New research provides guidance for implementing clinician dress codes at health systems, hospitals, and physician practices.
Physician attire impacts patient satisfaction, with preferences for clinician couture varying by care setting and patient attributes such as age, researchers have found.
"Our work shows that patients care. So, for institutions that don't have a dress code or formal policy for attire, it might be time to consider one," article co-author Vineet Chopra, MD, MSc, of the University of Michigan Medical School and VA Ann Arbor Healthcare System told Healthleaders this week.
Out of 4062 patients surveyed, 53% said physician attire was important to them. The research was published in BMJ Open.
Overall, patients preferred formal attire with a white coat, ranking that ensemble an 8.1 on a scale of 1 to 10. "Our work shows white coats matter the most. I think this is an important takeaway for institutions," Chopra says.
The researchers found that preference for physician attire is influenced by patient attributes and care settings:
Female patients preferred scrubs with white coats in emergency room and hospital setting compared to men (41% vs. 31%)
In hospitals, patients 65 and older preferred formal attire with white coats more than younger patients (44% vs. 36%)
Younger patients preferred scrubs and white coats over formal attire (28% vs. 21%)
Patients with a college degree preferred formal attire and white coat for family physicians more than patients without a degree (48% vs. 42%)
Patients preferred formal attire with white coat for primary care (44%) and hospital physicians (39%), but scrubs were rated highest for ER physicians (40%) and surgeons (42%)
Patients also had regional differences in their preference for physician attire.
"While formal attire and white coats were preferred across all regions, 50% of respondents in the West and 51% in the South selected this as their preferred option compared with 38% and 40% in the Northeast and Midwest, respectively," the researchers wrote.
The findings on patient preference variation for physician attire indicate that healthcare organizations should take a nuanced approach to dress codes, Chopra says.
"Preferences may vary based on location and context. Institutions may want to consider examining specific areas to understand whether or not more defined dress codes might be indicated."
The research is consistent with common perceptions about professionals, the researchers wrote.
"These findings make intuitive sense: Patients often have notions of how a 'professional' should dress and are more likely to respond positively to those that meet these stereotypes. Strategies targeting physician dress may therefore enhance trust and satisfaction."
The research is based on a questionnaire that included photos of a male and a female physician in seven different sets of attire. Patients were asked to rate the physicians in several clinical settings. The rating system had five domains: knowledgeable, trustworthy, caring, approachable, and comfortable.
Formal attire with white coat scored highest for all five domains.
The research includes several other key data points:
In the overall rankings, scrubs with a white coat ranked second to formal attire with white coat. Formal attire without a white coat ranked third.
In ER and surgery settings, scrubs alone were preferred by 34% of patients followed by scrubs with white coats (23%)
36% of patients said physician attire impacted satisfaction with their care
55% of respondents said doctors should wear a white coat during office visits with patients
Matching physician attire with patient expectations can improve patient experience, the researchers wrote.
"Providers engaged in care of elderly patients … may consider donning formal attire more so than surgeons or emergency room physicians where scrubs may be more important. Similarly, hospitals in Southern regions of the USA may wish to endorse formal attire and white coats."
The research has policy implications, they wrote.
"Patients appear to care about attire and may expect to see their doctor in certain ways. Hospitals, clinics, emergency departments and ambulatory surgical centers should consider using these data to set dress codes for physicians providing care in these settings."
Several factors are making specialists hot commodities, including the aging population, lifestyle-related diseases such as obesity, and a shortage of psychiatrists, healthcare staffing agency says.
In an annual healthcare staffing survey, family physicians rank as the top requested recruiting assignment for the 12th year in a row, but demand for specialists is trending upward.
Recruitment activity is shifting toward medical specialists, according to the 2018 Review of Physician and Advanced Practitioner Recruiting Incentives. The survey, published by Dallas-based Merritt Hawkins, found 74% of search assignments were for specialists, up from 67% three years ago.
In physician compensation, the survey found invasive cardiologists had the highest average starting salaries at $590,000. Orthopedic surgeons were second at $533,000.
