APPROACH 43 A SYSTEMS VIEW OF CLINICIAN BURNOUT AND WELL-BEING The committeeâs framework for a systems approach to clinician burn- out and professional well-being is based on theories and principles from the fields of human factors and systems engineering and job and organizational design (see Box 2-2) and draws on the literature and programs from the field of occupational safety and health (Lamontagne et al., 2007; NIOSH, 2019). The committeeâs systems framework emphasizes identifying interventions aimed at the critical factors contributing to burnout in order to foster an improved state of professional well-being (defined above) while improving patient care. The evidence-based interventions that the committee highlights in the report (see Chapter 5) focus on organizational strategies addressing the primary drivers of burnout (see Chapter 4). The committee believes that burnout prevention efforts should involve both risk reduction and wellness promotion and that every stakeholder at every level of the system must embrace the responsibility to build a healthy and safe work environ- ment and to foster a culture of wellness while also supporting individualsâ efforts to improve their own well-being. The committeeâs framework for a systems approach to clinician burnout and professional well-being is in line with recommendations in multiple Institute of Medicine (IOM) and National Academies reports targeting quality of care (IOM, 2001), patient safety (IOM, 2000), diagnostic errors (NASEM, 2015), global quality of care (NASEM, 2018), and learning health care (IOM, 2007). The litera- ture offered many opportunities to better understand work organization, job stress, and professional well-being and provided the committee with a number of health work design approaches to consider. Chapter 5 further discusses these approaches and their integration in well-being systems. A SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING The committee concluded that the processes associated with clinician burnout and professional well-being are complex and occur over time within the context of a multi-level system that influences those processes. The committeeâs systems model of clinician burnout and professional well- being is an adaptation of various models of multi-level systems in health care and workplace safety that describe hierarchical levels that interact with each other to influence the health care process (Berwick, 2002; Carayon et al., 2015; NASEM, 2018; Rasmussen, 2000; Shanafelt and Noseworthy, 2017; Skeff, 2018).
44 TAKING ACTION AGAINST CLINICIAN BURNOUT BOX 2-2 The Science of Systems Reflected in the Framework There are many systems approaches in various scientific disciplines. The com- mitteeâs framework for a systems approach to clinician burnout and professional well- being is based on the following theories and principles. Sociotechnical Systems and Complex Adaptive Systems Sociotechnical system design is an approach to work design that focuses on the broad system in which people work and the interaction between humans and technol- ogy (Carayon, 2006; Clegg, 2000; Pasmore, 1988). The goal is to design technologies (which constitute the âtechnical sub-systemâ) that better fit and support the rest of the system (the âsocial sub-systemâ) (Kleiner, 2007). The organizational concept of so- ciotechnical systems recognizes interdependencies between people and technology; therefore, technologies should not be designed without consideration of the people and the work they perform. The concept has been applied to improving the design and implementation of health information technology through systematic consideration of people and organizational issues (Harrison et al., 2007; Sittig and Singh, 2010; ÂWaterson, 2014). In the organizational context, complex adaptive systems are a type of socio- technical systems that adapt to changes (e.g., changes in the external environment or technologies, disruptions, or unexpected events) (Braithwaite et al., 2018; Plsek and Greenhalgh, 2001). Plsek and Greenhalgh describe a complex adaptive system as âa collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agentâs actions changes the context for other agentsâ (Plsek and Greenhalgh, 2001, p. 625). There- fore, whenever an organizational change is implemented (e.g., work re-organization to address clinician burnout), adaptations will occur, sometimes in unanticipated ways. The concept of complex adaptive systems emphasizes the need for organizations to establish learning mechanisms as part of change management. Human Factors and Systems Engineering Human factors engineering (HFE) is a scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the HFE profession applies theory, principles, data, and methods to design in order to optimize human well-being and overall system performance (Dul et al., 2012). Thus, the fundamental characteristics of HFE are the following: (1) it takes a systems approach; (2) it is design driven; and (3) it focuses on three related outcomes: per- formance, safety, and well-being. An important principle of systems engineering is to
