Episode 14: The Great Resignation
How has the prolonged COVID-19 pandemic devastated our already overburdened healthcare workforce? Is the “Other Pandemic” of experienced providers leaving the workforce in droves making health care less safe? Join host Karen Wolk Feinstein and physician leader Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association, and nursing leader Dr. Terry Fulmer, president of The John A. Hartford Foundation, for a striking conversation about the extent of the crisis facing the healthcare workforce and what steps we can take to reverse this devastating trend.
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- Karen Wolk Feinstein, PhD, President & CEO, Jewish Healthcare Foundation & Pittsburgh Regional Health Initiative
- Terry Fulmer, PhD, RN, FAAN, President, The John A. Hartford Foundation
- Christine Sinsky, MD, Vice President of Professional Satisfaction, American Medical Association
Referenced Resources (in order of appearance)
- Why Health-Care Workers Are Quitting In Droves (The Atlantic, 2021)
- The “Great Resignation”: What health care leaders need to know now – January 7th, 2022 Daily Briefing (Advisory Board, 2022)
- How the era of travel nursing has changed health care (Vox, 2022)
- Health IT and Patient Safety: Building Safer Systems for Better Care (Institute of Medicine, 2011)
- CMS Announces Membership of Independent Coronavirus Commission on Safety and Quality in Nursing Homes (CMS, 2020)
- The Effect of Redeployment During the COVID-19 Pandemic on Development of Anxiety, Depression, and Insomnia in Healthcare Workers (Journal of General Internal Medicine, 2022)
- Trends in Electronic Health Record Inbox Messaging During the COVID-19 Pandemic in an Ambulatory Practice Network in New England (JAMA Network Open, 2021)
- Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations (Annals of Family Medicine, 2017)
- COVID-Related Stress and Work Intentions in a Sample of U.S. Health Care Workers (Mayo Clinic Proceedings: Innovation, Quality & Outcomes, 2021)
- Nearly One in Five American Adults Who Have Had COVID-19 Still Have “Long COVID” (CDC, 2022)
- New Survey Shows That Up To 47% of U.S. Healthcare Workers Plan to Leave Their Positions By 2025 (Forbes, 2022)
- A Worrisome Drop In The Number Of Young Nurses (Health Affairs, 2022)
- Helpful or hurtful? The “double-edged sword” of travel nursing (Advisory Board, 2021)
- 2022 U.S. Monkeypox Outbreak (CDC, 2022)
- The Attending Nurse: An Evolving Model for Integrating Nursing Education and Practice (The Open Nursing Journal, 2011)
- Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors (U.S. General Accounting Office, 2001)
- Medical errors may stem more from physician burnout than unsafe health care settings (Stanford Medicine, 2018)
- Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General U.S. Working Population Between 2011 and 2020 (Mayo Clinic Proceedings, 2022)
- Mini Z Survey (Institute for Professional Worklife)
- National Death Index (CDC)
- Joy in Medicine™ Health System Recognition Program (AMA)
- Over 200,000 Residents and Staff in Long-Term Care Facilities Have Died From COVID-19 (KFF, 2022)
- “Abandoned” Nursing Homes Continue to Face Critical Supply and Staff Shortages as COVID-19 Toll Has Mounted (JAMA Network, 2020)
- AHCA/NCAL Highlights Growing Nursing Home Closures (AHCA/NCAL, 2022)
- COVID-19 Infections and Deaths among Connecticut Nursing Home Residents: Facility Correlates (Journal of the American Geriatrics Society, 2020)
- A nurse was just sentenced to 3 years of probation for a lethal medical error (Vox, 2022)
- To Err is Human: Building a Safer Health System (IOM, 2000)
- National Steering Committee for Patient Safety (Institute for Healthcare Improvement)
- National Action Plan to Advance Patient Safety (Institute for Healthcare Improvement)
- The Commercial Aviation Safety Team: Goal, Mission, Vision (CAST)
- What is Human Factors and Ergonomics? (HFES)
- Creating a “Manageable Cockpit” for Clinicians: A Shared Responsibility (JAMA Internal Medicine, 2018)
- Age-Friendly Health Systems (John A. Hartford Foundation)
- Discovering the 4Ms: A Framework for Creating Age-Friendly Health Systems (John A. Hartford Foundation, 2018)
- About Paul Keckley, PhD: Independent Healthcare Research and Policy Analysis (Paul Keckley)
- The Keckley Report: It’s Time For Hospitals To Implement Plan B (Paul Keckley, 2022)
- Ezekiel Emanuel: About
[00:00:00] Terry Fulmer: We have to get to a point where we all do things in a reliable, consistent way, and we don’t have that now…
[00:00:15] Christine Sinsky: Currently, we really depend on individual nurses and individual physicians compensating for a chaotic system in which they work…
[00:00:28] Terry Fulmer: The level of stress going on is almost as profound as it has been for the last two years. But it’s off the front page, it’s not off the units…
[00:00:41] Christine Sinsky: The burnout rates are higher than they have ever been…
[00:00:46] Karen Wolf Feinstein: Welcome back to Up Next for Patient Safety. Where we envision a world where medical errors, adverse events, and preventable harms are avoided and where we examine the most promising paths to prevent these tragedies before they occur.