Three factors are driving increased demand for medical specialists, starting with the country's aging population, says Travis Singleton, Merritt Hawkins executive vice president.
"It is specialists such as cardiologists, orthopedic surgeons, pulmonologists and others who care for the ailing organs, bones, and brains of our fastest growing patient cohort—seniors, who are disproportionate users of care."
Lifestyle-related disease and behavioral health are also increasing demand for specialists, he says. "Rising rates of obesity, diabetes, drug abuse, and mental health problems are creating a sicker patient population, the kind commonly treated by specialists."
The third factor boosting demand for specialists is the cyclical nature of the physician employment market, Singleton says.
"Hospitals, medical groups, and other healthcare facilities have emphasized primary care recruitment in recent years, and now they need specialists to whom their primary care doctors can refer."
The survey was conducted from April 2017 to March 2018, and it is based on a sample of 3,045 clinician search assignments. In addition to the medical specialist and top compensation findings, the survey has six other key points:
Reflecting an ongoing shortage, psychiatrists were second on the list of Merritt Hawkins' most requested recruiting assignments for the third year in a row.
Demand for nurse practitioners (NPs) and physician assistants (PAs) is rising. Merritt Hawkins conducted more search assignments for NPs and PAs than in any other 12-month period tracked by the company.
While the tying of physician compensation to value is spreading, value was linked to only 8% of compensation in the survey.
In record highs for the survey, the average physician signing bonus was $33,707, the average starting salary for family physicians was $241,000, and the average starting salary for a nurse practitioner was $129,000.
Employment remains the dominant physician staffing model, with more than 90% of Merritt Hawkins' search assignments set at employed practice settings and less than 10% at independent practices.
In a record high for the survey, 62% of recruiting assignments were in communities of 100,000 or more. The survey authors linked the trend to the rising demand for medical specialists, who tend to practice in large communities.
The shortage of psychiatrists has been worsening for years, Singleton says.
"In 2005, psychiatry was No. 13 in our list of most requested types of searches. Five years ago, in 2013, psychiatry was No. 4 on the list. For the last three years, it has been No. 2, trailing only family medicine."
Psychiatrists are a dire pain point in the nation's clinician shortage, he says. "We judge the shortage in psychiatry to be more severe than any other specialty we recruit."
There is little relief in sight, Singleton says. "Though there has been increased interest in psychiatry among medical graduates selecting residency programs recently, our ability to train more psychiatrists remains limited because residency positions are limited."
A physician group repositioned itself on firmer ground by implementing a plan that not only helped patients, but its bottom line.
Clinical care and access initiatives played key roles in a $56 million year-over-year operational budget turnaround at Atrius Health in Massachusetts.
The Newton-based physician group posted a $31.6 million operating loss in 2016 and a $24.4 million surplus last year, according to the President and CEO Steven Strongwater, MD, at Atrius Health.
Reasons for the weak financial performance at Atrius in 2016 included unsustainable staffing costs, he says.
There were three core elements in Atrius' turnaround plan: patient volume growth, cost control, and medical expense management.
1. Increasing patient volume
Increasing access to care was a crucial component of increasing patient volume, says Strongwater. "Our core approach is to improve access. We try to make ourselves available when and how our patients need us."
To supplement its primary care and urgent care clinics, Atrius has recently launched several telemedicine services, including dermatology, behavioral health, urgent care, and developmental pediatrics. At least 10,000 patients have used the telemedicine dermatology service.
"We like telehealth," Strongwater says. "We believe it should be incorporated into usual care within our practices as opposed to the big national firms like American Well and Teledoc. They are not your doctor. They are not accessing your electronic medical record. When you have a telehealth visit with us, we are in your record, we know who you are, we have access to prior treatment."
Atrius, which features 825 physicians practicing in 32 locations, plans to continue expanding telemedicine services. The next service set for launch is OB/GYN care for routine pregnancies.
