To Reduce Physician Burnout Eliminate Garbage Time

Here's a new chart from the AMA (reprinted from work done by Dr. Shanafelt and colleagues in Mayo proceedings) that reports the percentage of burnt out physicianssorted by specialty.  It's a pretty horrifying report.   I'm not at all surprised to see emergency medicine at the top of the list.

There are a bunch of theories on the origins of physician burnout.  I've heard that administrative busy work, a degradation of professional status and the adoption of the EMR have all contributed.  I've also heard that the constant barrage of sick patients is a factor (although I can't imagine it's any worse today than it was a decade ago...) I have another theory- which is that broken operational processes are driving this trend, and that the specialists displaying the greatest degree of burnout are also those with the greatest number of system interdependencies.  That's why emergency medicine, family medicine and general internal medicine exceed the mean burnout rate.   In other words, specialties that rely on complex professional networks (those requiring frequent cross-speciality and cross-professional communication to get work done) are most susceptible to the corrosive effects of dysfunctional operational systems. Spend some time in the ER and you'll quickly see that the ED physician spends the entire day on a phone connecting with specialists, admitting teams, X-ray, MRI, the lab and so on.  The daily agony of cajoling, pleading, tinkering, waiting and fighting to get the cogs moving grinds people down.  It's this cajoling that healthcare operations folks call "garbage time" and the more of it that you see, the more convinced you become that good people are getting burnt up by crummy, thoughtless systems.

Here's the good news:  there is a discipline of healthcare operations research and improvement that offers some pretty basic tools for managers to improve systems and reduce garbage time.  The bad news is that, for whatever reason,

healthcare operations knowledge has struggled to make it to the front lines

. It's a hidden discipline. IHI founder Don Berwick wrote the introduction to what I think is

the

seminal book on healthcare operations:   Focused Operations Management for Health Services Organizations, written by Boaz Ronen and Joseph Pliskin.  Berwick noted:

I was lucky enough to have Joe Pliskin as one of my professors in university.  Joe is one of the world's leading experts in healthcare operations and makes the point that healthcare leaders must understand processes, and more important focus like a laser on bottlenecks (which are by definition the variable limiting more or faster work) if systems are to improve. Here are Pliskin's rules for optimizing a healthcare operation:

1. Determine the Goal 

2. Establish system performance measures

3. Identify the System Constraint

4. Decide how to Expolit the Constraint

5. Subordinate the rest of the system to the constraint

6. Elevate and break the constraint

7. When the constraint is broken, return to step 3.

Here is a small case study of Pliskin's rules and tools in action.  I'm in the weeds a bit because I want to make the point that this stuff isn't rocket surgery, and that this sort of operations improvement work can happen outside of a a system's process improvement office. This was a project a group of us did several years ago.  

Our big problem at the time was that admitted patients were hanging around the ER and so we had no place to put new patients, which meant that they were in the waiting room for hours. 

We knew that our goal was to improve the ED length of stay (LOS) to a certain number of hours, reduce our left without being seen (LWBS) rate to a certain number, improve the time to admission (TTA) and reduce the waiting time to see a doctor.  

As a first step we sketched out our admitting process

.  On a busy day a team followed patients waiting to be admitted.  They recorded the time it took to reach a milestone, and the "non-garbage" time where actual work was being done.  

On a series of a few very busy days we could see that it took 17.5 hours from the time the decision to admit was made until the time the patients left the ED

. Of that 17.5 hours, 115 minutes were spent doing valuable work.  The rest was garbage time.

We quickly identified two bottlenecks in the system:  

the availability of a resident to admit the patient

and

the availability of a bed upstairs

.  The admitting team and beds were completely at capacity.   The problem was that these were both pretty expensive resources to augment.  (If the transport staff were the limitation, this would have been a far cheaper and easier problem to fix).  Here was our diagram plotting percent resource utilization versus relative expense.

We decided as a team

to exploit our constraints

and not focus on distractions.  When we dug into the cause of the bed jam, we found that a

policy of discharging patients early in the day wasn't being followed

and so patients ready for discharge were using a needed bed.  This meant that during ED admitting prime-time hours of 4 and 6pm, the nurses upstairs were trying to discharge patients and they couldn't accept an admission.

We also found that the volume of admissions exceeded the amount that a resident could process (per a regulatory cap) which meant that patients often waited until the next team had come on duty.  In fact, we found, there was a perpetual shortage of resident admission slots compared to demand. The group's recommendations were to

offload the constraints

by: 1) opening a holding area for admitted patients (in an unused post-op area) 2) move educational rounds to the afternoon so that teams could see and discharge patients on the floor in the morning and 3) add nurse practitioners to admit patients during times of high demand. Problem solved...         (Partly...)

Even simple improvements, if well studied and targeted, can have a huge effect on  the patient experience and on physician wellness.

  The shame is that few operations folks, and fewer clinicians still have been exposed to these basic but transformative concepts. Here's my takeaway.  

If we want to reduce garbage time and improve the dismal rate of physician burnout, we're going to need to insist that healthcare operational analysis and improvement becomes foundational

.  The health of American health depends on it.