memo minimizing error, maximizing outcome the physician worklife study ii mark linzer, uw, principal...
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MEMO
Minimizing Error, Maximizing Outcome
The Physician Worklife Study II
Mark Linzer, UW, Principal Investigator
Mark Schwartz, NYU, Co-PI
Linda Baier Manwell, UW, Project Director
Learning Objectives
To better understand how the work environment affects physicians and patients
To learn more about the MEMO project To see how gender, race, and ethnicity
interact with working conditions To realize the impact of a hectic or
chaotic work environment
Background
Physician Worklife Study I (PWS) Funded by Robt Wood Johnson Found, 1995-1998 National, random sample of 5,704 MDs Stratified by five specialties Findings
Time pressure is major source of stress/dissatisfaction Stress and dissatisfaction predict burnout and intent
to leave Work control is powerful predictor of satisfaction Burnout is 60% higher in women MDs
What is MEMO?
Funded by AHRQ, 2001-2005Effect of primary care working conditions on MDs and quality of care
Funded by Robt Wood Johnson, 2005-2006Effect of workplace on health care disparities
101 clinics in Chicago, Madison, Milwaukee, New York City, rural/small town Wisconsin
420 MDs, 1785 patients
MEMO Conceptual Model
WorkplaceCharacteristic
s
Structure
Culture
Workflow
Policies,
processes
Patient
demands
Patient satisfaction
Quality of care
Medical errors
Burnout
Mental health issues
MD
Stress
MD Satisfaction
MEMO Data Collection Points
Time 1 Time 2Jan-May/02 (Oct-Dec/02) (Jan-Jun/05)Focusgroups
Clinic recruitment 5 regions
• MD survey #1• Clinic manager survey• Researcher clinic observation
Patientrecruitment101 clinics
• MD survey #2• Patient survey• Chart review
Measuring Quality
Up to 6 patients per MD with diabetes, HTN, and/or CHF
Assess: Patient satisfaction Patient quality of life Errors/omissions in
care Disease
management Preventive activities
QualityErrors
Determining Errors
Clinicians reported errors in disease management during past year
Clinicians rated their stress & predicted likelihood of making future errors on the OSPRE (Occupational Stress and PReventable Error) instrument
Researchers performed confidential chart reviews
420 primary care physicians (85.2% of target 500)
59.2% of those surveyed responded
51% GIM 49% FP
44% female
83% white
83% full-time
Age 44 (range 29-89)
Physician Participants
MEMO Results: Measures
Organizational Culture Domainsalpha
Quality emphasis (.86)Leadership/governance (.86)Organizational trust (.79)Information/communic. (.68)Cohesiveness (.66)
Stress Scale alpha (.84)Feel stress due to to jobFew stressors at workJob is extremely stressfulAlmost never stressed at work
Prediction of Preventable Error (OSPRE): alpha (.85)
High BPs & missed dx of HTNNo depression screen w/symptsNo ACE for diabeticNo aspirin for diabetes w/CADMissed drug-drug interactionNo diabetic eye exam referralNo alcohol screen for HTN
MEMO Results: MD Outcomes
Of 420 physicians... 79% highly satisfied with their jobs
61% said jobs were stressful
53% need more time for physical exams
27% burning out or burned out
31% moderately or more likely to leave job within 2 years
MEMO Results: Organizational Culture
Predict job satisfaction: Work control (.001) Trust in the organization
(.001) Resource availability
(.001) Less clinic chaos (.001)
Predict poorer MD mental health: Fewer resources (.001) Less work control (.006) More clinic chaos (.001)
Predict future error: Less clinic emphasis on
information (.017) Less clinic emphasis on
diversity (.001)
Predict intent to leave: Less trust in the
organization (.001) Fewer resources (.001)
Chaos ratings similar between MDs and their clinic managers (r=0.30, p<.001)
46% of MEMO physicians rated their practices as chaotic (4 or 5)
“Describe the atmosphere in your office…
Calm Busy, but Hectic,
reasonable
chaotic 1 2 3 4 5
MEMO Results: Chaos in the Clinic
Chaotic offices are associated with: More minority patients More patients with public or no insurance Fewer exam rooms Fewer staff Less practice emphasis on communication Less practice emphasis on information
technology
MEMO Results: Chaos in the Clinic
Perceived Leadership Integrity Index (PLII)
Attitudes of organizational leaders to (e.g.) physician´s core values controlling costs vs. quality
Negative perceptions about perceived integrity correlated with physician stress, burnout, and intent to leave the practice
MEMO Results: Organizational Culture
Background
The 1995-98 Physician Worklife Study found Women MDs have more
female patients complex patients managed care, uninsured, and Medicaid patients
Women MDs have less work control All MDs need more time than allotted to see
patients, but women need a greater percentage Burnout was 60% higher in women physicians
MEMO Results: Gender Differences
Workplace characteristicsWomen MDs
Men MDs p-
value
Job control (1=none, 4=great)
2.35 2.69 <.001
Trust in the organization (1=none, 4=great)
2.47 2.69 <.001
Values aligned w/organization (1=no, 4=great)
1.97 2.39 <.001
Physician characteristics
Women MDs
Men MDs p-value
Stress (1=low, 5=high)
3.45 3.23 <.003
Burnout (1=none, 5=completely)
2.32 2.07 <.001
MEMO Results: Gender Differences
Despite widespread dissemination of similar data, assessments of organizational climate and worklife by women MDs continue to be lower compared to males, and in many areas have worsened.