There is significant potential for more telemedicine offerings at Atrius, he says. "Whenever patients can avoid an in-office encounter and get treated in the comfort of their own home, those are the ideal opportunities to roll out telemedicine. Almost every specialty has an application for telemedicine."
2. Controlling operational costs
Expense management efforts at Atrius included layoffs totaling 188 FTEs, supply chain cost cutting, and controlling site of service.
"It is more expensive to be treated in an inpatient unit than an ambulatory unit. We moved thousands of patients who would have otherwise been in a hospital unnecessarily to ambulatory units," Strongwater says.
Ambulatory surgery has been a prime area to generate site-of-care savings, he says. "We moved surgeries that were going to be done in hospitals to ambulatory surgery centers. We set up a program using our VNA Care in the home."
Atrius also has limited hospitalizations by bringing the hospital to the home.
"This allows us to move patients who traditionally would have been hospitalized—mostly medical patients but sometimes surgical patients—and set up a hospital in their home. We put a biometric patch on them, put telehealth in the home, and there is bidirectional video connected to a 'mission control,' " he says.
The home hospital service includes visiting nurse care.
"Our VNA goes into the home and provides care and services that are needed. We can provide pretty much everything except advanced imaging. We can provide antibiotics, we can provide fluids, we can do physical therapy and behavioral health, and we can deliver meals."
Patients are screened for home hospital suitability, Strongwater says.
"Patients have to have the right social environment at home. The patient has to be safe, there needs to be confidence that there will be electricity and other basic services, and the patient needs to be relatively intact cognitively," he says.
3. Medical expense management
Boosting population health capabilities was a primary strategy to control the medical cost trend at Atrius.
"Generally, about 5% of patients drive about 30% to 40% of healthcare spend. If you can manage those people, keep down their hospitalization rate, keep them out of skilled nursing facilities, and provide services in the home, their costs will go down. That is what we have been doing," he says.
Analytics have help boost population health at Atrius.
"We try to identify high-risk patients through risk predictors, then triage the information to the right people. It could be triaged to a VNA, a case manager, a population health manager, or a care facilitator. Then the appropriate intervention is tailored to the needs of the patient," Strongwater says.
Expansion of behavioral health services also has helped reduce medical expense at Atrius, he says.
"Behavioral health comorbid conditions increase total medical expense by two- to sevenfold. So, we have created new triage programs to get our sickest behavioral health patients seen quickly and get intensive therapy. Instead of coming in every month, we have patients come in every week."
At Atrius, behavioral health offerings are financially negative on a standalone basis, but it is money well spent, Strongwater says.
"We subsidize behavioral health—we don't break even on that service. We subsidize it because we believe it has a big impact on total cost of care. We also believe it's related to why our medical expense trends are lower than other physician groups."
To improve its behavioral health assessment capability, Atrius has adopted Patient Reported Outcome Measures.
"We are one of the earliest in Massachusetts to usePROMs in behavioral health," he says. "We tend to use PROMs more in surgical conditions like total joint replacement or back pain. In behavioral health, it's exciting. You can get a much better view of how the patients are doing by having the patients report it to you using these standardized screening tools."
Atrius has repositioned itself on firmer ground, Strongwater says. "We are better coordinating our clinical protocol across all of our sites, we are standardizing a lot of our clinical care, and we are improving access for patients."
With safety and finances on the line, effective patient identification methods include requiring adults to present a photo ID, having patients read their wristbands to confirm information, and installing patient registration kiosks.
Effective patient identification is one of the keys to ensuring quality care and avoiding financial losses at health systems, hospitals, and physician practices.
"The misidentification of patients in clinical settings has untold financial impacts for an organization in uncompensated care as well as serious patient safety consequences, such as wrong-side surgeries and even death," according to an article in the Journal of AHIMA's June edition.