I’m your host, Karen Feinstein, CEO and president of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative. We’ve been working to reduce medical error for over 20 years, mostly unsuccessfully, but we can’t give up, because there’s too much at stake. And that is the loss of approximately 250,000 lives a year and long-term injuries for many more.
In this podcast series, we’ve considered the impact of the COVID-19 pandemic from many perspectives. What could, however, be one of the most important side effects of greatest long-term significance is the impact of the pandemic on the adequacy and sufficiency of the healthcare workforce. Exhausted, fearful, depressed, and frustrated nurses, physicians, and other clinical care participants are resigning and retiring in record numbers. Established and familiar teams are dissolving. Agency nurses can’t replace experienced veterans who once handled many routine tasks efficiently and automatically together as a team. All of which has created a situation where adverse events and medical errors have sadly multiplied. Some have already called this the other pandemic. On today’s episode, we’ll talk with two distinguished and knowledgeable guests about the extent of this problem and what we can do moving forward.
Dr. Christine Sinsky is the vice president of professional satisfaction at the American Medical Association. She previously served on an expert advisory panel for the CMS Innovation Center’s Comprehensive Primary Care Initiative. The Veteran Administration’s primary care redesign and on the National Committee for Quality Assurance provider programs committee with oversight of the Patient Centered Medical Home, from 2007 to 2011. She is co-author of the Institute of Medicine’s 2011 report, Health IT and Patient Safety.
Dr. Sinsky was a director on the American Board of Internal Medicine and a trustee for the American Board of Internal Medicine Foundation. She’s provided testimony to the Office of the National Coordinator for Health IT on EHRs with respect to both care coordination and usability. Dr. Sinsky received her BS and MD degrees from the University of Wisconsin-Madison and completed her postgraduate residency at Gunderson Medical Foundation/La Crosse Lutheran Hospital in La Crosse, Wisconsin. We’re so glad to have you here, Chris.
Dr. Terry Fuller is the president of the John A. Hartford Foundation in New York City. A foundation dedicated to improving the care of older adults. Established in 1929, the Foundation has a current endowment of more than half a billion dollars. She serves as the chief strategist for the Foundation and her vision for better care of older adults is catalyzing the age friendly health system social movement. She’s an elected member of the National Academy of Medicine and served on the Independent Coronavirus Commission for Safety and Quality in Nursing Homes established to advise the Centers for Medicare and Medicaid Services.
She previously served as Distinguished Professor and Dean of Health Sciences at Northeastern University. Prior to that, she served as the Erline Perkins McGriff Professor and Dean of the New York University College of Nursing. She received her bachelor’s degree from Skidmore College. Her masters and doctoral degrees from Boston College and her Geriatric Nurse Practitioner Post-Master’s Certificate from NYU. She completed a Brookdale National Fellowship and she’s the first nurse to have served on the Board of the American Geriatric Society. She’s also the first nurse to have served as president of the Gerontological Society of America, which awarded her the 2019 Donald P. Kent Award for exemplifying the highest standards for professional leadership in the field of aging. So, as you can see, we have the right people here to talk about this critical topic.
The COVID pandemic has resulted in a massive workforce shortage. Can you tell us more about the relationship between an overwhelmed and increasingly insufficient workforce and medical error? Dr. Sinsky from the medical MD perspective and Dr. Fuller from the nursing perspective. Chris, you wanna head this off?
