A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study

Abstract

BACKGROUND: Work conditions in primary care are associated with physician burnout and lower quality of care. OBJECTIVE: We aimed to assess if improvements in work conditions improve clinician stress and burnout. SUBJECTS: Primary care clinicians at 34 clinics in the upper Midwest and New York City participated in the study. STUDY DESIGN: This was a cluster randomized controlled trial. MEASURES: Work conditions, such as time pressure, workplace chaos, and work control, as well as clinician outcomes, were measured at baseline and at 12-18 months. A brief worklife and work conditions summary measure was provided to staff and clinicians at intervention sites. INTERVENTIONS: Diverse interventions were grouped into three categories: 1) improved communication; 2) changes in workflow, and 3) targeted quality improvement (QI) projects. ANALYSIS: Multilevel regressions assessed impact of worklife data and interventions on clinician outcomes. A multilevel analysis then looked at clinicians whose outcome scores improved and determined types of interventions associated with improvement. RESULTS: Of 166 clinicians, 135 (81.3 %) completed the study. While there was no group treatment effect of baseline data on clinician outcomes, more intervention clinicians showed improvements in burnout (21.8 % vs 7.1 % less burned out, p=0.01) and satisfaction (23.1 % vs 10.0 % more satisfied, p=0.04). Burnout was more likely to improve with workflow interventions [Odds Ratio (OR) of improvement in burnout 5.9, p=0.02], and with targeted QI projects than in controls (OR 4.8, p=0.02). Interventions in communication or workflow led to greater improvements in clinician satisfaction (OR 3.1, p=0.04), and showed a trend toward greater improvement in intention to leave (OR 4.2, p=0.06). LIMITATIONS:We used heterogeneous intervention types, and were uncertain how well interventions were instituted. CONCLUSIONS: Organizations may be able to improve burnout, dissatisfaction and retention by addressing communication and workflow, and initiating QI projects targeting clinician concerns.KEY WORDS: burnout; primary care; quality improvement; work conditions.

Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey

“…These findings provide a substrate for solutions in terms of remediable factors that can be addressed through workflow redesign and communication improvements. 10 Because many clinicians have already reduced involvement in primary care or plan to leave their practices, the need is urgent to reestablish a sustainable equilibrium between clinicians' work responsibilities and their devotion to patient care. While faculty in the 15 divisions surveyed were diverse in terms of geography and role, findings were remarkably consistent.…”

Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place Study

“…6 In brief, three study sites were chosen to provide a mix of urban, rural, and academic practices. Primary care clinicians (n = 165) were recruited from 34 clinics, and included family physicians and general internists as well as nurse practitioners and physician assistants (advanced practice providers, or APPs).…”

“…17 Subgroups were specified after data collection was completed but prior to constructing the analysis. We used the three main categories of intervention types determined in the first HWP paper 6 to model improvement in outcomes as a function of type of intervention. Because no intervention was designed to allow us to look at specific types of interventions, we performed this analysis to determine whether some intervention types were better than others.…”

“…Additionally, clinics undertaking communication improvement measures or workflow redesign demonstrated more frequent improvement in professional satisfaction than control clinics (OR 3.1, p = 0.04) and tended to have fewer clinicians with intentions to leave than control clinics (OR 4.2, p = 0.06). 6 The current analysis of HWP data asks the following questions: 1) Do clinicians in clinics undergoing work-life interventions provide higher-quality care and make fewer errors than those in control clinics? 2) Do specific types of work-life interventions, effective in improving clinician outcomes, result in higher-quality care and fewer errors?…”

Wellness in Graduate Medical Education: Is It Time to Pull the Andon Cord?

“…For clinical practices, the Healthy Work Place study has shown that targeted interventions can be successful in reducing burnout and improving the professional satisfaction of physicians. 8 The Accreditation Council for Graduate Medical Education (ACGME) annual faculty and resident/ fellow surveys are an opportunity to measure wellness. These surveys can provide a national baseline to define the current status and future data to follow targeted interventions and policy recommendations.…”