A Ponemon Institute survey of 503 nurses, physicians, and health IT workers, the "2016 National Patient Misidentification Report," details some of the negative consequences associated with patient identification failures:
86% of survey respondents said they had witnessed or were aware of a medical error caused by patient misidentification
Survey respondents said 35% of claim denials are the result of inaccurate patient identification or faulty patient information
On average, claim denials linked to inaccurate patient identification or faulty patient information cost $1.2 million annually
The Journal of AHIMA article, "Tips for Trusting Identity in the Era of Cybercrime and Fraud," highlights six best practices for patient identification:
Two-factor authentication is the industry standard for verifying patient identity such as name and date of birth, but using three or four factors such as adding home address is more effective.
Asking patients to verbally state their authentication factors is more effective than having registrars ask "yes" or "no" questions to verify information.
Adult patients should be required to present a driver's license or some other form of photo ID as part of the identification process.
If possible, patients should read their wristbands to confirm the accuracy of their registration. Patients can also be asked to confirm the accuracy of their information on the registrar's computer screen.
Healthcare organizations should consider taking photos of patients and including those images in medical records. Benefits of photographing patients include deterring medical ID fraud and helping clinicians to see that they are treating the right patient.
Patient registration kiosks have several benefits: they can take a patient's photo, they can match images of a patient to a photo ID or photos in a database, and they can require patients to verify their demographic information.
While most physicians surveyed recently saw a need for chronic care management services, barriers to adoption include patient skepticism, doctor unfamiliarity with Medicare reimbursement, and physician concern over complicated coding.
Most primary care physicians would like to offer chronic care management (CCM) services to their Medicare-eligible patients, but there are several barriers to adoption, a recent survey found.
Chronic conditions include hypertension, cancer, arthritis, and diabetes. These kinds of conditions are not only associated with long-term impairment, but also 71% of healthcare costs, according to the Quest Diagnostics survey, "Hidden Hazards: Closing the Care Gap Between Physicians and Patients with Multiple Chronic Conditions."
"Three in four Americans over the age of 65 have two or more
chronic health conditions. These patients are generally sicker, more likely to use hospitals and emergency rooms, have greater limitations
in their daily living, and experience accelerated decline in their quality of life," the survey authors wrote.
CCM services are designed to guide and support patients who have multiple chronic conditions (MCCs). CCM services include electronic and phone consultation, medication management, and 24-hour access to care providers. Medicare Part B pays for CCM, with average reimbursement ranging from $42 to $62.
Physicians see a need for CCM, according to the survey, which polled 801 primary care physicians and patients over 65 with MCCs:
93% of the physicians wished they had help ensuring MCC patients were adhering to their care plans
92% reported MCC patients struggled with adhering to their care plans
85% said they lacked the time to provide adequate care for MCC patients
Only 9% said their MCC patients were getting the care and attention they needed
There are several barriers to CCM adoption, the survey found:
MCC patients surveyed said they were largely satisfied with the care provided at their primary care physician office, with 92% reporting they were getting all the attention they needed at their PCP
Only 51% of physicians surveyed knew that the Centers for Medicare & Medicaid Services pay separately for CCM under the Physicians Fee Schedule for qualified patients with MCCs
77% of the physicians said they had not implemented CCM, with 43% citing complicated coding, 37% citing burdensome paperwork, and 25% citing low Medicare reimbursement
3 Strategies
There are three strategies to overcome the barriers to CCM adoption, according to the survey:
To address the perception of CCM complexity among primary care physicians, adoption solutions should include simplifying the process such as providing coding expertise.
PCPs can make convincing arguments to patients to use CCM services, including medication adherence and reassuring patients that CCM has only modest copays under Medicare.
Physicians can explain to patients that CCM helps address health concerns before they become major medical problems. In the survey, the Number One worry among patients was "getting another medical condition" (43%).
A doctor offers four recommendations to curb harassment and assault against healthcare providers.
A Massachusetts-based physician is calling on the healthcare community to develop more effective responses to patients who engage in harassment or other negative interactions.
"There is only a relatively small body of literature on harassment in medicine, and it tends to focus on acts committed by colleagues and superiors rather than by patients or clients," Charlotte Grinberg, MD, wrote in an article for Health Affairs.
"Clearly, patients can also be offenders. This should not be ignored."