[00:05:37] Christine Sinsky: Sure, thanks so much, Karen. As we all know, the first year of the pandemic brought a lot of unknowns and I think it brought unprecedented levels of death – levels that nurses and physicians had generally not personally experienced before. And this coupled with higher workloads and dealing with a disease for which we had no known treatment, with fears of personally becoming infected or bringing the virus home to your family… it was more than most physicians and nurses had ever experienced. In addition, many of our healthcare workers were redeployed to units where they had less experience. So, they felt less competent and that too added to the stress.
In the second year of the pandemic, the workload just didn’t abate. And in fact, for some, it seemed like it just kept increasing. There’s this really interesting study that showed that the number of patient portal messages – that is the communication that patients did with their physician or APP (Advanced Practice Providers) through electronic means, through an equivalent of an email – increased abruptly by 157% at the onset of the pandemic. And that even as in person visits return to their normal levels, the number of patient portal messages did not decrease. And so it was as if there was this second after hours job that physicians and others were managing and so no relief there. And even before the pandemic, we had good evidence that for primary care physicians who were seeing patients 36 hours of patient schedule time a week, that that actually translated into a 72-hour work week. That was before we had this massive increase in the amount of electronic communication and care via electronic means. And so we know that the workload has even increased further.
So I don’t think it’s a surprise that in a survey that we did in the second year of the pandemic, 24% of physicians and 40% of nurses said that they were likely to leave their current position in the next two years. And Karen, I don’t know how we’re gonna handle that. You know, we’ve got an aging population we’ve got now all the… perhaps as many as 20% of patients who’ve had COVID that will develop long COVID symptoms. There may be higher rates of diabetes and heart disease in the population because of the widespread COVID infections. And I think we are facing some really serious workforce woes. I think we have a bill coming due. The people who’ve kind of stood up to the challenge during the first portion of the pandemic are saying, “yeah, but I can’t keep this up.”
[00:08:31] Karen Wolf Feinstein: I have heard – and I know both of you have – from a number of systems, health systems, who say to me, candidly, “even with more nurse applicants for nursing schools, we will never replace the nurses we’ve lost. It… they’re not out there. It won’t happen, you know?” And so, we’re maybe looking at a redesign. Terry, tell us about this from the nursing perspective, the hemorrhaging is painful.
[00:09:00] Terry Fulmer: Yes, it is. And as I’m listening to Chris speak, my anxiety level is going up and because it’s-it’s so real to any of us who lived through that. And I was speaking to a friend yesterday and said, “this summer is fundamentally different than the last two summers, where there was never a moment where I felt like I could let up.”
[00:09:28] Christine Sinsky: And, you know, Karen, I think one of the things you said that was just brilliant was this articulation that established teams are dissolving. And I think as Terry talks about the fact that we may not ever recover the nursing workforce that we need… I also think, or – that we had – I also think it’s important to realize that when we have many of our nurses filling in in traveler positions and moving, and the great reshuffle of nurses who’ve been at one institution now are at another, you know, our effective nursing workforce has dropped because those who are working in a traveling position cannot possibly contribute the same amount that they were contributing in their home institution. And so, my fear is that that’s actually resulted in sort of an effective workforce that may be 30 or 40% lower than the body count would suggest.
[00:10:28] Karen Wolf Feinstein: And it is interesting, Chris, in the vast UPMC Health System, one unit always stands out. It’s a GI unit at one of our hospitals as the quality champion unit. Those nurses have been there together for almost 30 years. They know exactly what they’re doing. They, and you know, it is a nurse-run unit. But they’re this flawless team and they work as a team. Once you start moving people around, once they start dissolving, I don’t think you can replace that.
[00:11:04] Terry Fulmer: You can’t replace it. And I’m going to give you a perspective of nursing administration where they have been as innovative and creative as they know how to be. And even in the midst of say additional lines, their ability to staff a unit is – as you pointed out – extremely limited. And the answer to that is to close units. Now, imagine you’re telling your CEO as a nurse administrator, that you need to close units for safety. That’s what we’re talking about here today. And so that does not go over well and it’s seen as a flaw of the nurse administrator that he or she doesn’t have the capacity to staff up and be ready. Everybody wants to do more surgeries because people have waited, I understand that, and by the way, there’s still COVID out there and now people are concerned about Monkeypox.
