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

10/26/2015 1

Joy in Practice:

Reconnecting with the Meaning and Mission of

• ur Work

19th Annual Management

• f the

Hospitalized Patient UCSF

Christine A Sinsky, MD, FACP Oct 15., 2015

Disclosures

• Advisory board for healthfinch
• (HIT start-up)

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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

Joy  Triple Aim

• Engaging

physicians

• Unleash

professionalism

• Better care
• Better health
• Lower cost

Quadruple Aim

Take-away: Attending to joy in practice

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Approaches professionals as knaves and pawns, the more kn and pn behavior Deep growing dissatisfaction… Imbalance of forces I

Knights, Knaves or Pawns

• JAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)

Core Q: How can we contribute external environment approach physicians more

Nearly ½ of MDs Burned Out

Arch Intern Med 2012; E1-9 Many physicians would not choose again Calculus: spending d doing wrong work

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Nearly ½ of MDs Burned Out

General Internal Medicine

Arch Intern Med 2012; E1-9

http://www.medscape.com/features/slideshow/compensation/2013/public

Hospitalists ~ GIM

J Hosp Med. 2014 Mar;9(3):176-81

Calculus: spending d doing wrong work

Burnout affects Patients

Physician burnout is associated with…

• ↑ Mistakes
• ↓ Adherence
• Less empathy
• ↓ 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

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My health, safety and well- being as a patient in your care are absolutely linked to your

• wn 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…

• ↑ Malpractice risk
• ↑ Part time
• ↑ MD and staff turnover
• $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

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Burnout May Cost US Healthcare

Physician burnout is associated with…

• ↑ Referrals
• Workforce
• $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…

• ↑ Disruptive behavior
• ↑ Divorce
• ↑ CAD
• ↑ Substance abuse/addiction
• ↑ Suicide (2-4 x)

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Burnout in Hospitalists

1/3 likely to leave w/in 2 yrs

• “Glorified resident”
• Lack of longitudinal care

Depression

• 40%
• 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

• ut implies origins

are rooted in the environment and care delivery system rather than reflecting weakness on part

• f a few

susceptible individuals.

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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.

External environment?

Three Studies and an Email

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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

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JGIM 2014 29(Supple 2):S555-62

Top 3 of 4 Challenges: EHR

VA

↑ EHR Functions  MD Burnout

and intent to leave practice

http://jamia.bmj.com/content/early/2013/09/04/amiajnl-2013- 001875.short?rss=1 Fn’s: CDS, alerts, reminders, e-mail w/pts and colleagues

JAMIA 2013 4

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“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

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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.

Betrayals of purpose

• 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.”

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ER physicians

• 10 hr shift
• 44% data entry
• 4000 clicks
• 28% pt care

Hospitalist

• 23% direct pt

4000 clicks per day

Am J Emerg Med 2014;31(11):1591-1594 J Hosp Med 2010;5(6):353-9 Tiny betrayals of purpose

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

Billing templatepseudotext

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The patient’s story matters

More than waste

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

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Matching Work to Worker

Worker is over trained for the task Worker is under trained for the work

Complexity

• f work

Training

Unsafe Inefficient (Waste) Sweet spot: worker and

work are well matched Modified from A. Mulley

Y X calculus: wrong work

Current Work Distribution

Complexity

• f work

Training

MA RN RN NP PA MD

Med rec Data entry Inbox mgmt Relationship bldg Complex chronic Dx and Rx plan Shared decision making Script renewals Prior authorization Data gathering

Vitals PAs

“Production Line” High value Good match “Solution Shop”

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“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

Complexity

• f work

Training

Med rec Prior authorization Data entry Script renewals Inbox mgmt Data gathering Vitals

Allows greater MD focus on high complexity tasks

E/M acute sx Chronic illness ca Bio/psycho/social Shared decision m

MA RN RN NP PA MD

“Solution Shop” “Production Line”

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Documentation specialist? Round with nurse, pharmacist, SW

David Reuben

UCLA

• “Physician Partners”

– COE – Charting

• JAMA IM 5.14

– Pt satisfaction w/MD time ↑ – Save 1.5 hr/4hr

• Training Academy

Innovation

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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