A FRAMEWORK FOR A SYSTEMS APPROACH 45 go beyond improving single system elements, such as technology or physical environ- ment, and instead to analyze and improve the entire system, including both the system elements and their interactions (Carayon et al., 2018). Systems engineering applies multiple methods and principles to model, improve, optimize, and integrate complex socioÂechnical systems (and systems of systems); these systems often have multiple t (sometimes conflicting) goals and various stakeholders (Cassel and Saunders, 2014; NAE and IOM, 2005; PCAST, 2014). The 2005 report by the National Academy of EngineerÂng and the Institute of Medicine, Building a Better Delivery System, described i systems engineering in health care in the following categories: systems design tools (e.g., human factors), systems analysis tools (e.g., modeling and simulation), and systems control tools (e.g., quality engineering) (NAE and IOM, 2005). A systems approach in the context of systems engineering and HFE commonly addresses three questions: What is the system? What are the system goals? And, how can we design, redesign, or improve the system to achieve these goals? System Properties There are many system properties that are relevant to the committeeâs under- standing of health care systems (Waterson, 2009; Wilson, 2014). The committee dis- cussed key characteristics of systems thinking and systems design in its deliberations about the identification and implementation of system changes. Some of these relevant systems characteristics are as follows: Systems have multiple levels; for example, each hospital and the individual units within the hospital represent levels in a health care system. Successful interventions pay attention to the interactions and interdependen- cies between levels. A solution in the local context may be optimal for the local context but may create negative consequences at higher levels, such as at the health system level or the regulation level. For instance, one could optimize workload for one group (e.g., physicians), but create additional workload, stress, and burnout for another group (e.g., nurses). In a similar manner, a solution enacted at a higher level (e.g., the health care organization or the regulation level) may not have the desired effects or may even lead to negative consequences when implemented in local contexts. Complex sys- tems, such as health care systems, have emergent properties: this means that when a change is implemented, behaviors and outcomes occur that were not predicted and that emerge from system interactions and the adaptation of individuals to the system and vice versa. Therefore, mechanisms need to be in place to monitor the impact of changes (e.g., a change may be a job redesign to address clinician burnout) and the potential (positive or negative) consequences of these changes; such monitoring makes it possible to learn from the effects of the changes and to better predict and allow for such effects in the future.
46 TAKING ACTION AGAINST CLINICIAN BURNOUT A SYSTEMS MODEL OF CLINICIAN BURNOUT A N D P R O F E SS I O N A L W E L L- B E I N G l Env ironm rna te en Ex e Orga t Car ni za l th OUTCOMES e C a re De a ti He in on Clinician tl liv Burnout Fron Wo r k Syste m Individual ery Fa c to r s M e d i at i n g Fa c to r s P ro fe ss i o n a l We l l - B e i n g CONSEQUENCES for: Pat i e n t s Clinicians H e a l t h C a re O rg a n i z at i o n s Society L E A R N I N G A N D I M P R OV E M E N T FIGURE 2-1â The systems model of clinician burnout and professional well-being. Figure 2-1 is the committeeâs conceptual model of the clinical work system and its relationship to burnout and professional well-being and the consequences.2 In this model, there are three interacting system levelsâ frontline care delivery, health care organization, and external environmentâ whose characteristics influence the factors contributing to burnout and professional well-being. Decisions made at the three levels of the system have an impact on the work factorsâjob demands and resourcesâthat clinicians experience. The collection of job demands and resources can be balanced or op- timal and thus enhance professional well-being, or it can be unbalanced or less than optimal and thus predispose clinicians to burnout (Carayon, 2009; Demerouti et al., 2001; Siegrist, 1996; Smith and Sainfort, 1989). Individual factors, such as personality traits and personal experiences, play a role in the effects of job demands and resources, although that role is less important than that of the job demands and resources themselves. See Chapter 4 for a further description of the various factors that contribute to burnout. See Chapter 3 for a description of the consequences that burnout and professional well-being have for patients, clinicians, health care orga- nizations, and society. 2 The concepts articulated in the framework are intended to address burnout and profes- sional well-being in health care clinicians and learners.
