Disclosures Advisory board for healthfinch (HIT start-up) 1 - PDF document

10/26/2015 Joy in Practice: Reconnecting with the Meaning and Mission of our Work 19 th Annual Management of the Hospitalized Patient UCSF Christine A Sinsky, MD, FACP Oct 15., 2015 Disclosures • Advisory board for healthfinch • (HIT start-up) 1

10/26/2015 Agenda • Introduction – Burnout • Meaning and Mission – Begin to unravel the knot keeping us from meeting our best intentions – Focus on impact of Documentation/Regulation – Importance of matching the work to the worker • Recommendations – High level multiple actors in healthcare ecosystem – Create space to reconnect • Discussion Take-away: Attending to joy in practice Joy  Triple Aim Quadruple Aim • Engaging • Better care physicians • Better health • Unleash • Lower cost professionalism 2

10/26/2015 Core Q: How can we contribute external environment approach physicians more Knights, Knaves or Pawns Approaches professionals as knaves and pawns, the more kn and pn behavior Deep growing dissatisfaction… Imbalance of forces JAMA . 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250) I Arch Intern Med 2012; E1-9 Nearly ½ of MDs Burned Out Many physicians would not choose again Calculus: spending d doing wrong work 3

10/26/2015 Arch Intern Med 2012; E1-9 Nearly ½ of MDs Burned Out Hospitalists ~ GIM General Internal Medicine J Hosp Med. 2014 Mar;9(3):176-81 Calculus: spending d doing wrong work http://www.medscape.com/features/slideshow/compensation/2013/public Burnout affects Patients Physician burnout is associated with… o ↑ Mistakes o ↓ Adherence o Less empathy o ↓ Patient satisfaction Sources: Shanafelt Ann Surg. 2010;251(6):995-1000; Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.; http://www.ncbi.nlm.nih.gov/pubmed/10672116 Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.; http://psnet.ahrq.gov/resource.aspx?resourceID=1909 http://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians__Empathy_and_Clinical_Outcomes_for.26.aspx 4

10/26/2015 My health, safety and well- being as a patient in your care are absolutely linked to your own health, safety and well being. Meg Gaines, founder UW Center for Patient Partnerships, personal communication 8.21.14 Burnout Costs Organizations Physician burnout is associated with… o ↑ Malpractice risk o ↑ Part time o ↑ MD and staff turnover o $250,000 to replace MD (1999) Am J Man Care Nov 1999:5(11):1431-1438 Am J Man Care Jul 2001;7(7):701-713 Health Serv. Res. Oct 2004;39(5):1571-1588 Med. Care Mar 2006;44(3):234-242 Journal of Applied Psychology, Vol 73(4) Nov 1988, 722-735 http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/0021-9010.73.4.727 5

10/26/2015 Burnout May Cost US Healthcare Physician burnout is associated with… o ↑ Referrals o Workforce o $500,000 to train one MD Social Science and Medicine 1999; (48):547-557 Family Practice doi:10.1093/fampra/cmt060. Arch Intern Med. 2011;171(17):1582-1585 http://content.healthaffairs.org/content/29/5/835.full Burnout Costs Physicians Physician burnout is associated with… o ↑ Disruptive behavior o ↑ Divorce o ↑ CAD o ↑ Substance abuse/addiction o ↑ Suicide (2-4 x) 6

10/26/2015 Burnout in Hospitalists 1/3 likely to leave w/in 2 yrs o “Glorified resident” o Lack of longitudinal care Depression o 40% o 9.2% suicidal J Hosp Med 2014 Mar;9(3):176-81 http://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor- burnout / 1 in 2 US physicians burned out implies origins are rooted in the environment and care delivery system rather than reflecting weakness on part of a few susceptible individuals. 7

10/26/2015 External environment? 50+ organizations Obs: 70-80% work effort, Not add value or not need done; surprising # Finely ingrained, do not see it ½ Re-engineering ½ Mismatch policy/tech Ultimately hopeful Solvable problems Individual can’t solve alone By coming together, understand fit multiple stakeholders can make a signif impact. Three Studies and an Email 8

10/26/2015 Physician Career Satisfaction • Quality: Major Driver of Satisfaction – Dissatisfaction: Early warning sign of dysfn http://www.rand.org/news/press/2013/10/09.html Physician Career Satisfaction • EHR: Major Driver of Dissatisfaction – Too much time per task, clerical – ↓ Face-to-face time – ↓ Quality of visit note http://www.rand.org/news/press/2013/10/09.html 9