Grinberg, resident physician at Mount Auburn Hospital in Cambridge, Massachusetts, shares three incidents from her past to illustrate potentially dangerous workplace environments:
When she was a sophomore in college, Grinberg did GED tutoring at a correctional facility. After an inmate masturbated during a tutoring session, she reported the incident to a guard, who said, "These things sometimes happen."
As a second-year medical student, Grinberg volunteered at a homeless shelter, where she connected residents with community resources. After a resident with whom she had worked was charged with raping a store clerk, it changed her: "I kept the visits brief. I avoided physical contact. I didn't give out my phone number or offer to call patients on other days of the week to follow up."
In her third year of medical school, an end-stage liver disease inpatient tried to pull Grinberg into his bed while making sexually suggestive comments. "I wondered if this was somehow my fault, and how I could ever provide care to Steven again," she wrote.
Although all three incidents were reported, only the inpatient encounter was reviewed. "I started feeling little less alone and a little less responsible," Grinberg wrote.
There are rarely easy answers when patients harass or assault their caregivers, she wrote, "Sometimes, these assaults are by-products of diseases such as psychosis and dementia. We wouldn't want to react to someone who lashes out because of dementia in the same way we react to someone who is lashing out for reasons within their control."
She offers four recommendations to curb harassment and assault in healthcare settings:
There is widespread promotion of safety incident reporting. Similarly, healthcare organizations should foster workplace environments where it is safe to report harassment and other negative interactions with patients.
Raise awareness among healthcare staff members about the potential for patients to engage in harassment and assault, and explain the benefits of reporting incidents.
Form a culture that allows caregivers to discuss incidents with patients directly. "Our duty is to serve all patients, no matter what sort of people they are. But this does not mean we need to accept or ignore abuse," Grinberg wrote.
Carefully examine existing interventions to guide the creation of new policies. "Such policies will help doctors like me in the future and ensure that although these things do sometimes happen, there is something we can do about them," she wrote.
A children's hospital has more than doubled its number of submitted incident reports, overcoming challenges such as employees' fear of retaliation for reporting.
Over a three-year period, Children's National Health System in Washington, D.C., more than doubled the number of incident reports filed by employees, creating opportunities to improve quality and safety for patients.
"If we don't know what's going on in our organization, we can't improve," says Rahul Shah, MD, MBA, vice president, chief quality and safety officer. "Any organization that fears increased reporting is missing the boat."
A research study about the incident report initiative was recently published in Pediatric Quality & Safety. Data in the study quantify the achievement at Children's National as follows:
2014 safety event reports totaled 4,668
2017 safety event reports totaled 10,971
Report submission time was decreased by nearly 30%
Number of submitting departments increased by 94%
Anonymous reporting decreased 69%
Overcoming 3 Challenges
Before Children's National, which features the Sheikh Zayed Campus for Advanced Children's Medicine with 316 inpatient beds, doubled their incident report numbers, they identified three incident report challenges that it needed to work through to achieve the goal of improving quality and safety for its patients.
"What we realized is we had to improve technology, we had to change the culture so it was safe to report, and we had to show reporting made a difference," Shah says.
Improve technology
To ease reporting through improved technology, Children's National rolled out mobile reporting with an app-based platform and optimized the platform with specific reporting categories such as falls and compliance. In another effort to save time, the number of mandatory fields in the reporting templates was reduced.
The technology upgrades have made it easier to submit incident reports, helping to cut submission time from 12 minutes to 7 minutes, Shah says. "That's a big 5-minute time saving for a clinical nurse or respiratory therapist who is busy."
Change organizational culture
Creating a culture where employees feel safe to submit incident reports is a significant challenge, Shah says.
The decrease in anonymous reporting reflects well on efforts to assuage fear of making a report, he says.
"People will say they are making an anonymous report out of fear and to avoid retaliation. We worked on that aspect of our culture. We believe the decrease in anonymous reporting is a surrogate for our culture improving," he says.
Shah continues, "We adopted the concept of a just culture, where everyone in the organization gets treated in the same way. We partnered with human resources to ensure that we embodied, espoused, and showed employees that we had a just culture."
