Addressing Human Factors in Burnout and the Delivery of Healthcare: Quality & Safety Imperative of the Quadruple Aim

Human factors in the delivery of service are considered in many occupations of high impact on others such as airline industry and nuclear power industry, but not sufficiently in healthcare delivery. A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction (The Triple Aim). Many industries which support healthcare and healthcare administrators do not have firsthand knowledge of the complexities in delivering care. As a result, the experience and human factors of providing care are often overlooked at high level decision-making unless incorporated into the healthcare delivery framework, proposed as the fourth aim of The Quadruple Aim framework. Research is pointing to consequent negative effects on quality, safety, joy, meaning and sustainability of healthcare practice. High acute occupational stress and chronic occupational stress can cause direct and indirect effects on safety and quality of care. The biological, psychological and social consequences of burnout from excessive acute and chronic occupational stress are more of a threat to healthcare than commonly acknowledged. Patient safety, quality of care and clinician well-being are inextricably linked. This report will describe the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center. Developing the fourth aim of improving the experience of providing care, had high acceptability and aligned with other health system goals of optimization of safety, quality, and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations. The goal of HFE is to fit the healthcare system to the human instead of the human to the healthcare system. Concepts include removal of extraneous cognitive load, using clinician neural resource (brain power) optimally for highest order decision making in patient care. An integrative model of patient safety and clinician wellbeing is a product of this effort.

Human Factor Based Leadership: Critical Leadership Tools to Reduce Burnout and Latent Error in a Time of Accelerating Change

The majority of errors in healthcare are from systems factors that create the latent conditions for error to occur. The majority of occupational stressors causing burnout are also the result of systemic factors. Advances in technology create new levels of stress and expectations on healthcare workers (HCW) with an endless infusion of requirements from multiple authoritative sources that are tracked and monitored. The quality of care and safety of patients is affected by the wellbeing of HCWs who now practice in an environment that has become more complex to navigate, often expending limited neural resource (brainpower) on classifying, organizing, constantly making decisions on how and when they can accomplish what is required(extraneous cognitive load) in addition to direct patient care. New information demonstrates profound biological impact on the brains of those who have burnout in areas that affect the quality and safety of the decisions they make-which affects risk to patients in healthcare. Healthcare administration curriculum currently does not include ways to address these stress-induced problems in healthcare delivery. The science of human factors and ergonomics (HFE) promotes system performance and worker wellbeing. Patient safety is one component of system performance. Since many requirements come without resource to accomplish them, it becomes incumbent upon health system leadership to organize the means for completion of these to minimize the needless loss of brain power diverted away from the delivery of patient care. Human Factor-Based Leadership (HFBL) is an interactive, problem solving seminar series designed for healthcare leaders. The purpose is to provide relevant human factor science to integrate into their leadership and management decisions to make HCWs occupational environment more manageable and sustainable-which makes safer conditions for clinician wellbeing and patient care. After learning the content, a cohort of healthcare leaders believed that adequately addressing HFE in healthcare delivery would significantly reduce clinician burnout and risk of latent errors from upstream leadership decisions. An overview of the content of the seminars is described. Leadership feedback on usability of these seminars is reported. Three HFBL seminars described are Human Factor Relevance in Leadership, Biopsychosocial Approach to Wellness and Burnout, Human Factor Based Leadership: Examples and Applications.

