MEMO Minimizing Error, Maximizing Outcome The Physician Worklife Study II

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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

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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

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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

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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

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MEMO Conceptual Model
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MEMO Data Collection Points
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Measuring Quality
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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

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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)

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MEMO Results Measures
Organizational Culture Domains alpha
Quality emphasis (.86) Leadership/governance (.
86) Organizational trust (.79) Information/commu
nic. (.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
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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

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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)

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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 (r0.30, plt.001)
• 46 of MEMO physicians rated their practices as
  chaotic (4 or 5)

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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

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Impact of Chaos on MDs
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MEMO Results Organizational Culture

• Perceived Leadership Integrity Index (PLII)
• Attitudes of organizational leaders to (e.g.)
• physicians core values
• controlling costs vs. quality
• Negative perceptions about perceived integrity
  correlated with physician stress, burnout, and
  intent to leave the practice

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MEMO Results Gender Differences
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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

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MEMO Results Gender Differences
Workplace characteristics Women MDs Men MDs p-value
Job control (1none, 4great) 2.35 2.69 lt.001
Trust in the organization (1none, 4great) 2.47 2.69 lt.001
Values aligned w/organization (1no, 4great) 1.97 2.39 lt.001
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MEMO Results Gender Differences
Physician characteristics Women MDs Men MDs p-value
Stress (1low, 5high) 3.45 3.23 lt.003
Burnout (1none, 5completely) 2.32 2.07 lt.001
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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.

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MEMO Results Effect of the Workplace on
Healthcare Disparities
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Minority Practices
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MEMO Results Disparities
CLINIC VARIABLES Minority clinics Non-minority clinics
Minority MDs 39 12 plt.001
Adequate access to supplies, equipment, referral specialists 42 70 plt.001
Exam rooms per MD 2.1 2.7 plt.001
Staffing ratio RNLPNMA MDDOPANP 0.9 1.2 p.018
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MEMO Results Disparities
MD VARIABLES Minority clinics Non-minority clinics
Feel time pressure 57 39 plt.001
Burning or burned out 32 23 p.030
Clinic atmosphere (1calm, 5chaotic) 3.8 3.2 plt.001
Amount of work control (1none, 4great) 2.3 2.7 plt.001
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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 plt.001
Patient satisfaction with care (1very, 5not at all) 1.44 1.40 p.423
Patient trust in the physician (1 not at all, 5complete) 4.54 4.47 p.373
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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.

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MEMO Current Activities

• Patient outcomes (n1785, 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

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Next Steps for MEMO

• Analyses
• Patient outcomes
• Regression analyses
• Research Practice Redesign
• Preventing burnout
• Ameliorating chaos
• Improving work control
• Facilitating communication (language, literacy)

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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.

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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

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MEMO Limitations

• Only primary care practices enrolled
• Only 5 regions included (NYC and upper Midwest)
• Self-reported data

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MEMO Team

• Consultants
• Eric Williams
• Bob Konrad
• Elianne Riska
• Bill Scheckler
• Stewart Babbott
• JudyAnn Bigby
• Peggy Leatt
• Said Ibrahim
• Jacqueline Wiltshire

• 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