A FRAMEWORK FOR A SYSTEMS APPROACH 47 Ideally a system will continuously learn and improve using measure- ments of burnout and professional well-being and findings about the con- sequences. Learning and improvement activity can be integrated into the system via feedback loops, which lead to changes in various elements at various levels of the system; these changes in turn affect job demands and resources and ultimately improve the outcomes that clinicians experience. SYSTEM LEVELS AND INTERACTIONS Figure 2-2 shows the three interacting levels of the committeeâs sys- tems model of clinician burnout and professional well-being. At each level, decisions are made that influence the balance between job demands and resources (i.e., psychosocial work factors). THE THREE LEVELS OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING gulations, and , Re Sta ws nd | La ar ry ernance | Orga ds st ov |G niz du nt at |S e i In l Conditi oc m ona on ati are on iet s ge iz | al n al th C na Re ga Te Val Ma wa Or ch Heal ues hip and nolo rds and Beneï¬t Local gies Care Team Members* aders | P | Le h es ys al s iti ic En ti v v i ro Ac n m ent | | Frontline Care Delivery | Health Care Organization | External Environment *Note: Care team members include clinicians, staff, learners, patients, and families. FIGURE 2-2â The three levels of the systems model of clinician burnout and profes- sional well-being.
48 TAKING ACTION AGAINST CLINICIAN BURNOUT Frontline Care Delivery Frontline care delivery is where interactions between clinicians and patients occur in the local context. In sociotechnical systems terms, front- line care delivery is the âwork systemâ (Carayon, 2009; Kleiner, 2008). Frontline care delivery takes place in the context of a care team, including clinicians, learners (including trainees and students), patients and families, and support staff (Skeff, 2018), who engage in activities using various tools and technologies according to established policies and procedures within the available resources and infrastructure. Clinical care team members have individual characteristics (e.g., age and gender, educational background, clinical experience). The parallel and often interacting activities of the care team members occur in a physical environment and under local organiza- tional conditions (e.g., the role definitions of team members, team cohe- sion, communication and coordination among the team, unit leadership). Organizational conditions include how members of the care team perceive the organizational culture. This perception informs the organizational cli- mate. This description of frontline care delivery is based on an established work system model (Smith and Carayon, 2001) and is consistent with the description of microsystems3 in health care quality improvement (Mohr and Batalden, 2002; Nelson et al., 2002). The Health Care Organization The health care organization, the second level of the systems model, is composed of multiple interconnected work systems that share com- mon structures and processes. Many of their decisions and activities are interÂ ependent; for instance, the transfer of a patient from the emergency d department to an inpatient unit requires extensive unit-to-unit communica- tion, coordination, and collaboration, with the different units needing to have common expectations and norms. Thus, the health care organization is characterized by a wide variety of elements (Trist, 1981), including orga- nizational culture, payment and reward systems, the management of human capital/human resources, leadership and management style, and organiza- tional policies (e.g., regarding scheduling, vacation, part-time/full-time, and the use of electronic health records [EHRs] and other technologies). See Chapter 5 for further description of the influence and role of health care organizations in clinician burnout. 3 Microsystems are the small clinical care teams that provide care during most health care encounters.
A FRAMEWORK FOR A SYSTEMS APPROACH 49 The External Environment The third and final level of the systems model is the external environ- ment, which includes political, market, professional, and societal factors. This level contains opportunities and constraints that influence decisions and actions at the health care organization level and the work done by clinicians at the frontline care delivery level. Many elements of the ex- ternal environment play a role in clinician burnout and well-being (Trist, 1981), including structural changes in the U.S. health care industry and the landscape of laws, regulations, and standards for the oversight of U.S. clinicians (e.g., those relating to payment policies, clinical documentation, quality measurement and reporting, prescription drug monitoring, privacy rules and procedures, pre-authorization forms, professional and legal re- quirements for licensure, board certification, and professional liability). Societal factors, such as changing attitudes, expectations, and values about health care, are also part of the external environment influencing the work system. See Chapter 6 for a discussion of these elements of the external environment. Frontline care delivery, the health care organization, and the external environment all influence each other. For instance, documentation require- ments by regulators and insurance entities represent an element of the external environment that influences what health care organizations do with regard to EHR implementation and configuration, which in turn influ- ences the actual work of the care team and, in particular, of clinicians who directly interface with the EHR (Erickson et al., 2017). Influences