I think that the level of stress going on is almost as profound as it has been for the last two years, but it’s off the front page. It’s not off the units. So we-we have to… I mean I personally witness this when I’m at the hospital where I work and it’s quite shocking to see just how almost numb people are. So we have to think about solutions and we have to think about how to support people in their work so that there isn’t a massive exodus of nurse administrators. That’s as bad as losing a nursing assistant and losing a nurse, is losing those nurse administrators who have extraordinary talent and capacity and knowledge and history and experience.
And Karen, that’s your point, you know. What do we do if we lose these people with experience and they’re hanging on by their fingernails right now. So getting to them, supporting them. And that’s Karen where you hear me talk about my nurse attending model where every faculty member in the United States, in nursing and beyond – you know it’s a multidisciplinary effort – but needs to see a role for themselves in a practice site, whether it is in a nursing home, whether it is in an ICU, no matter where it is… mental health clinic, etc. See a role and be there to support, enhance communication, participate, and bear witness so that when you teach a student, you’re doing it with real experience.
[00:13:40] Karen Wolf Feinstein: And it is interesting, we were involved in the nursing crisis of the early 2000s, which at that point seemed serious, but nothing like where we are now, but we did a survey and we wanted to understand why nurses were leaving and we were quite surprised. We thought it would be the compulsory extra shifts – we had a number of assumptions which turned out not to be true.
The number one reason on our survey was when nurses were moved to a unit that dealt with a condition with which they weren’t familiar. And we were so surprised at that, but I know when our woman’s hospital became a general hospital, the maternity nurses, the obstetric nurses, they were very discombobulated when they were caring for a lot of very senior frail men. That was just not their forte. So where we see this happening a lot right now during of course at COVID crisis, but not understanding the impact that’s having.
[00:14:47] Terry Fulmer: But Karen, you have to ask yourself, what’s the alternative? What is the alternative there? You try to retain those nurses, but you have to support them. You have to give them the guidance and support and listen to their concerns and find a place in the organization where they can participate in a safe and meaningful way. You can’t just move people around like widgets, but I have seen very effective administrators listen, take the advice of those nurses about where they can be most useful, which may be in a very different place than you’d think, and then retain them by doing that respectful listening. I also think – and then back to Chris – that we use the word crisis as if it’s… everything’s a crisis these days, and people are not listening anymore.
When we say we have a nursing crisis, it’s like, “sure, what else do you wanna talk about?” I think we’re gonna have to use as much data as possible to make the points that are going on. How many… how many units are closing? How many errors are happening because of insufficient clinical staffing? And what are the solutions? So I know we’re talking about that today.
[00:15:59] Karen Wolf Feinstein: One thing that surprised us way before the pandemic – we do a fellowship for graduate students in health professions, we actually do three – and one student did a project as part of the fellowship. And so she did a survey of our graduate students say 35 of our graduate students in health professions. And it was part of a project she was doing and she asked them a number of questions and one, have you ever contemplated suicide? And I don’t know if this will shock you, but we had a third of the students say, “yes, they, at some point in their life, they thought about suicide.” So, Chris, I know your role at the AMA focuses on the problem of physician burnout, but we know this problem preceded COVID people think this is a COVID crisis. Could you talk to us a lot about burnout, depression, anxiety, how the AMA addresses this problem?
[00:16:58] Christine Sinsky: Sure, I’m happy to Karen. We’ve been tracking burnout at the AMA in partnership with researchers from Mayo Clinic and Stanford since 2011. And we do a national representative survey every three years. And so we’ve been tracking this since 2011. Burnout rates peaked in 2014 at 54% of physicians experiencing some sign of burnout. And of course, that’s worrisome because when we’re burned out, we make twice as many errors as when we’re not. So it really is a patient safety issue. We had our fourth survey hit at the fall of 2020 – so in the first year of the pandemic. And we were really interested to see what those rates would be and somewhat counter to the narrative. The rates were actually the lowest that they had ever been in the period of time we’ve been monitoring, 38%. However, in physicians who were in specialties that were involved in direct care of COVID patients, they didn’t show improvement, they had stayed steady. And there are reasons why… the population of physicians may have shown a decrease, you know, more meaning and purpose in work, more community. And for some of our physicians, elective care was on hold. And so the workload for some was less.
