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Health Care, Education and Research www.billingsclinic.com

Reducing Burnout Through Quality Improvement

Objectives

• We will be able to design a process improvement project which is guaranteed to fail and worsen burnout

• We will also be able to design one that will enhance engagement and succeed through teamwork.

– Based on 3 theories

• Self Determination Theory

• Relational Coordination Theory

• IHI Model for Improvement

Why do quality improvement?

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Priorities?

• Personal?

• Organizational?

• National?

Why worry about burnout?

• 60% of respondents on MD survey are considering leaving practice

• 70% knew at least one MD who left practice due to poor morale

• 37% of newly licensed RNs are thinking of leaving their job

• 13% vacancy rate for RNs

• Impact not limited to cliniciansLucian LeapeInstitute. 2013. Through the eyes of the workforce: creating joy, meaning and safer health care. Boston, MA: National Patient Safety Foundation.

Impact of burnout on our patients

• Lower levels of empathy

• More mistakes

• Less patient satisfaction

• Reduced adherence to treatment plans

• Overuse of resources

Bodenheimer, T., Sinsky, C. From the Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, Inc.,: 2015.

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Business impact of burnout

• Customer satisfaction

• Productivity

• Profit

• Employee turnover

• Accidents

Harter, J. K., Schmidt, F. L., & Hayes, T. L. (2002). Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes: A meta-analysis. Journal of Applied Psychology, 87(2), 268-279. http://dx.doi.org/10.1037/0021-9010.87.2.268

Designing QI program

• Design a quality improvement program that – worsens engagement

– or is guaranteed to fail

– Can include either• Quality (maximizing positive outcomes)

• Or safety (minimizing negative outcomes)

Debrief Design Exercise

• What did we learn?– About engagement/burnout

– QI

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Enhancing Engagement

• Healthcare organizations with high employee engagement not only boost patient outcomes, but also diminish employee burnout: Gallup analytics show that engaged employees are four times less likely to feel burnout at work.

https://www.gallup.com/workplace/236132/remedies-reducing-burnout-among-healthcare-workers.aspx

When have you felt most engaged?

When have you felt most engaged?

• Billings Clinic “Engaging in Quality” Survey

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In your time at Billings Clinic, when did you feel most engaged in quality work? What made

this possible?

• Working collaboratively with others and guided by a clarity of purpose to address something important to the well-being of our patients.

– “Device implant infection reduction….All departments from outpatient (cardiology office) to hospital surgery and infection control wanted to help and worked together well. Open and positive lines of communication. I met a diverse group of people through the process and really enjoyed the physician commitment and their engagement…It was all about the patient.” B.D.

What quality efforts have you been engaged in that make you feel most proud? Why?

• When involved on a multidisciplinary team with people from other disciplines and services, that is making a difference on important patient safety or quality issue like MRSA, obstructive sleep apnea, hypertension and sepsis.– “Teams have more wisdom than one person, they open out a

bigger environment of possibilities” L.S.

– “Sepsis team, because it was multidisciplinary team that was highly functional, engaged, and demonstrated mutual respect.” S.H.

If Asked to Work on an Important Problem, Would You Say Yes?

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Self Determination Theory

• Ryan and Deci.

Self Determination Theory

Illustration by Laura Kriegel

Self Determination Motivation ContinuumDetermined by Needs of Autonomy, Competence, and Relatedness

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Self Determination Motivation ContinuumDetermined by Needs of Autonomy, Competence, and Relatedness

Non-Regulation Non-Regulation

Impersonal

No Intention Lack of control

Sepsis bundle (SB) mandated

External RegulationExternal Regulation

External

External rewards or punishments

Compliance with SB rewarded

Introjected RegulationIntrojected Regulation

Somewhat External

Approval from others

My colleagues use the SB

Identified RegulationIdentified Regulation

Somewhat Internal

Endorsement of goals

I reviewed the SB data and it makes sense!

Integrated RegulationIntegrated Regulation

Internal

Synthesis with self

The SB is great, it’s just want I would do!!

