Posts Tagged with burnout

posted by adgrooms on June 19, 2019

On March 27, 1977, two Boeing 747s collided killing 583 on a runway in Tenerife, in the Canary Islands, off the coast of Morocco. This accident led to a new era of standardization and safety in aviation. Aviation studied its vulnerabilities and innovated to be a much safer form of transportation with .07 deaths per billion passenger miles, reducing the number of commercial fatalities from the thousands at the time of the Tenerife accident to a few hundred in recent years.

Medical errors and injuries are an ongoing problem for healthcare. Are there systemic gains that aviation has accomplished that healthcare can use to improve outcomes?

In comparison, both professions require years of rigorous training. One difference is that aviation includes extensive leadership, decision making, teamwork, and other non-technical skills where physicians receive little, if any, of this line of training. Physicians are required to interact with patients and staff as a leader while making numerous difficult decisions. Why wouldn't this type of training and support be provided in healthcare?

The safety initiative in aviation discovered that lack of communication was the root cause of many accidents. One response was a move to flatten hierarchies. The captain is in charge and has the last say in decision making, but if a co-pilot sees a problem, they are encouraged to speak up, not shut up. Collaborative approaches like team-based care have a positive impact in the clinical setting, but it only works if every team member feels valued and each voice is welcome. A culture of mutual respect for every role is needed for a cohesive, well-functioning medical environment.

The healthcare industry needs to provide an avenue for physicians to report a mistake without fear of repercussion. Aviation has cultivated a culture of reporting mistakes through the Aviation Safety Reporting System run by NASA. It is a place where pilots, air traffic controllers, flight crew, and maintenance can report errors voluntarily. The reporting is then used to improve whole systems, not to punish individuals. This allows for constant improvement in safety processes that benefit the whole industry. Healthcare already suffers from too much bureaucracy but a similar, industry-wide reporting system could simplify and standardize reporting while creating a culture of safety and a shared resource for improvement.

Aircraft have systems that collect a massive amount of information. This information is used to refine workflows. Much of the process has been automated such as controlling the plane in level flight. Healthcare has gone in the opposite direction with the implementation of EHRs. Doctors are burdened by required manual input in clunky interfaces. Modern aircraft interfaces offer inspiration to the development of more robust clinical software.

Airlines invest heavily in the wellbeing of their staff. There are strict guidelines on how much pilots can work, and psychological staff are readily available for support. This is not necessarily the case for physicians. With ongoing shortages, physicians are working longer hours, and burnout has become a heavily discussed problem. The safety improvements of the airline industry provide good justification to healthcare for making similar investments in the wellbeing of their team.

There is an effort in health care to learn from aviation. Captain Chelsea "Sully" Sullenberger, famous for the miracle on the Hudson emergency landing, speaks to doctors on improving systematic processes in the pursuit of patient safety. Although there are differences between the two disciplines, safety and the outcomes of patients/passengers are a shared objective.

posted by adgrooms on June 4, 2019

A recent report in the Annals of Medicine provided an estimate of the institutional cost of physician burnout. The researchers used mathematical data from other recent studies to come up with the conservatively estimated total annual cost of $4.6 billion or $7600 per physician. The study notes that it focused on the cost of replacing physicians and lost income from unfilled positions. When we consider other organizational costs of overburdening physicians, the amount is much higher.

Inefficient systems, which contribute to burn out, are a cost unto themselves. When Physicians are required to spend more than half of their (12 hour) workday in the EHR, their training is not put to best use. The amount of available time for patient care is unnecessarily limited. What would the impact be of reclaiming just one hour for each person? Spent on patient care or spent on self-care, either would lead to a greater benefit to the individual and the organization.

Beyond this, a 12-hour workday is wearing people out to the point of error. Mistakes due to decision fatigue are another hidden cost. At the end of a long day, of course, decisions are not going to be the same quality as those at the start. Minor mistakes lead to costs in unnecessary tests and prescriptions. Major mistakes, in the case of injury, add large costs of lawsuit settlements and legal bills.

Cost-effective solutions to this include:

  • Proper delegation of tasks. e.g. If another staff member can do the task, move it to their queue.
  • Streamlined interfaces.
  • Effective automation.
  • Communication triage.

This study and others have found that a moderate investment per physician can reduce burnout. Considering the extra costs not included in the study, the potential for a large return on investment is very high. Do you see a downside?

posted by adgrooms on May 8, 2019

Time is money. With the implementation of EHRs, a doctor's workflow has changed drastically since the time of paper records. Doctors are expected to maintain the same volume of patients while navigating and logging more information than ever in a cumbersome EHR system. Can we quantify the wasting of time among the healthcare front lines?

Before anything happens in the EHR, you have to log in. Logging in takes time. If a doctor isn’t lugging around their own laptop, they will have to log into a computer in the room. In a typical round, they might have 20 patients to see. Gregory Schmidt, M.D. did some research and came up with a 3 minute average login time and some take up to 5 minutes! Even if we consider faster computers, network, and software, a 30 second login time adds up quickly when you calculate for the one million doctors in the United States. And we are not talking about one login at the start of the workday. To protect patient data, doctors are logging in and out all day long.

The problem is worse. Often a provider is using an array of apps in tandem with the EHR, each one with its own username and password. Having to log in to all of these, multiple times a day takes a tremendous amount of time. At a minimum, the hospital should implement single sign-on (SSO), which is a system that consolidates access to all enabled systems into a single username and password. One not so recent study found that moving to SSO could save a hospital over 1400 hours per year across medical and ancillary staff. This resulted in an estimated savings of over $90K per year for each participating hospital.

Even faster, and built upon single sign-on, are physical access tokens. One example of a physical access token is a USB PKI device, such as YubiKey. To use it, the physician would plug the device into the USB port, touch it to confirm their physical presence and be instantly logged in to all SSO enabled software.

Faster still, are scanning technologies, which can log a person in just by their close physical proximity, similar to how modern car keys work. Some even save the state of the desktop as a provider moves from room to room, saving even more time having to locate where they left off.

Evolving fingerprint, eye scan, and voice recognition technology could also be implemented in the future to make logging in even more secure and efficient. The cost of adding these systems would quickly pay for itself in time savings alone, not to mention reduced burnout and increased quality of care.