Promoting Clinician Well-Being and Patient Safety Using Human Factors Science: Reducing Unnecessary Occupational Stress

Our healthcare delivery system has accumulated complexity of payment, regulation systems, expectations and requirements. Often these are not designed to align with clinical thinking process flow of patient care. As a result, clinicians are utilizing enormous mental (cognitive) resource to comply with these complexities, over and above the baseline mental effort required to give good care to the patient. Recent studies suggest a significant number of physicians, advanced practice providers and nurses no longer want to stay in healthcare due to difficult work expectations and conditions that have become unreasonable. Technology has benefitted healthcare delivery, but also is a conduit of many expectations that have been grafted upon clinician workloads, exceeding the resources provided to accomplish them. Cognitive load is a measure of mental effort and is divided into Intrinsic, Germane and Extraneous Cognitive Load. Extraneous Cognitive Load (ECL) is what is not necessary and can be removed by better design. High cognitive load is associated with increased risk of both medical error and clinician burnout. Chronic high level occupational stress occurs from dealing with this job/resource imbalance and is showing serious personal health impact upon clinicians and the quality of the work they can provide for patients. Since organizational systems have become more complex, leadership methods, clinician wellbeing and patient safety efforts need to adjust to adapt and succeed. Safety efforts have tended to predominantly follow methods of a few decades ago with predominant focus upon how things go wrong (Safety I) but are now being encouraged to include more of the study of how things go right (Safety II). Human Factors/Ergonomics (HFE) science has been used in many industries to preserve worker wellbeing and improve system performance. Patient safety is a product of good system performance. HFE science helps inform mechanisms behind Safety I and II approach. HFE concepts augment existing burnout and safety interventions by providing a conceptual roadmap to follow that can inform how to improve the multiple human/technology, human/system, and human/work environment interfaces that comprise healthcare delivery. Healthcare leaders, by their influence over culture, resource allocation, and implementation of requirements and workflows are uniquely poised to be effective mitigators of the conditions leading to clinician burnout and latent medical error. Basic knowledge of HFE science is a strategic advantage to leaders and individuals tasked with achieving quality of care, controlling costs, and improving the experiences of receiving and providing care.

Human Factors/Ergonomics (HFE) in Leadership and Management: Organizational Interventions to Reduce Stress in Healthcare Delivery

Clinician Burnout is a personal and public health issue. Most occupational stressors contributing to clinician burnout are systemic. The combination of organizational interventions along with individual interventions is necessary to make significant lasting difference in reducing burnout, improving clinician and patient satisfaction and reducing latent error in healthcare delivery. Application of Human Factors/Ergonomics (HFE) science in healthcare leadership and management is a gap in current training for leaders. HFE uses concepts from organizational, educational and cognitive science, systems science and industrial engineering. HFE application is especially necessary in a fast changing highly stressful healthcare environment which impacts the wellbeing of clinicians and the safety of patients under care. Practical suggestions for working with various healthcare leadership styles and organizational dynamics, while aligning wellness efforts with institutional mission are discussed. Concrete examples of decreasing extraneous mental load on clinicians to preserve their brainpower to achieve quality patient care are illustrated. Organizational interventions in combination with individual interventions to reduce and manage burnout have enormous potential to improve clinician wellbeing and satisfaction in taking care of patients, reduce costs, risk of error and create the safe working environment needed to sustainably give high quality care to patients.

Organizational Contributions to Healthcare Worker (HCW) Burnout and Workplace Violence (WPV) Overlap: Is This an Opportunity to Sustain Prevention of Both?

The effects of Burnout in healthcare workers (HCW) are experienced by the worker, other staff, the institution and patients under their care on a daily basis. Workplace violence (WPV) has a spectrum of forms. In more extreme forms it generally is low frequency but has high impact when it occurs. Healthcare systems’ efforts to reduce Burnout are more likely to remain sustained since the impact is experienced daily and awareness is increasingly publicized. The efforts to reduce WPV are harder to sustain due to the lower frequency combined with daily competing administrative demands despite best intentions. Could efforts to reduce the overlapping organizational contributions to both HCW Burnout and WPV be a strategy to sustain prevention of WPV while preventing Burnout? A model of overlapping organizational contributions to HCW Burnout and WPV is built from supporting literature. Recommendations are made for leadership and management style interventions. Potential benefits would be higher quality and satisfaction in patient care by means of higher satisfaction in the delivery of care, recruitment and retention of excellent staff, retention of high quality institutional knowledge and reputation.