So we performed an off cycle burnout assessment a year later, so late in the course of the second year of the pandemic. And we have just submitted that manuscript for publication. And I can give you a sneak preview just to say that the burnout rates are higher than they have ever been. Using the very same methodology that we have used since 2011. And so that’s very worrisome. In another database that we have completely separate, methodology in tracking burnout rates using the Mini Z instrument, we also found that burnout rates just accelerated at the end of 2021 to the point where it was over 60% of physicians experiencing some sign of burnout.
I think, you know, you started out by talking about suicide and that’s really an important topic and it’s absolutely tragic when anyone dies by suicide. And it has, you know, rippling consequences for everyone around them. And I think it’s important for us to distinguish between depression and burnout, because they’re not the same. Burnout is an occupational distress disorder, and it is related to the external environment. It is not an individual illness or weakness or flaw. Depression is a really complicated mental illness and it has complex contributing factors. You know, our genetics, our biology, our social circumstances, all contribute to depression, but they’re just not the same. And it’s been really challenging to identify the rates of suicide among physicians.
There are some off quoted numbers, but we are currently working with Stanford to do a more in-depth study of the National Death Index to see if we can get clear data on the rates of suicide among physicians. And the AMA has invested several million dollars every year, over the past decade to address physician burnout, supporting research into the drivers and consequences of burnout and in interventions and solutions, Terry, as you mentioned, that can help to solve the problem. We do a lot of burnout assessment and organizational wellbeing assessments at no cost. We’ve had over 1.4 million unique users to some of our toolkits and podcasts. So we are really working to reduce the rates of burnout among physicians and their teams. And then finally, I’ll just mention one last thing that we’ve created at the AMA, and that’s the Joy in Medicine™ Health System Recognition Program.
And we created that because we know that we need not more resilient individuals, we need more resilient organizations. Organizations that are structurally organized in a way that supports and protects the individuals within. And so that’s what this recognition program does. It celebrates those vanguard health systems that are already on the journey, but more importantly, it provides a roadmap for organizations who say, “oh my gosh, I know we have a problem, but I just don’t even know where to start.” And we’ve been pleased to find that many leaders have used this program as their guide, as they develop wellbeing as a strategic value within their organization.
[00:22:18] Terry Fulmer: I love that, Chris, and the other thing I would say about that is we have language now, and we have data now about burnout. When I was beginning my career, you would never say that you were tired or that you were stressed. That was considered a good way to get kicked outta your internship if you were a physician and if you were a nurse, it’s like, “what’s wrong with you if you can’t keep up?” We are very harsh and it’s a sea-change, and it’s hard for older clinicians to empathize completely with our newest clinician set who say, “you know, I need a mental health day”. It’s enactment to them. They don’t know what the other person is talking about and that’s a part of this whole solution. And I know it’s in your program cause I read about it, Chris. I also would like to talk for a minute about nursing homes, you know, I wanna talk about nursing homes and to say that when we talk about systems, nursing homes are a vital and critical element of our healthcare system as is public health.
But in, in COVID more than 200,000 deaths occurred among long term residents and staff… and staff. I’m in New York State in the city, in the early part of the pandemic, all PPE personnel and equipment was sent to the ICUs. And nursing homes were using cloth masks, garbage bags to cover up, and they are off the radar. Again, you know, as we talk about it sort of like that has not settled out, those systems have been devastated. Many are closing – many nursing homes are closing because they cannot maintain the regulatory capacity that is required of them to practice. And so I think… and their largest workforce shortages have been with the nursing aides and technical staff who oversee all the care needs – and not to mention the fact that then when we put everybody in social isolation in nursing homes and did not allow visitors to come in… older people had more pressure ulcers, more delirium, which is acute confusion, they had more medication errors… they had just a lot of terribly serious problems that happen.
And a recent study in Connecticut nursing facilities found that an increase in registered nurse staff of 20 minutes a day resulted in 22% fewer cases of COVID. So it’s very clear that when you have adequate staff, be they nursing assistants, licensed practical nurses, or nurses, you increase the quality of care you improve the opportunity for those staff members to take care of the person, and you decrease hospitalizations. Take a look at your data, Chris, and I know you know this… when do most people get transferred to the hospital? Friday afternoon, right? Here comes weekend staffing, here comes, “I don’t know what to do,” and they go to the emergency room. So I think all those things are a part of the safety quality partnership that we need to have as a honest-to-God healthcare system, where every point of care is noted in the system. Back to you, Karen.