Children's National also adopted a positive philosophy for incident reports, he says.
"Many organizations call these documents incident reports. We call them safety reports, which takes away a pejorative and negative connotation. The whole initiative was called 10,000 Good Catches and when people make good catches, we celebrate them," Shah says.
Other efforts to gain trust and reporting participation from Children's National staff have included one-on-one outreach, naming a monthly Reducing Harm Hero, and the awarding of "Zero in on Zero Harm" pins.
Staff members also know their incident reports are being reviewed at a senior executive level, Shah says. "I read every incident report in the organization. I made that pledge about three-and-a-half years ago, when we had 4,000 incident reports. I still stand by that pledge when we have 11,000 incident reports."
One of Shah's subordinates also reads all incident reports, as does the chief risk officer and a deputy. "Everyone in the organization knows that when they file an incident report, at least four leaders will look at it," he says.
Show reporting makes a difference
Showing employees that their incident reports make a difference also can be challenging. But Shah cites two examples of incident reports that led to significant quality or safety improvements.
Example 1: Code Simulation Program
In one instance, a patient required resuscitation at a Children's National satellite clinic. "That is pretty much all the incident report said," Shah says.
Based mainly on the incident report, Children's National decided to spread its emergency code simulation program from the main hospital to the satellite clinics. The simulation program focuses on cardiac arrest and other resuscitation emergencies. Children's National subject-matter experts developed the program, which is also staffed internally.
Shah believes the new code training has saved at least one life.
"Six months later, a child was having a seizure in one of our satellite clinics, turned blue, and needed resuscitation. It took EMS about 10 minutes to get to the clinic. By the time EMS arrived, the child was intubated, stabilized, and properly coded."
Example 2: Safe Restraint Techniques
Another example of incident report impact involves behavioral health patients.
"One area that hospitals all over the country struggle with is behavioral health and violence in those patients. We had a safety event report regarding violence toward staff from behavioral health patients," Shah says.
Several safety changes were adopted, he says. "From that safety event report, we asked, 'How can we keep our staff safe?' Now, we have training. We have Kevlar sleeves for our employees to use. We have different techniques for restraining patients."
National Children's incident report initiative has far exceeded Shah's expectations.
"To see those 11,000 reports come in, they are almost changing in front of my eyes. I'm seeing them getting rich with information and opportunities for improvement. People are trusting me and the organization, and they know we have their back," Shah says.
The health system's multipronged initiative promotes doctors' well-being.
Cleveland Clinic is expanding efforts to address physician burnout that the health system began a decade ago with a coaching and mentoring program.
Cleveland Clinic has not only launched new physician health initiatives but also adopted a new philosophy.
"We made a strategic decision when we started our efforts a couple years ago to focus on well-being rather than burnout. We prefer to focus on getting well and staying well," says Susan Rehm, MD, executive director of physician health at Cleveland Clinic.
Last year, internal engagement survey data shows modest but statistically significant improvement in several key measures for physician satisfaction at Cleveland Clinic. The data is represented on a scale of 0 to 5:
+.04 for engagement
+.03 for continuous improvement
+.04 for well-being
+.04 for trust
+.04 for communication
Financial impact?
Gauging the financial impact of the well-being programs is imprecise because it is difficult to assess turnover, says Rehm. Tracking physicians who leave the health system due to burnout is a work in progress, she says.
However, turnover prevention goes a long way financially, she says. "The literature suggests that turnover of a physician costs the organization somewhere between $250,000 and $500,000. It wouldn’t take too many retained doctors to completely pay for the programs."
Cleveland Clinic's well-being programs have been staffed internally, so costs have been low.
"Because we used existing resources, the amount of new money that went into these programs was relatively small," Rehm said. "The biggest investment is training up clinicians to participate in these activities. If you take a surgeon out of the operating room for a day, that's potentially a big-ticket item that impacts us in areas like patient access."
