The triple aim's fourth leg? Improving clinicians' work life

Healthcare's triple aim — enhancing patient experience, improving population health and reducing costs — is a widely accepted set of priorities, but new studies suggest it may be failing to address a critical component of the healthcare model: the providers.

According to Annals of Family Medicine's recent article, burnout and dissatisfaction among physicians and other healthcare workers — associated with lower patient satisfaction, reduced health outcomes and increased costs — has become endemic in healthcare, thus posing major obstacles to achieving the triple aim. The authors of the article, Thomas Bodenheimer, MD, and Christine Sinsky, MD, suggest adding a fourth leg to the triple aim that focuses on the need to improve the work life of healthcare workers to improve health system performance.

While visiting primary care practices around the country, Dr. Bodenheimer and Dr. Sinsky reported repeatedly hearing statements such as, "We have adopted the triple aim as our framework, but the stressful work life of our clinicians and staff impacts our ability to achieve the three aims," according to the article.

Primary care physicians' inability to achieve the three aims is largely due to the rising expectations society imposes on them, and the gap between these expectations and the reality of the medical profession has contributed to significant rates of burnout among physicians. Nearly half, 46 percent, of U.S. physicians reported experiencing symptoms of burnout, according to the article. Burnout appears most frequently among emergency department physicians, general internists, neurologists and family physicians, though it is present across all specialties. According to the article, a 2014 survey revealed 68 percent of family physicians and 73 percent of general internists would not choose the same specialty if they were starting their careers over.

According to the article, physician and care team burnout can lead to overuse of resources and prescription of inappropriate medications, which can result in expensive complications. Also, dissatisfied physicians are more likely to leave their jobs, which can incur significant expenses to the practice: The cost of family physician turnover can near $250,000 per physician.

Burnout also affects healthcare workers other than physicians. Thirty-four percent of hospital nurses and 37 percent of nursing home nurses report burnout. Those in administrative roles also experience burnout and high levels of stress. According to the article, 68 percent of receptions have endured verbal abuse from patients. A 2013 survey found that 60 percent of administrative workers reported burnout and 34 percent planned to look for a different job.

Working in a setting where people are "burnt out" of their job can fuel further dissatisfaction among other workers, according to the article.

Citing a RAND survey, the primary influencer of physician satisfaction is the ability to provide quality care. Therefore, physician dissatisfaction should be a warning sign that the healthcare system is constructing barriers to high-quality practice, according to the article.

Installing the fourth aim into the triple aim framework is critical for knocking down these barriers. The following list includes Dr. Bodenheimer and Dr. Sinsky's suggestions for improving primary care physicians' work lives:

1. Implement team documentation systems. Have nurses, medical assistants or other staff present during patient visits to help enter some or all documentation into the EHR, assist with order entry, prescription processing and charge capture. According to the article, team documentation has been associated with increased physician and staff satisfaction, improved revenues, and increased team capacity to manage a larger panel of patients during regular work hours.

2. Use pre-visit planning and pre-appointment laboratory testing to reduce the amount of time wasted on the review and follow-up of the results.

3. Under physician-written standing orders, allow nurses and medical assistants to be responsible for preventive care and chronic care health coaching.

4. Create standardized workflows for prescription refills. This approach can save physicians five hours per week while providing better care, according to the article.  

5. Co-locate teams: Physicians working in the same space as their team members have shown to increase efficiency and save 30 minutes of physician time per day.

6. Ensure staff who assume new responsibilities are well-trained and understand the necessity of their work for the health of the patients. This can help avoid shifting burnout from physicians to practice staff.

More articles on physician burnout:
6 key findings on clinician satisfaction, burnout
Pain specialists experiencing high burnout rates, survey shows
What factors contribute to varied levels of empathy among physicians?

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