5 best practices to achieve the ‘quadruple aim’ and prevent physician burnout in the post-EHR era

A landmark JAMA report in 2012 revealed that career dissatisfaction is more common among medical doctors than it is for those in other careers, with 45 percent of physicians reporting at least one symptom of burnout.

A recent report by the Experience Innovation Network revealed that the number has continued to climb, with 54 percent of physicians reporting they have experienced at least one symptom of burnout.

While many hospital and health system leaders across the country are focused on addressing the issue of physician burnout, the adoption of electronic health records (EHRs) appears to have made the situation worse by adding to the clerical burden of physicians, taking them away from their patients and effectively limiting moments of interaction that improve the physician-patient bond. In many instances, clinicians have become data entry clerks, with numerous administrative and regulatory requirements taking them away from the patient bedside and adding to their already full plates. Simply put, doctors and nurses are stressed out.
Despite the near-ubiquitous presence of “patient-centered” language in the healthcare quality discourse, the full realization of human-centeredness—which also includes well-being of physicians, nurses and care teams – remains elusive in most care settings. This has to change.

Achieving the ‘Quadruple Aim’

That’s why the Experience Innovation Network, an international group of chief experience officers (CXOs) and other healthcare experience leaders, is dedicated to helping hospitals and health systems meet the “Quadruple Aim” by addressing the inherent trauma in the system and by deploying innovative technologies that streamline processes and build trusted relationships.

The Quadruple Aim builds on IHI’s Triple Aim – improving patient experience, improving population health, and decreasing the cost of care – by adding a fourth measure focused on achieving joy, well-being and resilience among care teams. Hospital leaders not only need to prevent and combat burnout, but they also need to foster an environment that restores joy to medical practice and reminds physicians why they chose their careers in the first place.

This issue is so important to me that I have dedicated my life to furthering it. After more than 25 years of lessons learned as a physician, as the first CXO in healthcare, as the co-founder of an international network of experience leaders, and as a chief medical officer, I offer the following five best practices as a starting point to move the dial on preventing clinician burnout and restoring joy to the practice of medicine.

1. Deploy Technologies that Ease the Burden of Being a Clinician. While providers interact daily with many technologies, EHRs in particular have become a double-edged sword. While an important repository for clinical, financial and regularity data, the EHR has become an administrative drain as well as a physical barrier between doctor and patient. Doctors must repeatedly break focus with the patient to enter data, effectively limiting moments of interaction that improve the physician-patient bond. In an effort to quantify the impact of EHRs, a 2016 study observing 57 physicians for a total of 430 hours revealed that 49 percent of a physician’s day was spent doing clerical tasks, while only 33 percent was spent interacting with patients.

The key to improving quality, safety, efficiency, and the patient experience is adopting a human-centered approach to technology that simplifies workflows and streamline processes for care teams that remove barriers to care and takes things off of physicians’ plates, rather than adding to them.

Being thoughtful about technology is central to prioritizing physician and care team well-being and performance, and ensuring better care experiences for patients. By reducing administrative burdens and creating an environment that is optimized for healing, we can leave more space for connection and joy, driving improvement in all other areas. This approach means that physicians can be physicians without checking their souls at the door.

The goal is to roll out solutions focused both on efficiency and empathy. The right technologies, implemented in the right ways, will restore the narrative of the patient story, allowing physicians to truly listen to patients instead of being data entry clerks in the EHR. When physicians are freed up to actually make eye contact with patients and interact on a human level, they are more apt to follow their intuition and pick up on subtleties that they otherwise would have missed while typing and documenting.
This can be done by thinking differently about healthcare innovation and co-designing next gen technologies with the voice of physicians, nurses, frontline staff, patients, families and IT professionals all infused. Breaking down silos and restoring human connections in healthcare will go a long way to transforming care delivery – and sustaining it.

2. Engage Physicians Differently. We need to truly listen to physicians and empower them in all decision making. Trust that they entered this career because they genuinely want to care for people. Don’t treat physicians like employees; treat them like leaders. It’s astonishing how many hospitals make purely financial decisions when it comes to major changes, including technology, disregarding the feedback they receive from physicians.