[00:25:43] Karen Wolf Feinstein: I have to applaud the Joy in Medicine program. I know you have a lot of work to do. You know, we have a family member who just needed a break – a surgeon – so he didn’t go hiking. He went to a developing country just for six months to help residents learn complicated surgical techniques. And he – this is someone who had won the medical resident award for teaching – but the hospital sort of said, “we are not sure we’ll take you back, you know? Yeah, goodbye. Maybe you’ll come back. Maybe you won’t.” And I’m thinking, where is the understanding, you know, at the hospital level? I think if nurses and physicians need a break – not asking to be paid, you know – we need to have some flexibility here. These are human beings who are struggling, and we all know… we all know during the pandemic, some of us needed a break, but I like the Joy in Medicine. I like maybe a more sensitive attitude toward understanding what the clinical staff need when they need it.
So, let me just go back to medical error for one moment, cause I think of medical error and the workforce crisis as conjoint twins. We hired a young nurse, wonderful young woman – I don’t like to hire nurses – Terry knows this, and I say to them, “I want you in the hospital when I need help.” And they say, “we’re gonna leave, you know, like, and we would love to work for you” but if they don’t so we hired one and after two weeks, “how are you doing?” And she said, “I love my new job. I love my new job. I know at the end of the day; I haven’t killed anyone.” So let’s talk a little bit about building an environment where nurses feel they’re supported in not doing harm. So we all know, and we’re not gonna go back over a recent case that did get our attention at least where a nurse was criminally prosecuted and convicted for what was an egregious medical error, but also a great system failure in many ways. I’m trying to think of how do we build, as the human factors engineers would say, “a better airplane?” How do we create systems where people are less likely to create an error? We know other industries do this. We know that our astronauts who go to the space station and the moon, they’re protected by systems that are wired to keep them safe – they’re not necessarily keeping themselves safe! How do we help develop systems where physicians and nurses are prevented from committing as many errors as possible? So, I know Terry you’ve given this a lot of thought.
[00:28:35] Terry Fulmer: I have Karen, and I think that it’s predictable when you have people doing overtime, when you have people who are on a unit, that’s not appropriately staffed… you’re just setting yourself up for error. And in this case, you know, horrific error. And so, we have begun a narrative in this country and the American Medical Association and American Nurses Association have done a great job talking about, we will support you. You know, “To Er is Human” the report came out and to figure out where in this… what failed in the system that created the opportunity for something that bad to happen?
And so, I am very concerned about the number of workarounds that are going on in the clinical arena right now. What’s a workaround mean? Well, if you’re supposed to use a medication delivery cart in a particular way where there’s a failsafe check to make sure that you have done all of the steps, if you can work around that and in order to speed up your efforts, people will do that because they’re under so much pressure. So how do we figure this out? I think that… I know that IHI also has a National Patient Safety Committee and a National Action Plan going on. So they have like 37 organizations that are in that tent. The more all of us tell the story of how we’re gonna prevent error through system approaches… I do believe we’ll have a lot more electronical – is that a word – electronic capacity to stop us from those workarounds that do create error.
[00:30:22] Karen Wolf Feinstein: And, you know, I always look with envy at the Commercial Aviation Safety Team (CAST). And the reason not only because they’ve had an amazing impact on anticipating and preventing harm because they get accurate data, not only on incidents, but on near misses from every one of the airlines. The airlines came together and they said, “this is a joint problem. This is a problem for all of us. What happens in one place, affects others. And that the solution, if we’re gonna prevent errors before they happen, is that all of us have to share data. All of us have to come around the table. All of us have to salute interdisciplinary expertise to help us, the airlines be as safe as possible.”
Chris, what are the chances? How do we get health systems to come together and say, “look what happens at Vanderbilt University affects us at MGB (Mass General Brigham).” Where do we get a CAST-like let’s come together, let’s all share data, updated data on incidents, near misses, everything that will shed light on how we prevent harm?
[00:31:41] Christine Sinsky: Karen you said in the beginning to this conversation, how important human factors perspectives are. And I think we need to integrate human factors engineering into every single health system and into every unit within each health system. I think currently we really depend on individual nurses and individual physicians compensating for a chaotic system in which they work, and we assign responsibility and blame to the individual nurse or physician. If there’s a medication error or a different error in the care of patients, our infrastructures are based on that. Our quality metrics often are at the individual physician level, for example, rather than at the unit level or the system level. Malpractice is generally directed at the individual level. And I think we have to change those infrastructures. We have to be aware of cognitive workload. We expect our physicians and others to have like a superhuman capacity to work despite distractions and interruptions and a chaotic display of information, and somehow overcome all of those barriers to safe care.
