In the 20 years since publication of the landmark Institute of Medicine (IOM) studies To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) many strategies have been employed to improve the safety and quality of health care in the United States. Improving the performance of the U.S. health care system to achieve the goals of better population health, enhanced patient care experiences, and lower health care costs (Berwick et al., 2008; Sikka et al., 2015; Whittington et al., 2015) depends in large part on clinicians, the health care professionals who provide direct patient care.2 Delivering safe, patient-centered, high-quality, and high-value health care requires a clinical workforce that is functioning at the highest level. However, there is growing recognition among health
1 Excerpted from the National Academy of Medicine’s 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).
care system experts that clinician well-being, so essential to the therapeutic alliance among clinicians, patients, and families, is eroding because of occupational stress (Bodenheimer and Sinsky, 2014; Sikka et al., 2015; Street et al., 2009). The high rates of burnout reported among U.S. health care clinicians, and clinical students and trainees (“learners”), are a strong indication that the nation’s health care system is failing to achieve the aims for system-wide improvement.
Although occupational stress can take multiple forms, professional burnout, a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work, is the best-studied phenomenon (Bodenheimer and Sinsky, 2014; Schaufeli et al., 2009; Shanafelt et al., 2012, 2014). Extensive research has found that between 35 and 54 percent of U.S. nurses and physicians have substantial symptoms of burnout (Aiken et al., 2002b, 2012; McHugh et al., 2011; Moss et al., 2016; Shanafelt et al., 2009, 2012, 2015, 2019); similarly, the prevalence of burnout ranges between 45 and 60 percent for medical students and residents (Dyrbye et al., 2014; West et al., 2011). Burnout among health care clinicians and learners has been most studied in the medical and nursing professions; however, a growing understanding of the epidemiology and etiology of the syndrome suggests that burnout among all types of clinicians and learners is a growing public health concern (Jha et al., 2019). The high rate of clinician and learner burnout is a strong signal to health care leaders that major improvements in the clinical work and learning environments have to become a national and organizational priority.
A growing body of research suggests that the changing landscape of the U.S. health care system—how care is provided, documented, and reimbursed—has had profound effects on clinical practice and consequently on the experiences of clinicians, learners, patients, and their families. As the committee summarizes in the report, many mounting system pressures have contributed to overwhelming job demands for clinicians (e.g., workload, time pressures, technology challenges, moral and ethical dilemmas) and insufficient job resources and supports such as adequate job control, alignment of professional and personal values, and manageable work–life integration. A chronic imbalance of high job demands and inadequate job resources can lead to burnout. The job demand–resources imbalance in health care is exacerbated by the increasing push for system performance improvement (which leads to greater administrative burden, production pressures, and shifts in financial incentives and payment structures); by technology implementation that hinders rather than supports patient care; by changing professional expectations; as well as by standards and regulatory policies that are insufficiently aligned with the delivery of high-quality patient care or professional values. Intensifying these and other
health system pressures on the clinical workforce is the explosive increase in the amount of medical information and data collected and the growing demand for health care as the U.S. population ages, including care and services for chronic conditions (Irving, 2017) and social care3 (NASEM, 2019a), in the face of an existing shortage of health professionals in many areas (Gruca et al., 2018; IHS Markit, 2017; Zhang et al., 2018).
