MEMO

Minimizing Error, Maximizing Outcome

The Physician Worklife Study II

Mark Linzer, UW, Principal InvestigatorMark 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

BackgroundPhysician 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, 2001-2005

Effect 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

StructureCultureWorkflowPolicies, processesPatient 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 QualityUp 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% FP44% female83% white83% full-timeAge 44 (range 29-89)

Physician Participants

MEMO Results: MeasuresOrganizational Culture Domains

alphaQuality 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

Impact of Chaos on MDs

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

MEMO Results: Gender Differences

BackgroundThe 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 DifferencesWorkplace characteristics

Women MDs

Men MDs p-

valueJob 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

MEMO Results: Effect of the Workplace on Healthcare Disparities

Minority PracticesNu

mbe

r of C

linics

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/hecticPatient 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 EganChicago Region Anita Varkey Bernice Man Elizabeth ArceMilwaukee Region Ann Maguire Barb Horner-Ibler Laura Paluch

Rural/Small Town WI Mary Beth Plane John Frey Jessica Grettie Mary Lamon-SmithMadison Region Julia McMurray Jessica Sherrieb James GesickiNew York Region Mark Schwartz Joe Rabatin Karla Felix Debby Dowell

MEMO Team