Five of Cleveland Clinic's most prominent physician health programs are a blend of old and new initiatives:
1. Wellbeing Day
In January 2017, the 11-hospital health system established Wellbeing Day, granting time off for healthy activities. "We specify that it should be a day spent doing something that contributes to one's personal well-being," Rehm says.
Wellbeing Day is both a concrete and a symbolic effort, she says. "Wellbeing Day was a good start to demonstrate how Cleveland Clinic endorses well-being for the physician staff."
2. Coaching improvement
Nine years ago, Cleveland Clinic started a basic coaching and mentoring program, which featured a daylong orientation for staff members who wanted to be coached or to be a coach.
The program has grown over the years, including the addition of advanced peer coaches three years ago.
"An advanced peer coach receives four days of advanced training. They can help peers [with] career issues who need more intensive help than the average person looking for career development advice. We have trained more than 100 people in advanced peer coaching," Rehm says.
An internal questionnaire found that both coaches and the people they coach benefit. "We found that both were much more satisfied with their work and their lives," she says.
3. Engagement consulting
In 2017, the health system's professional staff affairs office took on a consulting role linked to a series of town halls that featured staff suggestions for operational changes. The engagement consulting features marshaling of resources and program development.
Engagement consultants also help managers with well-being–related staffing. "A couple of our departments and institutes have designated either engagement officers or well-being officers within their group to oversee well-being programs," Rehm says.
4. EMR ease
Since 2016, Cleveland Clinic has launched several initiatives to make the health system's electronic medical record more user-friendly, such as:
Developing two apps that allow viewing and interaction with the EMR on handheld devices
Freeing physicians of sole responsibility for routine tasks such as prescription refills
Cleveland Clinic's IT staff has been a crucial element of EMR enhancement initiatives, Rehm says.
"With every change that comes through, there are consultants from our information technology division who … help us with how we interact with the medical record, so we're not wasting a lot of time doing things that could be done more efficiently," she says.
5. Promoting empathy
For several years, all new hires at Cleveland Clinic have been required to take R.E.D.E. communication training. Empathy is a key ingredient in the Relationship: Establishment, Development, and Engagement training.
"The R.E.D.E. approach is an example of relationship-based communication. It can involve the use of empathy to bring out a patient's experience with their illness, their expectations, and how they wish to proceed," Rehm says.
R.E.D.E. has shown positive results with physicians, she says. "After going through the R.E.D.E. training, physicians reported feeling more empathy and less burnout."
To decrease burnout and increase resilience, you must deconstruct burnout into its component parts, understand the interplay between stressors and rewards, measure clinician experience, and design interventions.
Clinician burnout is a complex problem that can be addressed with thorough examination of working conditions and carefully targeted interventions, according to a Press Ganey reportreleased this week.
"The approach rests on the premise that the stressors and rewards that contribute to burnout risk derive from different sources, and the way individuals and teams respond to these stressors and rewards varies based on job responsibilities, personal values and professional experiences," the report says.
The report, "Burnout and Resilience: A Framework for Data Analysis and a Positive Path Forward," calls for a four-point approach to reduce burnout and increase resilience among medical staff:
Deconstructing burnout into actionable components
Understanding the interrelationships between burnout components
Measuring the clinician experience as it relates to components of burnout
Designing interventions that boost resilience and reduce burnout
1. Deconstructing burnout
The Press Ganey report deconstructs burnout by categorizing stressors and rewards as inherent to a caregiver's role or the result of external forces. "Deconstructing burnout into relevant component parts allows leaders and organizations to identify and manage each appropriately," the report says.
Inherent components of burnout and resilience:
The emotional drain linked to providing care to the ill
Witnessing suffering
The daily pressure of making clinical judgments that affect patients' lives
Rewards include the joy of helping people, doing meaningful work, and respect from patients, staff, and the community
External rewards include compensation, prestige, and recognition from patients
2. Interrelated stressors and rewards
The interplay between stressors and rewards is the key to understanding physician burnout, the report says. "These stressors and rewards define the clinician experience, and the balance between them influences clinicians' vulnerability to burnout."