Burnout resulting from chronic workplace stress is not a new phenomenon among clinicians or among other workers. However, the common perception that a job in the health care professions is generally associated with socioeconomic benefits may actually be a barrier to recognizing and addressing the wide-ranging effects of clinician burnout. Several decades of research on the characteristics, the causes, and the outcomes of burnout clearly show that burnout has high personal costs for individual workers, but it also has high social and economic costs for their organizations (Maslach, 2018) and for society as a whole. For example, in health care, studies have found strong links between clinician burnout and unprofessional behavior leading to undesirable patient experiences (Windover et al., 2018). Clinicians with burnout are at least twice as likely to report they have made a major medical error in the past 3 months as those without burnout, and they are also more likely to be involved in a malpractice litigation suit (Panagioti et al., 2018; Shanafelt et al., 2010; West et al., 2006, 2009). Physicians with burnout are more likely to reduce their clinical work hours, at least twice as likely to leave their job, and, worse yet, five times more likely to leave medicine altogether (Dyrbye et al., 2013; Hamidi et al., 2018; Linn et al., 1985; Shanafelt et al., 2009; Willard-Grace et al., 2019; Windover et al., 2018). Approximately 2,400 physicians leave the workforce each year, with professional burnout the largest factor influencing a decision to leave medicine early (Sinsky et al., 2017). Not only does this affect access to care, but an estimated $4.6 billion in societal costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States (Han et al., 2019). This figure does not account for the additional societal cost of burnout in other health care clinicians, which, to the committee’s knowledge, has not been estimated. These and other consequences of burnout are further discussed in Chapters 3 and 8.
There is growing momentum for taking action to improve the quality and safety of health care by addressing clinician and learner burnout (Aiken et al., 2002a; Dzau et al., 2018; Jha et al., 2019; Lake et al., 2019; Noseworthy et al., 2017; Perni, 2017; Shanafelt et al., 2017b). Catalyzing collective action to reduce burnout and improve clinician well-being is the core goal of the National Academy of Medicine’s (NAM’s) Action Collaborative on Clinician Well-Being and Resilience, which was developed
in collaboration with the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges. The calls to accelerate progress toward improving professional well-being among clinicians build on the current focus of professionalism in health care. Clinicians are intrinsically motivated and committed to providing patients with high-quality, patient-centered care (Chassin and Baker, 2015; Madara and Burkhart, 2015). It is when the health care system makes it difficult for clinicians to “fulfill their ethical commitments and deliver the best possible care” that work takes a personal toll (Dzau et al., 2018, p. 312).
Given the importance of burnout to health care quality and safety and the pervasiveness of burnout, there is a strong imperative to take a systemic approach to reduce it, focusing on the structure, organization, and culture of health care (Dzau et al., 2018; Shanafelt and Noseworthy, 2017; Shanafelt et al., 2017b). A systems approach incorporates thorough knowledge of several factors, including the stakeholders, their goals and activities, the technologies they use, and the environment in which they operate. In designing and implementing effective systems-focused interventions, it is crucial to consider the fact that health care is a “complex adaptive system” in which the complex interplay of all of these factors affects system outcomes (NASEM, 2018; Plsek and Greenhalgh, 2001; Rouse, 2008). The Crossing the Global Quality Chasm: Improving Health Care Worldwide (NASEM, 2018) report provides general principles for building a new health care system that consider the complex adaptive nature of the health care system (see Box 1-1).
A systems framework to improving health care more generally was the focus of a 2005 National Academy of Engineering and IOM report (NAE and IOM, 2005). The World Health Organization further advanced systems thinking as the standard in health system interventions and evaluation design by providing tools and guidance (De Savigny and Adam, 2009). More recently, a 2014 President’s Council of Advisors on Science and Technology report promoted the greater use of systems-engineering principles as a way of enhancing U.S. health care (PCAST, 2014). The subjects of recent systems-oriented approaches to complex public health issues have included diagnostic error (NASEM, 2015), global health care quality (NASEM, 2018), tobacco use (IOM, 2015), obesity (IOM and NRC, 2015), cancer control (NASEM, 2019b), and a variety of case studies (Kaplan et al., 2013).
Creating healthy and safe care systems for the nation’s patients and clinicians is a complex endeavor. Many factors over time have contributed to the current state. “Fixing” a single variable in the system, such as the electronic health record, will not solve the burnout problem by itself, nor will it be sufficient to gain the deep understanding necessary for a comprehensive solution. Many different aspects of the health care environment have to work together in an integrated way to prevent, reduce, or mitigate
burnout and improve professional well-being (Shanafelt and Noseworthy, 2017; Shanafelt et al., 2017b). Systems-oriented strategies will need to include making improvements in clinician workload and clinical workflow, providing more usable technologies that are focused on clinicians’ needs, and developing organizational structures and processes that better support clinicians and the interdisciplinary care teams in which they work (Andela et al., 2017; Bodenheimer and Willard-Grace, 2016; Catt et al., 2005). Individually focused interventions, such as group discussions and mindfulness education, can be complementary to system interventions (Krasner et al., 2009; Panagioti et al., 2017; West et al., 2014).
