1. 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

2. 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

3. Background Physician Worklife Study I (PWS)
Funded by Robt Wood Johnson Found,
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

4. 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,
Effect of workplace on health care disparities
101 clinics in Chicago, Madison, Milwaukee, New York City, rural/small town Wisconsin
420 MDs, 1785 patients

5. 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

6. MEMO Data Collection Points
Time Time 2
Jan-May/ (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

7. 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

8. 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

9. 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)

10. 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

11. 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

12. 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)

13. MEMO Results: Chaos in the Clinic
“Describe the atmosphere in your office…
Calm Busy, but Hectic,
reasonable chaotic
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)

14. 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

15. Impact of Chaos on MDs

16. 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

17. MEMO Results: Gender Differences

18. 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

19. 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

20. 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

21. 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.

22. MEMO Results: Effect of the Workplace on Healthcare Disparities

23. 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%])

24. 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

25. 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

26. 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

27. 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.

28. 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

29. WL Physician data: Your clinic MEMO clinics
From , 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
Score on quality index

30. 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)

31. 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.

32. 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

33. MEMO Limitations Only primary care practices enrolled
Only 5 regions included (NYC and upper Midwest)
Self-reported data

34. 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