between system levels go both ways. What happens at a lower level can influence what happens at a higher level. An example of this upward influence from the health care organization to the external environment was provided in the 2018 National Academy of Medicine report on interoperability (Â ronovost et al., 2018), which supports the belief that if health care organi- P zations demanded more usable, safer, and interoperable health information technology (IT) as part of their purchasing decisions, it would spur vendors to make developing this improved health IT a priority. IMPORTANT CONSIDERATIONS RELATED TO THE SYSTEMS MODEL Learning Health Care Systems As shown in the committeeâs systems model of clinician burnout and professional well-being (see Figure 2-1), learning and improvement feeds back into the three levels of the system in a process of continuous im- provement. The model is consistent with the work of the landmark report
50 TAKING ACTION AGAINST CLINICIAN BURNOUT produced by the IOM Committee on the Learning Health Care System in America, which laid out the foundation for building more effective learning processes and systems across health care (IOM, 2012a). The report called for improving organizational learning throughout the health care industry and highlighted the emerging capabilities offered by information tech- nologies. The report also described âprogress in human and organizational capabilities and management scienceâ (IOM, 2012a, p. xii) that could be used to better design health care work systems and improve outcomes for both patients and clinicians. Box 2-3 displays key characteristics of learning health care systems. The foundation for a learning health care system is âcontinuous knowl- edge development, improvement and applicationâ (IOM, 2012a, p. x). This approach is relevant not only to improving care processes and outcomes for patients, but also to improving health care work systems and the work experiences of clinicians. Expanding the focus of health system improve- ment beyond the triple aim (Berwick et al., 2008) to the quadruple aim (Â odenheimer and Sinsky, 2014; Sikka et al., 2015) is in line with this com- B mitteeâs proposed approach to expand the concept of learning health care systems to include improving clinician professional well-being. The 2012 IOM report on learning health care highlights the need to improve health care work systems so as to better support cliniciansâ work as well as the need to allow clinicians to continually learn and improve in their work (IOM, 2012a). In addition to the roles played by data collection, mea- surement, and the greater use of IT (Budrionis and Bellika, 2016), it is im- portant to consider the âhuman capitalâ of the learning health care system. For example, consistent with the management and organizational design literature (Argyris and SchÃ¶n, 1978; Hundt, 2012), cliniciansâ workload and work environment must support continual learning and participation in improvement activities. This is based on (and fosters) an organizational culture aimed at continually improving care work systems and processes (Grossman and Salas, 2011). Human-Centered Design The learning and improvement feedback loops of the committeeâs sys- tems model are in line with human-centered design (HCD), an approach anchored in human factors engineering and aimed at designing work sys- tems that match the needs of the users (clinicians) and, therefore, producing usable, healthy, and safe work systems. The International Organization for Standardization (ISO), an international standard-setting body composed of representatives from various national standards organizations, has defined HCD as an âapproach to systems design and development that aims to make interactive systems more usable by focusing on the use of the system
A FRAMEWORK FOR A SYSTEMS APPROACH 51 BOX 2-3 Characteristics of a Continuously Learning Health Care System A learning health care system is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care. A learning health care system has the following elements: Science and Informatics â¢ Real-time access to knowledgeâcontinuously and reliably captures, curates, and delivers the best available evidence to guide, support, and improve clinical decision making, care safety, and quality. â¢ Digital capture of the care experienceâdocuments the clinical encounter on digital platforms (e.g., in an electronic health record) for the real-time generation and application of knowledge for care improvement. PatientâClinician Relationships â¢ Engaged, empowered patientsâis anchored on patient needs and per- spectives and promotes the inclusion of patients, families, and other caregivers as vital members of the continuously learning care team. Incentives â¢ Incentives aligned for valueâactively aligns incentives to encourage continuous improvement, identify and reduce waste, and reward high- value care. â¢ Full transparencyâsystematically monitors the safety, quality, pro- cesses, prices, costs, and outcomes of care and makes information available for care improvement and informed choices and decision mak- ing by clinicians, patients, and their families. Culture â¢ Leadership-instilled culture of learningâis stewarded by leadership com- mitted to a culture of teamwork, collaboration, and adaptability in support of continuous learning as a core aim. â¢ Supportive system competenciesâconstantly refines complex care op- erations and processes through ongoing team training and skill building, systems analysis and information development, and the creation of the feedback loops for continuous learning and system improvement. SOURCE: IOM, 2012a.