Intrinsic RegulationIntrinsic Regulation

Internal

InterestEnjoymentInherent satisfaction

I came up with this really cool SB!!!!!

Autonomous Motivation Autonomous Motivation

What quality efforts have you been engaged in that make you feel most proud? Why?

• When involved on a multidisciplinary team with people from other disciplines and services, that is making a difference on important patient safety or quality issue like MRSA, obstructive sleep apnea, hypertension and sepsis.– “Teams have more wisdom than one person, they open out a

bigger environment of possibilities” L.S.

– “Sepsis team, because it was multidisciplinary team that was highly functional, engaged, and demonstrated mutual respect.” S.H.

Relational Coordination Theory

Dr. Jody Gittell, Brandeis University

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Measuring relational coordination

RC dimensions Survey questions1. Frequent communication

How frequently do people in each of these groups communicate with you about [focal work process]?

2. Timely communication

How timely is their communication with you about [focal work process]?

3. Accurate communication

How accurate is their communication with you about [focal work process]?

4. Problem solving communication

When there is a problem in [focal work process], do people in these groups blame others or try to solve the problem?

5. Shared goals How much do people in these groups share your goals for [focal work process]?

6. Shared knowledge

How much do people in these groups know about the work you do with [focal work process]?

7. Mutual respect How much do people in these groups respect the work you do with [focal work process]?

Relational coordination drives surgical performance

Health Care, Education and Research www.billingsclinic.com

Nurses4.2

RTs3.5

CM4.0

PT/OT3.8

Intensivists4.2

Pharmacy4.0

Chaplains3.8

Speech3.8

3.9

3.4

3.2 2.9

3.8 3.5

4.4

4.7

3.9

3.4

3.5

3.5

3.3

4.8

4.2 4.1

4.5

4.0

3.5

3.9

4.1

3.3

3.7

4.74.2

Between Groups# < 3.5 = Weak# 3.5 to 4.0 =

Moderate# > 4.0 = Strong

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ICU staff engagement before/after RC

QI – IHI Model For

Improvement

• Setting Aims– What are we trying to accomplish– The aim should be time-specific and

measurable; it should also define the specific population of patients or other system that will be affected.

• Establishing Measures– How will we know a change is an

improvement– Teams use quantitative measures to

determine if a specific change actually leads to an improvement.

• Selecting Changes– What changes can we make that will result

in the improvement--The how. – Usually come from the front line teams or

from prior experience of others

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Driver Diagram and

Model for Improvement

• Testing Changes– The Plan-Do-Study-Act (PDSA) cycle is

shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method adapted for action-oriented learning.

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Burnout and QI Design

• IHI Model for Improvement provides the Framework

• Self Determination Theory• To drive engagement and wellbeing:

• Autonomy, Competency, and Relatedness • Focus on Internal Motivation

• Relational Coordination Theory• To improve relatedness

• Shared goals, Shared knowledge, Muturalrespect

• Frequent, timely, accurate, and problem solving communication.

• These dimensions also improve the Competency of the team

Burnout and QI Design

• Form multidisciplinary teams• Invite people in. Early.

• Relatedness, RC.• Aims

• Use SDT continuum to help people internalize the aims and the changes

• Even externally mandated aims can be internalized• Autonomy

• Measures• Focus on leading indicators while tracking lagging

(outcomes) indicators• These are what you can immediately influence.

• competency• Changes

• Rely on your front line times to help identify and track• Autonomy, Relatedness, RC.

• PDSA cycles• Small tests of change. Allows the front line team to find out

what works• Competence, autonomy, relatedness, RC.

• Share the results in real time. • Competence, autonomy, relatedness, RC

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Priorities?

• Personal

• Organizational

• National

Aspirational Goal

• Become a true learning organization– All of us improving together everyday

– Focus not only on National and Organizational goal but also Personal Goals

– Remove the pebbles in our shoes and the boulders blocking our paths.