And when you mention the airline industry, what that brings to my mind is this notion of creating a manageable cockpit for clinicians. Just as the airline industry creates a manageable cockpit for pilots, they recognize the importance of human factors engineering and the importance of avoiding cognitive overload. So I have a series of pictures that a pilot sent to me of the cockpit over the decades. And in 1970s, it’s a wild mass of lights and beeps and buttons. And then in 2000, it’s a little cleaner. And in 2010, it is a beautiful, clean, crisp display with only the most important things, visible and process coupling so the things you need are next to that point of action. And at Boeing, and I suspect at other manufacturers, there’s a team of engineers whose sole responsibility it is to adjudicate all the potential things, lights, buzzers, warnings that can enter into the cockpit and make sure that in aggregate the pilots are in an environment where they can safely do their job, where they are not overwhelmed.
With too much information, too disorganized information, missing information, chaotic information or information and action that are accessed through a cumbersome series of screen changes. But we have the absolute opposite in healthcare. Our physicians are trying to make decisions by holding one little piece of information in one part of their brain as they scroll to three different screens to find another piece of information, then they scroll to another couple of screens to put that into action. And that’s just a really unsafe environment. And our technology, our electronic health records have not really been designed to make it a manageable cockpit to bring only the information you need at the point of care for that decision and not be overwhelmed by a clutter of distracting information. And so I’m optimistic that this can change, but we have to take it seriously.
[00:35:41] Terry Fulmer: I love that, Chris, and the metaphor of cockpits and chaos in the healthcare arena is a very powerful one. And I would be remiss if I didn’t make a comment about the American Organization of Nurse Leaders and the American Association of Colleges of Nursing who are working together constantly to think about ways to really improve the cacophony going on in the system right now that makes it so challenging to have an error free healthcare system. I think that what we lack so much is reliability. And I’ll talk about the practice of nursing for a minute and say that we have to get to a point where we all do things in a reliable, consistent way. And we don’t have that now, you know, I might change a dressing in a particular way and the next nurse in might do it differently and that has to stop. We’ve got to figure out how to ensure reliability in practice that is evidence based.
That’s why we work on age-friendly health systems. We believe improving care for older adults improves care for everybody. But when we work with our age friendly health system, we use a person-centered approach, and we always employ a 4M framework with every single person. And that is, the four M’s are What Matters to the older person and their families – what their goals and preferences are, Medications, ensuring that their people are not on too many or too few drugs, and that those drugs are consistently screened for potentially inappropriate medication use, which happens all the time – all the time. And each of us know a story that probably happened this week. I’m thinking about my brother-in-law when I heard what they were gonna put him on, I immediately said, do not take those pills. And he didn’t. But how many of those happen?
And then, so What Matters, Medication, Mentation, your mood and memory, what’s going on with the older person is their acute delirium, which is as serious as a cardiac arrhythmia. And then thinking about Mobility and is the person getting out of bed? Not for 10 minutes a day, but regularly. What is the reliable unit of time out of bed that’s gonna help a person avoid sarcopenia, avoid unnecessary restriction, and really work through the way in which people need to be kept as functionally strong as possible? Because if we improve the cardiac arrhythmia but at the same time if that person develops a pressure ulcer, they’re weak, they go home, they fall, they hit their head, they come back… What have we really done?
So thinking about this in a reliable, consistent data-based way. And we have lots on our website and we welcome everybody to look at our website at the John A. Hartford Foundation for the data, from the systems that are showing us that you can deliver reliable, consistent care that improves outcomes that it takes intentionality.
[00:39:02] Karen Wolf Feinstein: Amen.
[00:39:03] Christine Sinsky: Terry, if you don’t mind. I’d love to follow through-follow on, on something you said, because I think when we think about what will drive improvements in safety, you mentioned reliability and I think that’s really important. It made me think also that particularly in the ambulatory clinic space, which is where the majority of patients get their care and it’s where if we have really optimal care in the ambulatory space, we can decrease the amount of hospital care and the number of procedures that are done. And so what I think another dimension that will drive safety, particularly in the ambulatory space, is teamwork. And I mean something really specific when I mean teamwork. I don’t mean fragmenting care among a lot of different people. I mean, having a coherent stable team. And when I think of teamwork, I think of team structure, how many people are working together, team skill level – are these medical assistants or RNs? And have they been uptrained to the skills needed for their particular environment? Have we invested in that? And then stability, the same people working together day after day.