52 TAKING ACTION AGAINST CLINICIAN BURNOUT and applying human factors/ergonomics and usability knowledge and tech- niquesâ (ISO, 2010, p. 2). A key aspect of HCD is the participation and involvement of users through design and implementation whereby inputs from users and stakeholders are incorporated in a systematic approach to work system redesign. HCD allows iterative design, prototyping, and evaluation of a solution at all system levels, anticipating its effects on the entire work system, that is, individuals, tasks, technology, and the physical and organizational work environment. If appropriate, these designâevaluationâredesign cycles may be performed in simulations (computer-based modeling or clinical simulations of increasing fidelity) under both routine and non-routine conditions. Once a solution has been refined, it can be tested in small pilot trials in a particular care unit. Evaluations need to consider the contextual factors related to suc- cess or failure and to seek generalizability across different units, conditions of use, and user populations. Formal assessment and continuous improve- ment should continue into the post-implementation phase. The HCD approach can be scaled according to the magnitude and type of problem as well as to the time and resources available. Experience shows that although such techniques may impose additional up-front effort, that effort will be more than made up for by decreased (1) difficulties and expense of initial implementation, (2) time to full adoption, (3) number of workarounds required, (4) rework or other mitigations for design failures, and (5) harm from unintended errors and other negative consequences (Erwin and Krishnan, 2016; Harte et al., 2017; Sanders and Stappers, 2013). HCD should be implemented at multiple system levels, in particular by health care organizations in their effort of reducing clinician burnout and implementing well-being systems (see Chapter 5) and by stakeholders of the external environment who design new policies and need to anticipate potential negative consequences such as clinician burnout (see Chapter 6). Professionalism Health professions share an idealistic set of values, codified in historical documents such as oaths (Hippocrates, Maimonides), pledges (Nightingale pledge, Robbâs nursing ethics statement), and more contemporary codes of ethics that describe the aspirational expectations of members of profes- sional organizations (ACP, 2019a; ADEA, 2005; AMA, 2001; ANA, 2015; APA, 2013). These all share a focus on the primacy of cliniciansâ dedication to the well-being of the patient. Professionalism has been defined to include such attributes as integ- rity, altruism, fairness, compassion, and respect for the dignity of all per- sons, and it has informed the development of competencies that have been applied across the health care professions (ACP, 2019b; ANA, 2015).
A FRAMEWORK FOR A SYSTEMS APPROACH 53 Contemporary codes of ethics have expanded the concept of professional- ism to include obligations of clinicians to address transparency and hon- esty, the appropriate management of conflicts of interest, confidentiality, stewardship of resources, social justice, evidence-informed decision making and treatment, and preserving the integrity of the profession. Increasingly, these codes acknowledge the interplay between the well-being of clinicians and the quality of care they can deliver to those they serve. The ANA code (ANA, 2015), for example, obliges nurses to preserve their own integrity and well-being in order to continue to uphold their ethical commitments to the people they serve. The World Medical Association (2017) revised the Declaration of Geneva (the contemporary Hippocratic oath) by adopt- ing a requirement that obligates physicians to âattend to their own health, well-being, and abilities in order to provide care of the highest standardsâ (Parsa-Parsi, 2017, p. 1971). Threats to professionalism mirror work-related stressors thought to contribute to clinician burnout, such as interpersonal conflict, technology, market forces, health care systems strain, and broader sociological shifts in the role of physicians in society (ABIM Foundation, 2005; ANA, 2015) (see Chapter 4). As discussed below, the sources of these threats to professional- ism originate from all levels of the system: frontline care delivery, the health care organization, and the external environment (see Figure 2-2). Threats to Professionalism and Frontline Care Delivery Unprofessional behaviors, including threats of retaliation, disrespectful and disruptive behaviors (Dang et al., 2016; Hickson et al., 2007; Reddy et al., 2012), harassment, and other issues, occur at the frontlines of care. For decades, nurses have identified ineffective or conflictual professional relationships as a source of moral distress (Burston and Tuckett, 2013; Hiler et al., 2018), which in turn is a factor that contributes to burnout (Moss et al., 2016). Physicians in training have reported longstanding pat- terns of intimidation, retaliation, and disrespect (Karim and Duchcherer, 2014; Martinez et al., 2017) that can undermine their ability to speak up about clinical concerns (Martinez et al., 2017). Other disciplines, includ- ing dentistry (Rowland et al., 2010), have reported similar patterns. If organizations have a culture that tolerates lapses of ethical behavior, that discourages team members to speak up, or that erodes personal integrity, dignity, and sense of fairnessâall of which contribute to moral distress (Atabay et al., 2015; Epstein et al., 2019; Hiler et al., 2018; Rathert et al., 2016)âthere is an increased risk of clinician burnout, poor professional well-being, and the consequences described in Chapter 3. Over the past three decades there has also been a discernable shift from medical paternalism to models of shared decision making that emphasize