Nothing can make physicians, or anyone, feel less valued than to have their feedback ignored. Ensure that – as a cultural norm and formal policy – doctors are intimately involved and at the table in partnership with nursing in all decisions as they relate to new technologies and process improvement, or adoption of clinical standards. Use tools such as active feedback surveys to frequently capture the pulse and well-being of your physician and nurse community.

In addition, physicians can no longer abdicate their roles as leaders and blame “them,” administration, for the source of their ails. They must actively step up and be part of the solution. They must partner with their nursing counterparts and engage patients in their design thinking and mentor the next generation of physicians to lead in this way.

3. Map the Gaps in the Human Experience. Delivering an optimal healing experience is both an art and a science. Restoring the art of medicine is all about designing systems that allow the sacred encounter between a doctor, nurse and patient to occur. This means understanding the gaps in clinical standards, processes and in relationships.

Let’s be honest: Medicine traditionally was structured as a hierarchal, male physician-led culture. While that has begun to change over the years, especially as more women have entered medicine and moved into key leadership roles, sometimes carryover exists, and it can get in the way of developing strong working relationships in the hospital environment.

A nurse once told me that she wanted to retire but wouldn’t do so until the physicians at that hospital came upstairs from the operating room and once again shook the hands of new nurses and said welcome to the team. She simply wanted to work in an environment of collegiality and collaboration—where physicians valued nurses and nurses viewed them as trusted partners, and that they both had conversations about how to optimize the wellbeing of their patients vs. sitting at a computer outside the operating room typing their notes.

Stripping out waste and improving efficiency are only parts of the equation to improve outcomes. We must standardize innovations that restore empathy and build trusted relationships. This is the key to achieving physician and care team joy and well-being, which ultimately leads to a more healing environment.

4. Embed Patients as Design Partners. We need to disband patient and family advisory councils. It is insulting to patients to ask them to “bless” the design of a new lobby or facility after the design process or after a LEAN sprint. We need to embed patients as Experience Design Fellows and pair them with a physician and nurse to take on intractable issues in key areas of the patient experience. We must systematically do this from the first impression to the last. The system is broken from the check-in process to the discharge process. We no longer have the luxury of waiting and providing suboptimal experiences to our patient consumers. This will not be fixed unless we engage them differently and more effectively in human centered design.

5. Measure Physician Well-being. You can’t fix what you can’t measure. As a profession, leaders in medicine need to collectively develop a metric for physician well-being. Taking the pulse of a healthcare organization’s culture and well-being—beyond satisfaction, and beyond engagement and loyalty—is the holy grail of fostering an environment of resilience and purpose. As with clinical metrics, doing this will let us know when something we are doing is working, or when an intervention is needed. We should measure this before, during and after any new technology or process improvement is deployed. We can then evaluate whether these solutions truly add value. Had we done this before implementation of the EHR, we would have done things differently. This practice will lead to greater physician, care team and patient satisfaction, creating a safer, happier environment for all.

Stopping burnout before it starts
For too long, complex workflows, administrative bureaucracies, and disparate systems have caused unnecessary hassles and fatigued physicians in hospitals and health systems around the country. Physicians who have fewer administrative burdens and who have clerical tasks taken off their plates will be more joyful, and that will resonate in their interactions with nurses, other staff, patients and families.

We can and should pursue the Quadruple Aim of healthcare that includes restoring joy back to the practice of medicine. We have burned out an entire generation of clinicians. This is unacceptable. We need new metrics to make sure this never happens again. There are too many good nurses and doctors in the trenches. And we need to make sure they do not retire early or change careers. The country is depending on them, and us, to build systems that enable them to do what they were trained to do.

It's important to stop burnout before it happens through best practices designed to bring humanity back to healthcare, and by designing a healthcare system that simplifies and eases the healthcare experience for all. We need a new generation of healthcare leaders that value and will make creation of an ideal healthcare experience for everyone a top priority.


Bridget Duffy, MD, is the Chief Medical Officer of Vocera Communications, Inc. and co-founder of the Experience Innovation Network.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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