Transcript Impact of Working Conditions on Female and Male Primary Care

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

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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
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 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, 2001-2005
Effect of primary care working conditions on MDs
and quality of care

Funded by Robt Wood Johnson, 2005-2006
Effect 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
Workplace
Characteristics
Structure
Culture
Workflow
MD Stress
Burnout
Patient
satisfaction
Mental health
issues
Quality of care
Medical errors
Policies, processes
Patient demands
MD Satisfaction
MEMO Data Collection Points
Time 1
Jan-May/02
Focus
groups
Time 2
(Oct-Dec/02)
(Jan-Jun/05)
• MD survey #1
• Clinic manager survey
• Researcher clinic observation
Clinic
recruitment
5 regions
• MD survey #2
• Patient survey
• Chart review
Patient
recruitment
101 clinics
Measuring Quality
Up to 6 patients per MD with diabetes, HTN,
and/or CHF
Assess:
Errors
Quality
 Patient satisfaction
 Patient quality of life
 Errors/omissions in care
 Disease management
 Preventive activities
Determining Errors
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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
Physician Participants
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)
MEMO Results: Measures
Organizational Culture Domains
alpha
Quality emphasis
(.86)
Leadership/governance (.86)
Organizational trust
(.79)
Information/communic. (.68)
Cohesiveness
(.66)
Stress Scale
alpha(.84)
Feel stress due to to job
Few stressors at work
Job is extremely stressful
Almost never stressed at work
Prediction of Preventable Error
(OSPRE):
alpha (.85)
High BPs & missed dx of HTN
No depression screen w/sympts
No ACE for diabetic
No aspirin for diabetes w/CAD
Missed drug-drug interaction
No diabetic eye exam referral
No alcohol screen for HTN
MEMO Results: MD Outcomes
Of 420 physicians...
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79% highly satisfied with their jobs
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61% said jobs were stressful
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53% need more time for physical exams
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27% burning out or burned out
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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)
MEMO Results: Chaos in the Clinic
“Describe the atmosphere in your office…
Calm
1
2
Busy, but
reasonable
3
4
Hectic,
chaotic
5
 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)
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
Impact of Chaos on MDs
100%
87%*
79%*
80%
67%
60%
44%
41%*
35%*
40%
14%
20%
0%
Satisfaction
Stress
Hectic
Burnout
Not Hectic
20%
Leave
Practice
MEMO Results: Organizational Culture
Perceived Leadership Integrity Index (PLII)
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Attitudes of organizational leaders to (e.g.)
 physician´s core values
 controlling costs vs. quality
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Negative perceptions about perceived
integrity correlated with physician stress,
burnout, and intent to leave the practice
MEMO Results: Gender Differences
Background
The 1995-98 Physician Worklife Study found
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Women MDs have more
 female patients
 complex patients
 managed care, uninsured, and Medicaid patients
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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
Women
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
Workplace characteristics
MEMO Results: Gender Differences
Physician characteristics
Stress
(1=low, 5=high)
Burnout
(1=none, 5=completely)
Women
MDs
Men
MDs
p-value
3.45
3.23
<.003
2.32
2.07
<.001
MEMO Results: Gender Differences
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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: Effect of the
Workplace on Healthcare Disparities
30
74 Non-minority clinics
Minority Practices
25
Number of Clinics
20
15
10
27 Minority clinics
5
0
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
27 of 101 clinics had ≥ 30% minority patients
(average for these clinics =70% [95% CI: 60%, 81%])
100
MEMO Results: Disparities
Minority
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
CLINIC VARIABLES
MEMO Results: Disparities
Minority
clinics
Nonminority
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
MD VARIABLES
MEMO Results: Disparities
Minority
clinics
Nonminority
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
4.54
4.47
p=.373
PATIENT VARIABLES
(1= not at all, 5=complete)
MEMO Results: Disparities
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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: Current Activities
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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
Office & Work Life Feedback
From 2001-2005, your clinic took
part in a study, “Minimizing Error,
Maximizing Outcome (MEMO).
This form reports results from MEMO.
Physician data:
Your clinic
MEMO clinics
Organization data:
Your clinic
MEMO clinics
Patient survey data:
Your clinic
MEMO clinics
Chart audit data:
Your clinic
MEMO clinics
WL
Job stress: highly stressed
Burnout: definitely
Staffing ratio
Nursing atmosphere
Satisfaction with provider: very
Depressive symptoms: yes
Score on error index
Score on quality index
%
%
%
%
n/n
n/n
calm/hectic calm/hectic
%
%
0-100
0-100
%
%
0-100
0-100
Next Steps for MEMO
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Analyses:
 Patient outcomes
 Regression analyses
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Research: Practice Redesign
 Preventing burnout
 Ameliorating chaos
 Improving work control
 Facilitating communication (language, literacy)
Modifiable Factors
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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
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MEMO main results paper!
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Impact of the work environment on care quality and
errors
Other upcoming papers:
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Errors in primary care: prediction & relationship to quality
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Role of physician gender in quality & errors
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Effect of physician burnout on quality & errors
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Managing an ambulatory practice: lessons from MEMO
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Separate but unequal: where minority and non-minority
patients receive primary care
MEMO Limitations
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Only primary care practices enrolled
Only 5 regions included (NYC and upper
Midwest)
Self-reported data
MEMO Team
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 Consultants
 Mary Beth Plane
 Eric Williams
 John Frey
 Bob Konrad
 Jessica Grettie
 Elianne Riska
 Mary Lamon-Smith
 Bill Scheckler
 Stewart Babbott
Madison Region
 JudyAnn Bigby
 Julia McMurray
 Peggy Leatt
 Jessica Sherrieb
 James Gesicki
 Said Ibrahim
 Jacqueline Wiltshire
New York Region
Mark Schwartz
 Joe Rabatin
 Karla Felix
 Debby Dowell
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