Non-alignment of values may explain lower perceptions of work control and higher levels of stress and burnout among women MDs.
Women MDs and their patients remain at higher risk for the effects of stress and poor working climates.
MEMO Results: Gender Differences
Minority PracticesN
um
ber
of
Clin
ics
74 Non-minority clinics
27 Minority clinics
27 of 101 clinics had ≥ 30% minority patients (average for these clinics =70% [95% CI: 60%, 81%])
MEMO Results: Disparities
CLINIC VARIABLESMinority clinics
Non-minority clinics
Minority MDs 39% 12% p<.001
Adequate access to supplies, equipment, referral specialists
42% 70% p<.001
Exam rooms per MD
2.1 2.7 p<.001
Staffing ratio: RN+LPN+MA MD+DO+PA+NP
0.9 1.2 p=.018
MEMO Results: Disparities
MD VARIABLESMinority clinics
Non-minority clinics
Feel time pressure 57% 39% p<.001
Burning or burned out 32% 23% p=.030
Clinic atmosphere(1=calm, 5=chaotic)
3.8 3.2 p<.001
Amount of work control
(1=none, 4=great)
2.3 2.7 p<.001
MEMO Results: Disparities
PATIENT VARIABLESMinority clinics
Non-minority clinics
Average number of medications per patient
2.7 2.1 p=.003
Uninsured and Medicaid patients
58% 19% p<.001
Patient satisfaction with care (1=very, 5=not at all)
1.44 1.40 p=.423
Patient trust in the physician (1= not at all, 5=complete)
4.54 4.47 p=.373
Clinics that serve many minority patients have difficult working conditions that pose a special challenge to our health care system.
Improvements may be achieved if remediable factors are addressed at the organization, system, and policy levels.
MEMO Results: Disparities
Patient outcomes (n=1785, ave 4/MD) Focus groups in minority clinics to
identify factors that create barriers to quality care and exacerbate disparities
Focus groups in high quality clinics to identify factors/processes that facilitate quality care and minimize disparities.
Development of Office and Work Life (OWL) tool
MEMO: Current Activities
From 2001-2005, your clinic took part in a study, “Minimizing Error, Maximizing Outcome (MEMO). This form reports results from MEMO.Office & Work Life Feedback
WLPhysician data: Your clinic MEMO clinicsJob stress: highly stressed % %Burnout: definitely % %
Organization data: Your clinic MEMO clinicsStaffing ratio n/n n/nNursing atmosphere calm/hecticcalm/hectic
Patient survey data: Your clinic MEMO clinicsSatisfaction with provider: very % %Depressive symptoms: yes % %
Chart audit data: Your clinic MEMO clinicsScore on error index 0-100 0-100Score on quality index 0-100 0-100
Next Steps for MEMO
Analyses: Patient outcomes Regression analyses
Research: Practice Redesign Preventing burnout Ameliorating chaos Improving work control Facilitating communication (language,
literacy)
Modifiable Factors
Find ways to better manage resources to reduce disparities and improve physician and patient health.
Assess methods to reduce clinic chaos. Study practices that accomplish a lot
with few resources. Develop a tool kit for other practices to use.
Upcoming MEMO Papers
MEMO main results paper! Impact of the work environment on care quality and
errors
Other upcoming papers: Errors in primary care: prediction & relationship to
quality Role of physician gender in quality & errors Effect of physician burnout on quality & errors Managing an ambulatory practice: lessons from MEMO Separate but unequal: where minority and non-
minority patients receive primary care
MEMO Limitations
Only primary care practices enrolled
Only 5 regions included (NYC and upper Midwest)
Self-reported data
ConsultantsEric Williams Bob Konrad Elianne RiskaBill SchecklerStewart Babbott JudyAnn BigbyPeggy LeattSaid Ibrahim Jacqueline Wiltshire
MEMO Staff Jim Bobula Marlon Mundt Roger Brown Carolyn Egan
Chicago Region Anita Varkey Bernice Man Elizabeth Arce
Milwaukee Region Ann Maguire Barb Horner-Ibler Laura Paluch
Rural/Small Town WI Mary Beth Plane John Frey Jessica Grettie Mary Lamon-Smith
Madison Region Julia McMurray Jessica Sherrieb James Gesicki
New York Region Mark Schwartz Joe Rabatin Karla Felix Debby Dowell
MEMO Team