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Primary Care Physician Burnout: An Important Target for Lean Transformation

Jonathan S. Lee, MD, MASAssistant Clinical Professor of Medicine UCSF School of Medicine

Agenda

• Overview of literature on physician burnout• How Lean might reduce burnout• Current practice transformation and research efforts at

UCSF general internal medicine on Lean and burnout

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“Physician Burnout Is A Public Health Crisis: A Message To Our Fellow Health Care CEOs," Health Affairs Blog, March 28, 2017.

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What is Physician Burnout?

• “To fail, wear out, or become exhausted by making excessive demands on energy, strength, or resources.”

• State of mental exhaustion

• Z73.0 ICD-10 Diagnosis Code

Freudenberger, H. Staff burnout. J Soc Issues. 1974; 30: 159–165

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How is Burnout Measured?

• Maslach Burnout Inventory• 22 items measuring 3 domains of burnout (emotional exhaustion,

depersonalization, low sense of personal achievement)• Answers on a 7-point scale from “every day” to “never”

• High scores for emotional exhaustion and depersonalization are considered most important for physicians

• High score in either domain is considered burnout in the literature

• Many studies use abbreviated 2-item version• Emotional exhaustion and depersonalization

Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.

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Single-Item Mini-Z Burnout Question

Rohland BM et al. Stress Health. 2004;20(2):75–79.

6Linzer M et al. Ann Intern Med. 2009;151(1):28-36, W6-W9.

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How Big is the Problem?

High rates of burnout on Maslach Inventory increasing over time• 1996 survey of 1133 UK physician consultants: 35%

• 2011 survey of 7,288 US physicians: 45%

• 2014 survey of 6,880 US physicians: 54%

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Ramirez AJ et al. The Lancet. 1996;347(9003):724-728.Shanafelt TD et al. Arch Intern Med. 2012;172(18):1377–1385. T.D. Shanafelt et al. Mayo Clin Proc, 90 (12) (2015), pp. 1600-1613.

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Why Does Burnout Matter for Physicians?

Depression, CV disease, suicidal ideation and alcohol misuse

Reductions in work time and job turnover

• Prospective study of physicians surveyed in 2011 and 2013

• Each 1-point increase in the 7-point Maslach emotional exhaustion scale was associated with a greater likelihood of reducing FTE over the following 12-24 months

Shanafelt, TD et al. Mayo Clinic Proceedings , Volume 91 , Issue 4 , 422 – 431. Sinsky, Christine A. et al. Mayo Clinic Proceedings , Volume 92 , Issue 11 , 1625 – 1635.

Shanafelt TD et al. Suicidal Ideation Among American Surgeons. Arch Surg. 2011;146(1):54–62.9

Medicine as a Calling and Joy in Practice

• Burnout associated with less identification with medicine as a calling

• Committing one’s life to work that is personally meaningful and has a prosocial purpose

• Joy in practice• A high level of physician work life satisfaction, a low level of

burnout, and a feeling that medical practice is fulfilling

Jager AJ et al. Mayo Clin Proc. 2017 Mar; 92(3):415-422. Sinsky CA et al. Annals of Family Medicine. 2013;11(3):272-278. 10

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Why Does Burnout Matter for Hospitals?

• The cost to replace a physician is estimated at $500K to $1M

• Reductions in workload also decrease revenue• Turnover in multidisciplinary teams is associated with

increased burnout in other primary care team members

Shanafelt T et al. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826–1832.Helfrich, C.D., Simonetti, J.A., Clinton, W.L. et al. J GEN INTERN MED (2017) 32: 760. 11

Why Does Burnout Matter for Patients?

Relationship between burnout and quality/safety• Many cross-sectional studies have demonstrated

significant associations between burnout and quality and patient safety

• Patient satisfaction • Physician self-reported sub-optimal care and medical errors

Hall LH et al. Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One. 2016;11(7):e0159015.Linzer M et al. Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Intern Med. 2009;151:28–36. 12Dewa C et al. BMJ Open. 2017;7:e015141.

