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Curbside Consult with Dr. Jayne 10/22/18

October 22, 2018 Dr. Jayne 1 Comment

Clinician burnout is at epidemic levels, so I always keep my eye out for scientific papers looking at the issue. A recent paper titled “Implementing Optimal Team-Based Care to Reduce Clinician Burnout” talks about team-based care as a model that “strives to meet patient needs and preferences by actively engaging patients as full participants in their care, while encouraging all health care professionals to function to the full extent of their education, certification, and experience.”

The idea of working at the top of one’s education and licensure is one that I continue to struggle with as I work with physicians who feel that EHRs have turned them into data entry clerks. Although I work with some high-functioning offices, there are far too many where people are doing work that could be done by individuals with less training or experience and at a lower cost. Getting the team composition just right is a challenge, and in the corporate practices I work with, there are barriers such as headcount caps to content with.

I recently worked with a practice that was dealing with a “brick in, brick out” philosophy from their health system HR department. When a highly-paid and long-tenured RN retired, the practice wanted to split her salary and hire three lower-level resources to handle some high-volume office tasks. The hospital-focused HR team would have no part of that strategy, even though it was budget neutral and would benefit the practice, citing various policies and a temporary hiring freeze as barriers. The practice could hire a less-expensive resource to fill her shoes, but then it would lose that salary difference out of their budget for the following fiscal year, hobbling them in a different way.

The practice’s leaders elected to replace the nurse with a similarly-priced resource, which didn’t solve their problem, but preserved their overall budget in hopes that they might be able to make a change in the future if they could get the HR team onboard. It was sad to watch a practice be forced to make bad business decision that reduces their ability to deliver the patient care that needs to be delivered because the corporate structure couldn’t get out of their way.

The paper addresses digital barriers to team-based care, noting that “although EHRs have important advantages in terms of improving continuous access to legible clinical information, they are not optimally designed to support clinical care.” The authors encourage organizations to look at ways to expand the utility of EHRs, including:

  • Examining excessive signature requirements or mandates that physicians must perform certain documentation elements.
  • Accelerating information exchange.
  • Including systems other than EHRs in the discussion of interoperability, including patient health records, registries, etc.
  • Facilitating a learning health system including the use of predictive analytics and artificial intelligence.

They go further to call for CMS to modernize “outdated” documentation guidelines that were created to support billing in the era of paper records. They also suggest that ONC and CMS “could make prescribed medication selection, alternatives, and pricing transparency available to clinical teams at the point of care as a regulatory EHR requirement.”

I’m sure vendors wouldn’t be too thrilled about additional requirements, but as a clinician, I would be thrilled to have that kind of functionality in my EHR. Right now, the only price transparency I have for medications is for the prescriptions we dispense in-house, which are either $10, $20, or $30 at the time of checkout. We don’t make a lot of money on them and we don’t run them through insurance but offer them as a convenience to patients who don’t want to have to stop by the pharmacy on the way home.

The article also looks at workforce barriers, including issues “from the training and mind-set of health care team members to team organization and leadership.” Employee turnover is a challenge for many of the ambulatory organizations I counsel, and usually it’s driven by several factors: inadequate interview and hiring processes, inadequate training, lack of on-the-job mentorship and support, and work/life balance challenges.

Poor interview and hiring processes can lead to mismatched expectations and poor fit with workplace culture. Poor training can lead not only to patient care issues, but to fear and trepidation for employees who feel they’re being asked to perform beyond their comfort zone. When I worked for Big Hospital System, new medical assistants received zero standardized training beyond HIPAA and other compliance trainings. Any clinical training was at the purview of the office manager, who didn’t report to the physicians in the office but rather to a regional administrator. The result was a staff that didn’t always know what they should know to be successful, which led to physician distrust and reluctance to allow them to handle even basic clinical tasks such as taking a blood pressure.

At my current practice, clinical support staff are put through a rigorous training program including clinical terminology, procedures, organizational culture, patient communication, and more. They are then scheduled a certain number of “training shifts” with a clinical leader, where they must complete their procedure logs and document their clinical tasks. These training shifts are added on to a practice’s regular staffing. Although they are training on the job, they’re not expected to immediately fill a standard scheduled position – they are there to learn.

We lose some folks along the way with this rigorous training. Mostly people who realize that our staff really do work at the top of their licenses and who aren’t on board with working as independently as we allow our staff or doing the procedures we expect our staff to perform on a daily basis. I’d rather lose them in training, though, rather than a month or two in.

Once training is complete, each employee is assigned to a “core team” of employees for the purposes of communication, mentoring, and ongoing training. This core team may or may not include people they work with regularly, which gives them the opportunity to have a sounding board about situations which may have happened in the clinic or with other employees. It also provides accountability for ongoing training and mentorship opportunities.

Lack of work/life balance certainly contributes to burnout, not only among physicians, but among all clinicians. I’ve worked with practices where employees can only request a certain number of days off each month regardless of how much vacation they have in their bank. I spoke to one nurse recently who was working during a family wedding because his son also had religious confirmation that month and he was only allowed to “protect” one weekend.

Although I realize the need to balance schedule coverage, this doesn’t build loyalty or allow team members to meet their personal needs. This employee made no secret of the fact that he’s interviewing for a position in telemedicine, where he can work more flexible schedules. Employers need to be in tune with the needs of the current workforce, especially in fields where there are shortages and competition among employers to be the workplace of choice.

The paper closes by noting that our “current payment system is not designed to offset the costs associated with forming, training, and sustaining clinical teams.” Because these tasks are often considered soft skills, organizations often give them less attention than hard-data items like patient volume, patient satisfaction scores, and clinical quality metrics. The money spent on building high-functioning teams is well worth it, but comes at a cost that might derive from a chicken-or-egg finance equation. Programs like the Comprehensive Primary Care Plus initiative are designed to provide this money up front, but only time will tell if that approach is as successful as we hope.

What is your organization doing to foster team-based care? What are they doing to unwittingly sabotage it? Leave a comment or email me.

Email Dr. Jayne.

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Currently there is "1 comment" on this Article:

  1. Your story about losing someone in training rather than later reminds me of Zappo’s policy for new hires. As someone goes through their initial training, they’ll pay them $5k to leave. Basically, Tony Hsieh believed that if after seeing the culture of the company you’d rather take the $5k than work with them, then he was better off paying you the $5k than hiring a bad fit employee. Sounds a bit like what you saw.







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