Massachusetts Medical Society: The Quadruple Aim: Enhancing Patient Experience, Improving Health, Reducing Costs, Plus Improving Staff Morale

The Quadruple Aim: Enhancing Patient Experience, Improving Health, Reducing Costs, Plus Improving Staff Morale

By Vicki Ritterband
Vital Signs Staff Writer

At hospitals like the Cleveland Clinic, when caregivers are having a trying day, they can call a “Code Lavender.” A team of nurses is dispatched, bearing massages, energy treatments, healthful snacks, and a lavender armband, to remind the person to breathe and relax. It’s a temporary fix to a problem that’s a growing threat to the health care system: caregiver burnout.

Lots of research points to the fact that physicians today are unhappier than they’ve ever been. Some 54 percent of physicians surveyed for a 2014 study published in the Mayo Clinic Proceedings reported suffering from burnout. That was a noticeable jump from just three years earlier, when 46 percent of respondents reported being burned out. And that unhappiness has serious implications for patient care.

Increased rates of physician burnout and depression “lead to our loss of empathy for those who entrust their care to us,” said outgoing MMS president Dennis Dimitri, M.D., in introducing the annual meeting’s educational program, Sustaining Joy in the Practice of Medicine: Compassion, Innovation, and Transformation. But there’s hope, according to the session’s three speakers, who each offered ideas about how to put the joy back into medicine.

Christine Sinsky, M.D., the AMA’s vice president of professional satisfaction, put much of the blame for physician unhappiness on poorly engineered systems — offices where physicians are required to do too much documentation, use unwieldy electronic medical record systems, and spend too little time doing direct patient care. “Clinical excellence is dependent on operational efficiency and that drives satisfaction,” she said.

Small Changes, Big Results

Dr. Sinsky knows what well-adjusted practices look like. She was the lead author on a 2013 study, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”( www., published in the Annals of Family Medicine. The study highlighted practices that had cracked the code on physician happiness by instituting changes that included the following:

  • Pre-visit planning: A nurse calls patients a week prior to their appointments to schedule labs. At the doctor’s appointment, patients can talk about the results and make treatment decisions together, saving physicians time doing typical post-visit follow-up.
  • Automatic prescription renewals: Patients who are stable on their medications are given four 90-day refills so appointment time isn’t spent on prescription renewal.
  • Additional nurses or medical assistants who take on much of the administrative burden and lower level clinical tasks: In some offices, physicians have two or three nurses assigned to them. Nurses can do all of the immunizations, schedule cancer screenings, conduct and document diabetic foot exams and hypertension visits, etc.
  • Design changes to the environment: These include printers in every exam room so staff don’t have to leave patients, semi- circular desks that allow physicians to face patients, and radio frequency identification technology that enables physicians to sign onto computers with a wave of an identification card.

A Culture of Healing

M. Bridget Duffy, M.D., chief medical officer of Vocera Communications, cited her father, a retired periodontist, as one of her role models. At the end of the day, she said, he would call all the patients he performed surgery on that day to check up on them. “We invade people’s bodies, we crack their ribs, but we don’t call them to see how they’re doing,” said Dr. Duffy, who previously served as chief experience officer of the Cleveland Clinic, the first senior position of its kind in the country. “The best parts of our job are the human moments and relationships we have with patients.”

What Do MMS Physicians Say about Their Well-Being?

During the annual meeting’s educational program, Sustaining Joy in the Practice of Medicine, the MMS asked the audience the following: What is the number one reason you are not as passionate about your career as you once were?

  • Bureaucracy: 36%
  • EMR: 29%
  • Burnout: 16%
  • Other: 19%

Do you regularly take time for reflecting, strategizing, and thinking creatively?

  • Yes: 61%
  • No: 39%

Is your organization focused on ways to address the “Quadruple Aim” of enhancing the patient experience, improving health, reducing costs, and restoring joy back to the practice of medicine.

  • Yes: 25%
  • No: 75%

Dr. Duffy spoke about creating a culture of healing, in which patients are treated as people, not as medical cases. Now, in some operating rooms, it’s standard procedure for members of the surgical team to introduce ­themselves to the patient and explain what their roles are. She also pointed out the fear informed consent can provoke in a patient about to undergo a procedure, quoting a patient who asked, “Why, right before you put me to sleep do you tell me I can bleed, get an infection, and even die? Why not give us informed hope?” Dr. Duffy said that as a complement to informed consent, some health care organizations have instituted an informed hope process during which a caregiver — often a nurse anesthetist — asks patients about their health care goals, their fears and concerns, and the support they need to feel more comfortable with the procedure. Another hospital, seeking to make the admissions process less stressful for patients, has instituted what it calls a “sacred moment on admission,” when patients are asked similar questions to the pre-surgery ones.

An important part of creating a culture of healing is ensuring that each member of the staff — no matter how ostensibly removed from direct patient care — understands his or her importance to the care process, according to Dr. Duffy. She described a hospital where the housekeepers have business cards and are taught to view their role as preventing infection and making patients more comfortable. “There are many ways to make everyone on a team feel the purpose of their job and that’s what brings joy back to medicine,” she said.

Dr. Duffy stressed that these types of changes are much more likely to be embraced if they are promoted by physicians, not by the administration. “I often go and find the biggest curmudgeons — the biggest obstacles — in the organization and engage them to lead the work on well-being, resiliency, and patient experience,” she explained.

Understanding the Patient Experience

Jeffrey Cain, M.D., chief of family medicine at Children’s Hospital Colorado and a double below-knee amputee, talked about the hard-won insights he gained when he became a patient in his own hospital, following a plane crash that left him severely injured.

His experience as a patient profoundly changed him as a doctor, he said. He became more present for patients, sitting at the edge of their beds as he chatted. At first, his new habit was due simply to the fact it hurt to stand for too long, but later it transformed into something else. “Sitting next to them connected me with my patients in a way that reminded me why I went into medicine in the first place,” said Dr. Cain. “When we take off the white coat and really connect with our patients, we open the door for healing to begin.”

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