There is a serious problem of burnout among health care professionals in this country, with consequences for both clinicians and patients (e.g., safety), health care organizations (e.g., productivity), and society (e.g., cost of care) (Panagioti et al., 2018; Shanafelt et al., 2017a; West et al., 2018). This report by the Committee on Systems Approaches to Improve Patient
Care by Supporting Clinician Well-Being synthesizes current knowledge about the prevalence, causes, and consequences of clinician burnout and makes recommendations on how best to design systems approaches to reduce clinician burnout and support professional well-being.
ORIGIN OF THE TASK AND COMMITTEE CHARGE
The NAM’s Action Collaborative on Clinician Well-Being and Resilience (Action Collaborative) was launched in January 2017 in response to alarming rates of stress, burnout, and suicide among U.S. clinicians. The Action Collaborative is a network of more than 190 organizations committed to reversing these trends and improving clinician well-being. The leadership of the Action Collaborative requested that the Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine undertake a consensus study that would serve as one approach to achieving the Action Collaborative’s goals for addressing clinician burnout and well-being. The Action Collaborative has three goals: (1) to raise the visibility of clinician stress, burnout, depression, moral injury, and suicide; (2) to improve the baseline understanding of the challenges to clinician well-being; and (3) to advance evidence-based, multidisciplinary approaches to improving patient care by caring for the caregiver. The Action Collaborative’s working groups meet regularly to identify strategies for improving clinician well-being at both the individual and systems levels.4
With support from a broad coalition of sponsors (see Box 1-2), the study was launched in June 2018. The charge to the committee was to examine the scientific evidence on clinician burnout and well-being and to make recommendations about systems approaches to reduce burnout and improve well-being, including providing a research agenda to address areas of uncertainty (see Box 1-3).
An independent committee was appointed with a broad range of expertise, including in clinical care, health care systems and administration, health information technology, health care quality, health professional education, systems engineering/organizational science, human-systems integration, human factors and ergonomics, health care policy and financing, oversight of clinical documentation, burnout, research methodology, implementation science, and medical ethics. Brief biographies of the 17 members of this Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being are presented in Appendix A.
4 For more information about the Action Collaborative and to view the many resources developed on the topic of clinician well-being, please visit https://nam.edu/initiatives/clinician-resilience-and-well-being (accessed October 1, 2018).
METHODS OF THE STUDY
The committee deliberated during four 2-day, in-person meetings and many conference calls that took place between October 1, 2018, and May 31, 2019. At two of the meetings speakers were invited to inform deliberations and members of the public were given the opportunity to offer comments and suggestions. The speakers provided valuable input to the committee on a broad range of topics, including burnout, moral distress, resilience, workplace health and safety, the nursing work environment, patient safety, technology in health care, clinical documentation requirements, administrative burden, and the usability of electronic health records. A number of experts and organizations provided written input to the committee on an array of topics. In addition, the committee completed an extensive search of the peer-reviewed literature, ultimately considering more than 4,000 articles. The search targeted English-language articles published since 2000 concerning
U.S. and international health care professionals. International papers about physicians and nurses were referenced in some instances when the data were particularly strong or filled a void. In particular, because there were limited data on dentists and pharmacists, the committee had to rely more on research conducted in settings outside of the United States. The committee also reviewed grey literature, including publications by professional associations, government agencies, and business and industry. See Chapter 9 for a discussion about the gaps in the literature and the areas needing further research.
The study’s Statement of Task (see Box 1-3) places emphasis on “systems approaches” to achieve the dual objective of improving patient care and addressing clinician burnout and well-being. To help orient and organize its work, the committee developed a conceptual framework that harnesses systems thinking and design principles with the goal of fostering healthy and safe care systems for the nation’s clinicians and patients. In Chapter 2 the committee describes this framework and presents a systems model of clinician burnout and professional well-being, which is discussed and elaborated on throughout the report.
