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

Abstract

BACKGROUND: While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. DESIGN: A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. PARTICIPANTS: Primary care clinicians and their diabetic and hypertensive patients. INTERVENTIONS: Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. MAIN MEASURES: We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. KEY RESULTS: There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09). LIMITATIONS: Few quality metrics, short time span, fewer clinicians recruited than anticipated. CONCLUSIONS: Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care. Clinical trial registration number: ClinicalTrials.gov # NCT02542995.KEY WORDS: burnout; work-life; physician stress; physician burnout; work-life interventions.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review

“…Many causes of burnout derive from organizational-and system-level factors, including electronic health records (EHRs (5), 33,47,52,54,57 Canada (2), 42,48 Egypt (1), 53 and multinational (2). 24,35 Study designs included randomized controlled trials (10), 23,28,29,37,39,40,42,45,48,51 prospective studies (5), 43,44,50,56,60 cross-sectional studies (7), 19,38,47,52,53,66,68 and other designs (4). 24,27,35,59 The included studies evaluated interventions among primary care physicians and residents (12) 31,63,66 and groups of physicians with specialty unspecified (7).…”

“…73 Better communication among staff is part of optimizing workflow, with results from a prospective study revealing that communication improvement among staff and physicians was especially effective at reducing burnout. 28,29 Other successful Teamwork interventions supported peer-to-peer communication. Providing physicians with a sense of community bolstered by a culture of appreciation, support, and engagement can help reduce burnout.…”

“…25,33,37,38,40,42,44,45,48e51,53,56,57 Sixteen studies developed their own surveys to measure outcomes related to physician burnout including job satisfaction, burnout, depersonalization, fatigue, and stress. 22,37 Epworth Sleepiness Scale, 49,55 Office and Work Life measures, 29 survey tools from the Minimizing Error, Maximizing Outcome study and the Physician Worklife Study, 28 scales derived from the National Study of the Changing Workforce, 39 Massachusetts eHealth Collaborative survey, 63 and American College of Physicians/American Society for Internal Medicine physician satisfaction survey. 56 Two studies 34,64 provided qualitative findings, and 10 studies did not report the instrument used to measure burnout.…”

“…28 Additionally, high-quality evidence revealed that physician satisfaction increased (P<.001) and stress decreased (P<.001) with quality improvement interventions. 29 Technology Ten studies focused on technological interventions to improve efficiencies in the workplace, and all were centered around EHR health information technology. 59e68 Five (50%) of the 10 studies reported interventions that successfully improved burnout, satisfaction, and/or stress (Figure 3, Table 2).…”

Impacts of Operational Failures on Primary Care Physicians’ Work: A Critical Interpretive Synthesis of the Literature

“…72 The fictive schedule pushed compensatory labor into the interstices or out-ofhours, which further contributed to stress, low job satisfaction and burnout. 16,47,48,67,68,70,72,77,[101][102][103][104]…”