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Why are Physicians Burned Out?

• “Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations.”

Shanafelt T et al. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826–1832.

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Why are Physicians Burned Out?

• Workload• Efficiency• Flexibility and/or control• Work-life integration• Culture and values• Community at work• Meaning in workShanafelt T et al. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826–1832.

Shanafelt TD et al. Mayo Clin Proc. 2017;92(1):129-146.

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• For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day

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• 19 RCTs and controlled pre-post studies• Organization- vs physician-directed interventions

Panagioti M et al. JAMA Intern Med. 2017;177(2):195–205.

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Lean and Burnout

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Can Lean Help Reduce Burnout?

• Workload• Efficiency• Flexibility and/or control• Work-life integration• Culture and values• Community at work• Meaning in work

Continuous Process Improvement

Respect for People

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Importance of Leadership in Lean

• For successful Lean implementation and sustainment• Developing and setting the vision and strategy (hoshin kanri)

• “Lean organizations…need leaders who respect the knowledge and experience of the people on the front line of care.”

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Al-Balushi, S et al. Journal of Health Organization and Management, 2014:Vol. 28 No. 2, pp. 135-153Toussaint J. Management on the Mend. 2015.

Leadership and Burnout

Survey- 3896 physicians • Rated burnout,

satisfaction and leadership qualities of their immediate supervisors

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Shanafelt TD et al. Mayo Clin Proc, 90 (4) (2015), 432-440.

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Leadership and Burnout

• Each 1-point increase in leadership score was associated with a 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of overall satisfaction with the organization

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• 1133 physicians and staff in 46 primary care clinics• Workflow redesign – 5S, call management, care team

co-location and clinic flow• Evaluated engagement, burnout and perceptions of the

work environment with baseline and follow-up surveys• 73% pre and 74% post response rates

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Hung et al. BMC Health Services Research (2018) 18:274

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Physicians (N=680)

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Engagement Work Environment Burnout

* * * * * * *

*Statistically significant

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-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

Pilot (N=200) Beta (N=558) Remaining (N=1000)

*Statistically significant

Workplacestress

Emotional exhaustion Deperson Personal

accompWorkplacestress

Emotional exhaustion Deperson Personal

accompWorkplacestress

Emotional exhaustion Deperson Personal

accomp

* * * * * ** *

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Lean Transformation at UCSF

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UCSF General Internal Medicine

• 3 clinics• 1545 first and second floor and 1701

• 49 physician faculty• 45% 1 session/week• 31% 2-3 sessions/week• 24% 4+ sessions/week

• 72 residents and ~90 staff• ~25,000 patients

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UCSF Health’s Lean Journey

First VSM Executive Rounds

Lean Improvement Tools

Pediatric True North

UCSF Health True North 

20182012 2013 2014 2015 2016 20172011

Operational Leaders Leading Rapid Improvement Events  

5‐year Strategic Plan

A3 Thinking  

Active Daily Engagement

UCSF Health Affiliation

Lean Transformation at UCSF General Internal Medicine

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2015 Mini-Z Results (N=32)

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2017 Mini-Z Results (N=32)

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Future State

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Access

April 2018

Leader Standard

Work

Pre-Visit / Clinic Flow

Offline Managemen

t

Call Managemen

t

December 2017

Research Question

• Can Lean-driven practice transformation improve physician burnout at an academic general internal medicine practice?

• What is the impact on faculty with varying clinical loads?• What is the impact on residents?

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Study Design

• Quasi-experimental, controlled longitudinal observational study with multiple time points of data collection

• Compare to control clinics in the same practice not involved in the transformation program

• Comparative interrupted time series analysis

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Outcomes

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Call ManagementAccess

FlowOffline Work

Leader Standard Work

In-process

Physician and Staff:Burnout

SatisfactionTeam Culture

Primary

Patient SatisfactionQuality of Care

Safety

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Acknowledgements

• Ralph Gonzales• Lei Choi• Leah Karliner• Mitch Feldman • Cynthia Chiarappa

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