Target Population, Health Care Organizations, and Educational Institutions
Clinicians and Learners
The Statement of Task refers to “all clinicians and trainees on the care team.” In the committee’s framework, the term “clinicians” is used to refer to health care professionals who provide direct patient care. The term “learners” includes students and trainees, who learn and work within various and diverse settings, including classrooms, laboratories, and clinical settings.
After reviewing the literature, the committee found that much of the evidence is related to physicians and nurses. Although physicians and nurses are the focus of most of the available published research, there is limited but consistent evidence that burnout is also a significant problem among pharmacists, dentists, nurse practitioners, and physician assistants. Furthermore, the available evidence suggests that burnout is present to varying degrees in other health care professionals and clinicians (e.g., genetic and mental health counselors, perfusionists, respiratory therapists).
The evidence provided in the literature about burnout informed the development of the committee’s framework. On the basis of this evidence, the committee determined it was important to develop a framework that shines a light on many fundamental aspects of the health care system that are barriers to healthy work and learning environments. The principles that define the committee’s framework are based on theories and constructs from systems science (see Chapter 2, Box 2-2) that are applicable to various types of workers and workplaces. Based on the available literature the committee believes that many evidence-based approaches used by high-functioning systems and healthy work environments in other domains are relevant to health care inclusive of all clinicians. Because the factors contributing to burnout or affecting well-being will vary by clinical
profession, organization, and even by individuals in the same work environment, the committee’s report does not provide a prescriptive approach, but rather offers health care leaders and other stakeholders guidance to improve the well-being of clinicians in all disciplines to the extent they are relevant and meaningful to the local context. The committee’s framework is intended to be dynamic—it includes a learning feedback loop, by which the system can adapt to new or different inputs. These inputs can include new information and data about clinician characteristics or other variables that future research studies suggest are important. The next steps in understanding and acting on clinician burnout more broadly is to use the framework as a platform for expanding research and pilot projects relating to other disciplines and a myriad of other areas, as discussed in Chapter 9, A Research Agenda to Advance Clinician Well-Being. Like the early IOM studies about safety and quality (IOM, 2000, 2001), this report sets the stage for much subsequent work.
Health Care Organizations and Educational Institutions
In the report, the term “health care organization” (HCO) broadly applies to all types of care-providing entities—from single clinician offices to large, integrated health systems. All HCOs comprise people, processes, and resources that are part of a system that delivers care services to meet the health needs of patients. “Health professions educational institutions” refers to organizations that provide health care professional education and training (e.g., professional schools, undergraduate and graduate programs, sponsoring health care organizations). These organizations are a system comprising people, processes, and resources that provide structure, guidance, and support for learning.
ORGANIZATION OF THE REPORT
The committee organized this report into 10 chapters. Chapter 2 defines the concepts of burnout, professional well-being, and resilience. It further describes the committee’s systems approach and conceptual framework for addressing clinician burnout and professional well-being, which are grounded in the theories and principles of human factors and systems engineering, job and organizational design, and occupational safety and health. Chapter 3 discusses the prevalence and consequences of clinician burnout. Chapter 4 describes the contributing factors of clinician burnout and professional well-being in terms of job demands and job resources as well as the individual clinician factors that mediate burnout. Chapter 5 focuses on health care organizations, interventions that target burnout in the workplace, and the principles with which health care organizations can design well-being systems. Chapter 6 describes how the external environment (including the health care industry, laws, regulations, standards, and societal values) can contribute to workplace stress. Chapter 7 discusses current and future health information technology, how stakeholders across all levels can work to improve it, and the potential of emerging technologies to reduce some of the burdens that contribute to burnout. Chapter 8 discusses the prevalence and consequences—as well as the contributing factors—of burnout among students and trainees of the health professions. Chapter 9 discusses the gaps in the current research on burnout and well-being and proposes a research agenda to advance the field. Chapter 10 details the committee’s main conclusions and recommendations for reducing clinician burnout and improving professional well-being.
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