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 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 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 Policies, processes Patient demands Patient satisfaction Quality of care Medical errors Burnout Mental health issues MD Stress MD Satisfaction

MEMO Data Collection Points Time 1 Time 2 Jan-May/02 (Oct-Dec/02) (Jan-Jun/05) Focus groups Clinic recruitment 5 regions MD survey #1 Clinic manager survey Researcher clinic observation Patient recruitment 101 clinics MD survey #2 Patient survey Chart review

Measuring Quality Up 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 Quality Errors

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

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... 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)

MEMO Results: Chaos in the Clinic “Describe the atmosphere in your office… Calm Busy, but Hectic, reasonable chaotic 1 2 3 4 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

MEMO Results: Organizational Culture 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: Gender Differences

Background The 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 Differences Workplace characteristics 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 Values aligned w/organization (1=no, 4=great) 1.97 2.39

MEMO Results: Gender Differences 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: Effect of the Workplace on Healthcare Disparities

Minority Practices Number of Clinics 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 VARIABLES Minority clinics Non-minority clinics Minority MDs 39% 12% p<.001 Adequate access to supplies, equipment, referral specialists 42% 70% Exam rooms per MD 2.1 2.7 Staffing ratio: RN+LPN+MA MD+DO+PA+NP 0.9 1.2 p=.018

MEMO Results: Disparities MD VARIABLES Minority 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 Amount of work control (1=none, 4=great) 2.3 2.7

MEMO Results: Disparities PATIENT VARIABLES Minority 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

MEMO Results: Disparities 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 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

WL Physician data: Your clinic MEMO clinics 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 WL Physician data: Your clinic MEMO clinics Job stress: highly stressed % % Burnout: definitely % % Organization data: Your clinic MEMO clinics Staffing ratio n/n n/n Nursing atmosphere calm/hectic calm/hectic Patient survey data: Your clinic MEMO clinics Satisfaction with provider: very % % Depressive symptoms: yes % % Chart audit data: Your clinic MEMO clinics Score on error index 0-100 0-100 Score on quality index 0-100 0-100

Next Steps for MEMO Analyses: Research: Practice Redesign 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! Other upcoming papers: 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

MEMO Team Consultants Eric Williams Bob Konrad Elianne Riska 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 Mary Beth Plane John Frey Jessica Grettie Mary Lamon-Smith Madison Region Julia McMurray Jessica Sherrieb James Gesicki New York Region Mark Schwartz Joe Rabatin Karla Felix Debby Dowell Consultants Eric Williams Bob Konrad Elianne Riska Bill Scheckler Stewart Babbott JudyAnn Bigby Peggy Leatt Said Ibrahim Jacqueline Wiltshire