It is crucial to not only identify components of burnout but also understand how those components interact, according to the report. "The balance is not a simple, linear equation. … The relationship is modulated by the dynamics of the different sources of stress and reward and their interconnectedness."
For example, physicians are admired for mastering medical knowledge, but keeping up with the flood of medical information can lead to anxiety and self-doubt.
3. Measuring the clinician experience
Addressing burnout requires collecting data on multiple measures, the report says.
"Leaders focused on reducing burnout and improving resilience in the clinician workforce should be prepared to measure engagement with sufficient thoroughness and frequency that the data allow segmentation, benchmarking and detection of change."
Press Ganey has developed an eight-point assessment tool to measure clinician resilience. The first four questions gauge capacity to disengage from work:
I can enjoy my personal time without focusing on work
I rarely lose sleep over work
I can free my mind from work when I am away from it
I can disconnect from work communications during my free time
The last four questions in the assessment tool measure engagement with work.
I care for patients equally even when it is difficult
I see every patient as an individual with specific needs
The work I do makes a real difference
My work is meaningful
4. Designing interventions
The report says there are four steps to developing an organization strategy for enhancing resilience and decreasing burnout:
Communicate the gravity of burnout, accept responsibility for addressing external stressors, and offer resources for coping with inherent stressors
Measure engagement and resilience of physicians, nurses and other key personnel, benchmark at unit levels, and monitor change associated with interventions
Promote inherent rewards to boost clinician engagement
In a survey, 91% of emergency medicine physicians say they have recently experienced a drug shortage and 44% say their facilities are inadequately prepared for a surge of patients during a disaster.
The vast majority of emergency room physicians face shortages of key medications and doubt whether their organizations are "fully prepared" for a disaster, polling datashows.
The poll's findings were released today by the American College of Emergency Physicians in Washington, DC. The survey, which was conducted from April 30 to May 7, has 247 respondents.
"Hospitals and emergency medical services continue to suffer significant gaps in disaster preparedness, as well as national drug shortages for essential emergency medications. These shortages can last for months, or longer, and constitute a significant risk to patients," ACEP President Paul Kivela, MD, FACEP, said in a prepared statement.
The poll's findings are alarming. "Emergency physicians are concerned that our system cannot even meet daily demands, let alone during a medical surge for a natural or man-made disaster."
Most emergency medicine doctors are facing struggles with drug shortages, according to the ACEP poll:
91% of ER physicians reported experiencing the shortage or absence of a critical medication in the previous month
For ER physicians who reported medication shortages, 41% said they have shortages for as many as five drugs and 43% said they have shortages for as many as 10 drugs
69% of respondents said drug shortages have "increased a lot" over the previous year, and 16% said drug shortages have "increased a little"
97% of respondents said their primary emergency department has been forced to use an alternative to a medication because of drug shortages
36% of respondents said drug shortages have negatively impacted patient outcomes
88% of respondents said they have lost time with patients because drug shortages force them to search for alternative medications
The poll's findings on disaster preparedness are similarly sobering:
When asked whether their ERs were prepared for a surge of patients during a disaster, 27% of the physicians said their facility was "not completely" ready and 17% said their facility was "not at all" ready
Only 22% of respondents said their hospital has access to real-time data on regional healthcare resources, and 13% said their hospital has no access
ACEP wants Congress to examine a regionalized approach the Pandemic and All Hazards Preparedness and Advancing Innovation (PAHPAI) Act that includes:
Increased coordination among public health and safety services, emergency medical services, medical facilities, trauma centers, and other entities in a region.
Tracking resources, including inpatient bed capacity, emergency department capacity, trauma center capacity, on-call specialist coverage, and ambulance diversion status with regional communications and hospital destination decisions.
Consistent, region-wide prehospital, hospital, and inter-facility data management systems.
ACEP supports the inclusion in PAHPAI of legislation that makes military trauma teams available to civilian trauma centers.
For the past several years, drug shortages have become a growing problem across the nation in virtually all areas of care delivery.