Malcolm Gladwell

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

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Be Bold

Action Step: Institutions

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

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Finding Meaning in Medicine

Story Telling Sessions: Humility, Compassion, Gratitude

• Dr. Rachel Naormi Remen

“Spread like wildfire around our 44 hospitals”

• Dr. Ted Hamilton, VP Medical Mission

Adventist Health System, FL

Swartz Center Rounds

Action Step: Institutions Multi-disciplinary rounds to discuss difficult emotional and social issues; belonging to team, compassion, respect

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Protected Time

Action Step: Institutions 10-20% time on QI projects, patient safety or other passions JGIM 2013; 29:18-20

Research

Tests Treatment

>$100 Billion/yr

Delivery model

to wisely deploy

<$0.3 Billion/yr

Action Step

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Practice Science

Systems Eng. Human Factors

Action Step: Invest more in

To study innovations and optimize the delivery models Industry 2.0% Health 0.3% 19th of 22 industries

http://jama.jamane twork.com/article. aspx?articleid=20 89358

Cognitive Interruptions

Activity Timebelt

Pre- CPO E Post CPO E

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Avoid Compliance Creep

Action Step: Institutions Physicians overwhelmed w/clerical work;

• rigins complex MU CPOE

Rethink Signature

Action Step: Regulators Hrs/wk, do not add value

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Less is More

Action Step: Measure Developers Keep it simple, add it up

New Roles for Nursing Workforce

Action Step: Educators

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Relentless Focus Usability

Action Step: Vendors Vibrant community start ups EHR apps

AMA’s Strategic Focus Areas

Health Outcomes Medical Education Physician Satisfaction & Practice Sustainability

50

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www.stepsforward.org

• Teams

– Expanded rooming – Team documentation – Pre-visit planning/lab – Team meetings – Daily huddles – Hospitalist

• Culture

– Preventing Burnout – Resiliency – Wellness in Residency – Transforming culture

Transformation Toolkits

• Value

– Panel management – Medication adherence – Burnout Prevention – Diabetes prevention – Hypertension

• Technology

– Telemedicine – EHR implementation

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Collective work I

• JAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)

Knights, Knaves or Pawns

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Take-away: Attending to Joy in Practice

Joy  Triple Aim Quadruple Aim The Map is not the Territory

Steve Martin MD and Christine Sinsky MD

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The Map is not the Territory

"If you didn't document it, it didn't happen," Fresh ears are told in medical school. But then one day we realize that documenting doing doesn’t make it so, Experiencing makes it so. "Visited patient in her basement. Ascites worsening as she drinks more after death of son in motor vehicle accident." What more should I write? How do you document bearing witness?

10/26/2015 30 The Code is not the Care The Pocket Guide: It folds like origami and reads like computer code, this item we received early in residency. In small font and syllogism, It tells us what our time with a patient is worth. It sustains anachronisms like the review of systems. Three chronic conditions is the key that opens a Level 4 lock. Now we hear these notes are being poorly done. They have too much. They have too little. They don’t have the right elements. Doctors need better education. They need more detailed notes. We also hear there is burnout. Access problems for patients. People leaving primary care

• r not entering it.

We hear EHRs are good. We hear they are bad.

10/26/2015 31 Why don’t we start at the beginning? The care of the patient is what matters most. The map is not the terrain. The code is not the care. Colleagues have left practice Unable to keep up with the note-production complex. Charting encroaches on caring. This is what happens when a means for recording meaning is alchemized into a tool for billing, a means for monitoring, a line of defense. The patient-doctor “conversation” becomes an act of distraction, lapsed eye-contact, and keyboard tapping. This is pawn activity. Finishing a patient session becomes prelude to converting it into billable accounts. We rush. Patients notice.

10/26/2015 32 The map is not the terrain. The code is not the care. Doctors got to where we are because we follow rules well. What to do then, when the rules erode

• ur doctoring?

The map is not the territory. The code is not the care.

Collective work I

• JAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)

Knights, Knaves or Pawns

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Take-away: Attending to Joy in Practice

Joy  Triple Aim Quadruple Aim Discussion

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