10/26/2015 VA Top 3 of 4 Challenges: EHR JGIM 2014 29(Supple 2):S555-62 JAMIA 2013 ↑ EHR Functions  MD Burnout and intent to leave practice Fn’s: CDS, alerts, reminders, e-mail w/pts and colleagues http://jamia.bmj.com/content/early/2013/09/04/amiajnl-2013- 4 001875.short?rss=1 10

10/26/2015 “I am no longer a physician but the data manager, data entry clerk and steno girl. I am frustrated, unhappy and I am unable to do my best in caring for my patients. I became a doctor to take care of patients. I have become the typist.” physician, Boston 2013 Burnout is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. http://www.theatlantic.com/health/archive/2014/02/for-the- young-doctor-about-to-burn-out/284005/ Tipping point Perfunctory work Unsustainable 11

10/26/2015 Betrayals of purpose The EHR has been devastating. We can no longer teach medical students due to the time it takes to enter (primarily useless) data; I now see half as many patients and I actually spend less face time with these fewer patients. Working in clinic has become so painful that I have decided to leave my beloved patients—unbearable to think about. • 18 clicks to do one fn • EHR “so cluttered w/ non-information, hard to review past, so don’t” • “I used to leave at 6:30 and feel good about work; now leave several hours later and spend time on weekends catching up.” 12

10/26/2015 Tiny betrayals of purpose 4000 clicks per day ER physicians • 10 hr shift • 44% data entry • 4000 clicks • 28% pt care Hospitalist • 23% direct pt Am J Emerg Med 2014;31(11):1591-1594 J Hosp Med 2010;5(6):353-9 Billing template  pseudotext Clinical Documentation The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. – Six pages, no meaning; Pt’s story? Dr’s thinking? Care? – Like many barriers, etiology complex – End result: compromise of clinical quality and efficiency 13

10/26/2015 More than waste The patient’s story matters More than sum of drop down boxes Hx generic, see pt generic Stop fully listening Listen to your patient, he is telling you the diagnosis. Sr Wm Osler 14

10/26/2015 calculus: wrong work Matching Work to Worker Y Worker is under trained for the work Unsafe Complexity Sweet spot: worker and of work work are well matched Inefficient (Waste) X Worker is over trained for the task Modified from A. Mulley Training Current Work Distribution Dx and Rx plan High value Complex chronic Relationship bldg Good match Shared decision making “Solution Shop” Complexity of work Inbox mgmt Med rec “Production Script renewals Data entry Line” Data gathering Prior authorization PAs Vitals MA RN RN NP PA MD Training 15

10/26/2015 “ In few other sectors of the economy is the highest-level professional responsible for the majority of production, customer service, and clerical work. ” SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Coordinated Care. J Gen Intern Med 2007; 22: 400-109 Matching Work to Worker “Solution Shop” Bio/psycho/social Shared decision m Chronic illness ca E/M acute sx “Production Line” Complexity Allows greater of work MD focus on high complexity tasks Inbox mgmt Med rec Script renewals Data entry Data gathering Prior authorization Vitals MA RN RN NP PA MD Training 16

10/26/2015 Documentation specialist? Round with nurse, pharmacist, SW Innovation David Reuben UCLA • “Physician Partners” – COE – Charting • JAMA IM 5.14 – Pt satisfaction w/MD time ↑ – Save 1.5 hr/4hr • Training Academy 17

10/26/2015 Malcolm Gladwell Brilliantly gifted doctors forced to run patients through an electronic treadmill http://www.medscape.com/viewarticle/847711?src=wnl_edit_specol&uac=93495FK&impID=844582&faf=1 Reduce Burnout in Hospitalists • ↓ Time pressure • Teams: documentation specialists • ↓ Chaos • Checklists • ↑ Control over work • Flexible scheduling • ↑ Values alignment with leadership • Swartz conference • Administrators join rounds 18

10/26/2015 Action Step: Institutions Be Bold We have developed a new mental model: Pull the doctor out of the infrastructure (typing, EHR, etc) and get them back to being present to the patient. David Moen, MD Director Care Model Innovation, Fairview Clinic Mlps Personal communication 2.10.10 19