I was fortunate to work with a team of nurses in my practice as an internal medicine physician and one of my nurses and I worked together for over 20 years. Two of the other nurses were together with us for over 10 years. So that’s a situation where you can really work well together in service of patients. And if I could make one suggestion to improve safety for patient care in the ambulatory space to improve the outcomes, it would be to increase the number of RNs who are working in the ambulatory care space. Not off in an office by themselves doing prescription renewal or doing some sort of population health management, but integrated into the team, working shoulder to shoulder with the physician or APP who’s responsible for the patients and they’re responsible together.
I knew that we had reached a really important point in our development of our team when one of the nurses said, “my patients. These are my patients. This is what I can do for my patients.” And that’s exactly the kind of ownership mentality that I think is a consequence of being in tight stable teams, where you value relationships, where you prioritize relationships. And I think relationships throughout the healthcare system are the secret sauce that we’ve been ignoring. And we ignored it when we allowed nurses to just shuffle around from place to place. We ignore it when we think having anybody will do and in any location. We ignore it when we fragment care among many different locations. And we ignore it when we say pool nursing, any nurse can work in any ambulatory setting, that undermine the secret power of relationships.
[00:42:28] Terry Fulmer: I love that.
[00:42:30] Karen Wolf Feinstein: I think it’s a wonderful note to end on the one thing we know other countries have really done more to have a team responsibility for a distinct geographic area for people who live in that area in a very interesting way that transcends any particular setting of care. I think we all heard a report on this recently. Also, Chris, what you said today remind me, I saw a report it just came out at least to my attention today by Paul Keckley, It’s Time For Hospitals To Implement Plan B. And of course you would love it. He said a lot about the things you were discussing.
Maybe it’s time to have a major transformation to rethink where, how, by whom we deliver medical care with a kind of blending of in-hospital, community care, public health, and other healthcare. It’s just for both hospital care and skilled nursing it may be time for a Plan B. So that’s something for another podcast. Also, a recent article I just read by Zeke (Ezekiel) Emanuel and I guess another co-author, about how we’ll have safety when we have economic incentives. That’s a topic we could talk about for a while, I hate to think that that’s what’s going to make the difference, but both of these are another podcast.
Meanwhile, I know I can keep relying on advice from both of you on this critical topic. You’re both so intelligent, distinguished, compassionate, I couldn’t think of two people to discuss this critical issue with and get more wisdom, but we all know it’s the issue we can’t ignore. So, let us hope, um, whether it’s plan B or other kinds of transformations that we start rethinking, what is it we’re doing that isn’t working, and how do we make the changes that would be so critical? Not only to patient safety, but worker safety. Safety that’s not only physical, but that’s also emotional. So, thank you so much for today. I know we could keep going because this topic deserves it. Thank you.
[00:44:54] Terry Fulmer: Thanks for bringing us together.
[00:44:56] Christine Sinsky: Thanks Karen. Thanks Terry.
[00:44:58] Karen Wolf Feinstein: To learn more about the effort to establish a National Patient Safety Board, please visit npsb.org. We welcome your comments and suggestions. If you found today’s conversation enlightening or helpful, please share today’s podcast or any of our other podcasts with your friends and colleagues. We can’t improve the effectiveness of our health system without your help. You, our listeners, friends, and supporters are an essential part of the solution.
If you want a transcript or the show notes with references to related articles and resources, that can be found on our website at npsb.org/podcast/. Up Next for Patient Safety is a production of the National Patient Safety Board Advocacy Coalition in partnership with the Pittsburgh Regional Health Initiative and Jewish Healthcare Foundation. It is executive produced and hosted by me, Karen Wolf Feinstein. Megan Butler and Scotland Huber are my associate producers. This episode was edited and engineered by Jonathan Kersting and the Pittsburgh Technology Council. Thank you, Tech Council! Our theme music is from shutterstock.com. Social media and design are by Lisa George and Scotland Huber. Special thanks to Robert Ferguson and Steven Guo. Thank you all for listening.