54 TAKING ACTION AGAINST CLINICIAN BURNOUT the role of patients in health care decisions (IOM, 2001; Oshima Lee and Emanuel, 2013). This shift has created a tension between cliniciansâ desire to respect patient autonomy and the pressure they feel from being held to quality measures. These two goals may be in conflict with each other, and more research is needed to better understand the relationship between shared decision making, patient outcomes, and how clinicians can effectively include patients in clinical decisions (Hargraves et al., 2016; Montori et al., 2017). The increased emphasis on shared decision making (i.e., including patients to a greater extent in the process and planning of their health care), when done properly, actually leads to more trust between clinicians and patients and gives clinicians more professional fulfilment. This shift could also cre- ate more clinician autonomy since shared decision making requires both parties to work together to personalize the patientâs care and maximizes the likelihood that the highest value care (for that patient) will be delivered. Threats to Professionalism and Health Care Organizations Cliniciansâ primary obligations to patients may conflict with organizaÂ tional priorities driven by economic and business interests (Rushton and Broome, 2015). Clinicians are buffeted by conflicting pressures that depend on the local context. These pressures include cost reduction, personal or organizational revenue enhancement, and population health interventions, which sometimes conflict with individual patient preferences or needs. Volume-driven throughput incentives, pressures to âdo more with less,â and complex regulations (see Chapters 5 and 6 for additional details) con- front clinicians with ethical tensions among their obligations to serve indi- vidual patients, to be responsible stewards of health care resources, and to contribute to the solvency of their health care organizations. This constant dissonance can be cumulative, culminate in high levels of work stress, and erode even the most resilient clinicianâs professional well-being. Threats to Professionalism and the External Environment Cliniciansâ first duty is to provide care for individuals who need health care services. The ability to do so, however, is influenced by multiple factors outside the sphere of direct influence for most clinicians and even of the health care organizations in which they work. These factors, which contrib- ute to individualsâ health and their access to and the quality of care, include local and national public health issues (e.g., access to clean water and air, affordable housing and nutrition, health education), health care financing (e.g., treatment coverage decisions), and the economic pressures on the health care industrial complex (e.g., the rising cost of medical technology) (Adler et al., 2016). Clinicians have high levels of altruism and generally
A FRAMEWORK FOR A SYSTEMS APPROACH 55 want to address patientsâ needs. Doing so, however, can be difficult, if not impossible, given multitude of socioeconomic determinants of health and societal constraints. Health care organizations committed to upholding the âquadruple aimâ (Bodenheimer and Sinsky, 2014) are taking intentional and strategic steps to create the culture and conditions for clinicians to practice in accordance with their ethical mandates and to fulfill their social covenant with society. Leveraging the Charter on Professionalism for Health Care Organizations, and its recommendations relating to patient partnerships, organizational Â culture, community partnerships, and operations and business practices, may be a promising avenue for achieving needed culture change (Egener et al., 2017). The charter espouses developing organizational accountabil- ity for creating the conditions for individual professionalism to thrive by focused and sustained attention to systemic barriers and enablers of orga- nizational professionalism. Others have called for shifting organizational cultures to embrace humanism as a means for enabling professional and ethical practice (Rider et al., 2018). Engaging humanistic practices through- out the organization are necessary to align professional and organizational values, norms, and practice and to foster professional well-being. KEY FINDINGS Burnout is a work-related phenomenon. WHO defines burnout as a problem associated with employment, not as an individual mental health diagnosis, and sees it as distinct from mood disorders. Maslachâs defini- tion of burnoutâa syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishmentâand the accompanying measure- ment tool, the MBI, are the most widely used definition and measurement tool in studies of clinician burnout. Definitions of professional well-being reflect a clinicianâs experience of positive perceptions and the presence of constructive conditions at work and beyond, enabling the achievement of oneâs full potential. Professional well-being is further conceptualized as job-related and generally a function of job satisfaction, finding meaning in work, feeling engaged and fulfilled with work, having a high-quality working life, and professional fulfillment. However, little is known about how to best measure professional well-being, what contributes to profes- sional well-being, and which benefits are derived from the professional well-being of clinicians. Resilience generally reflects the ability of a person, community, or system to withstand, adapt, recover, rebound, or even grow from adversity, stress, or trauma. The identification of interventions aimed at tackling the critical factors contributing to burnout is a way of fostering an improved state of professional well-being while improving patient care. Personal resilience and other individual and contextual factors influence
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