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Running head: BURNOUT IN HEALTHCARE

Burnout in Healthcare

Jessica Ndegwa

University of San Diego

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Burnout in Healthcare

Burnout, as defined by Elmore, Jeffe, Jin, Awad, and Turnbull (2016), is a complex

syndrome of emotional distress that can disproportionately affect individuals who work in

healthcare. Healthcare in the 21st century has undergone a myriad of technological and

organizational changes, which have made its workers adapt. At present, burnout is an unintended

consequence of healthcare transformation. System-generated stressors, including cost cutting,

ever-increasing regulation, and the evolution of the electronic health record (EHR), have resulted

in “an erosion of control” and an abundance of new tasks for providers - without any more time

to accomplish their work (Sinsky et al., 2016). Burnout and its impact on patient safety, was

identified as one of top 10 patient safety concerns of 2019 by the emergency care research

institute (ECRI, 2018).

Change is often a stress inducer, which can precipitate burnout (Comerford, 2016).

Examples of changes in healthcare are introduction to EHRs and learning new equipment, tests,

and procedures. Consequently, an increase in the aging population with multiple morbidities and

emergence of novel diseases place additional pressure on healthcare workers to provide adequate

and more complex care to a larger group than in the past. Additionally, standards of care set by

government bodies, such as the Joint Commission, place more scrutiny on healthcare workers to

achieve certain quality initiatives and regulatory requirements, while maintaining patient

satisfaction and quality of care (Comerford, 2016).

Other causes of stress-induced healthcare burnout is a lack of adequate resources,

understaffing, increased workload, concern over litigation, emotionally challenging clinical

work, high mortality environment, frequent interaction with unhappy patients or family

members, high patient acuity, inefficient EHR workflows, redundant processes, high turnovers,
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time compression, feelings of not being valued or listened to, and a punitive culture. Clinicians

are also significantly impacted by work compression, which according to Shin, Gandhi, and

Herzig (2016) is the imperative to do the same work in less time. All these stressors have led to a

burnout epidemic that is a significant problem in the healthcare industry, as its effects on

healthcare workers impact patient care and safety.

Burnout is associated with patient safety problems such as increased medical errors,

suboptimal patient care, and increased hospital-acquired infections. Additionally, it may result in

low patient satisfaction and depersonalization of patients who are then viewed as diagnoses

rather than individuals (Comerford, 2016). Healthcare workers who experience burnout may

display emotional exhaustion, low job satisfaction, low levels of personal accomplishment,

suicidal ideation, and alcohol and substance abuse. The effect of burnout also creates a financial

burden on organizations (Shin et al., 2016). To avoid these far-reaching burnout sequels, it is

imperative for healthcare organizations to prioritize determining the cause of burnout and

collaborate with its employees to find solutions to mitigate it. The purpose of this paper is to

explore different causes of burnout and offer solutions to manage and prevent it.

Literature Review

The Meaningful Use program of the Health Information Technology for Economic and

Clinical Health (HITECH) Act of 2009 supported the adoption of EHRs with a goal of

improving patient quality of care, safety and satisfaction, along with improving efficiency and

productivity resulting in cost-savings for organizations. Unfortunately, EHR functionality and

reimbursement regulations have led to an increase in physician burnout related to clinical

documentation (DiAngi, Longhurst, and Payne, 2016). A selective review of literature on EHR-
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related burnout resulted in four articles discussed below that propose solutions to address this

issue.

DiAngi et al. (2016) recommended four solutions to improving EHR-related physician

burnout. The first recommendation was to redistribute data entry tasks to the healthcare team,

including patients. An example was to allow patients to fill out a chief complaint e-questionnaire

that would populate into the EHR, thus lessening the amount of time a physician needs to chart

that information. A second recommendation was to refine encounter documentation and limit

clicks. This could be accomplished by doing away with drop down lists in the flowsheet that

create additional charting time. The third recommendation was EHR and workflow coaching.

Determining what areas of an EHR a clinician spends the majority of their time on, would help

influence the areas that require restructuring or additional training to improve usability and time

management. The final recommendation was to enact policy, national collaborations, and

innovation supporting EHR evolution. This could be accomplished by ensuring EHR vendors

adhere to certain standards or regulations of usability before they can be certified for marketing.

DiAngi et al. (2016) proposed a federal rating system of EHR-user interface usability that would

mandate for better user-friendly products.

Guo, Chen, and Mehta (2017) proposed improving efficiency and click burden by making

changes to documentation, chart review, ordering, and patient safety. Documentation changes

would include lessening EHR interface clutter and clicks by compiling patient data. An example

is a physician having the ability to automatically populate vital signs, laboratory results,

allergies, and past medical history onto their charting in one click. Chart review would be

enhanced by reducing time spent on scrolling to view certain documents. An example of this was

instead of having to scroll down to view all lab results, the interface would be changed to
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automatically populate the critical results to the top of the page. Additionally, the use of color

coding for abnormal results and provision of a window to visualize trends would be of help. The

process of placing orders would be improved to reduce unnecessary tests using best practice, for

example using a soft or hard stop to alert a physician of duplicate orders (Guo et al., 2017).

Kroth et al. (2019) identified seven EHR design and user factors identified by clinicians

that were most associated with high stress and burnout. These were information overload, slow

system response times, excessive data entry, inability to navigate the system quickly, note bloat,

interference with the patient-clinician relationship, fear of missing something, and notes geared

toward billing. Recommendations to resolve those factors were identified as EHR improvement

by vendors and information technology personnel, EHR ongoing training for clinicians, and

decoupling clinical documentation from billing, regulatory, and administrative compliance

requirements. Additionally, reducing unnecessary, repetitive, and noncritical or normal data

displayed on the user interface, using specially trained medical assistants to relieve some of the

documentation workload from the clinician, and improving ergonomics during charting were

measures recommended to ease physician burnout related to EHR use (Kroth et al., 2019).

Ommaya et al. (2018) identified clerical burden associated with clinical documentation as

a major driver of clinician burnout. Required documentation that is clinically irrelevant but

fulfills billing and reimbursement stipulations and inefficient workflows with redundant or

irrelevant details increased burnout. Ommaya et al. (2018) identified the use of natural language

processing tools and dictation instead of a rigid template could enhance documentation while

also saving clinicians time. Changes in regulatory requirements by the Centers for Medicare and

Medicaid Service (CMS) would help avoid duplicate documentation of information already

present in another part of the chart such as vital signs. Machine-captured data could address
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billing needs instead of requiring clinician documentation. Clinician involvement in EHR

redesign and ongoing training would help improve usability (Ommaya et al., 2018).

All four articles discussed in this literature review identified documentation as being the

main cause of clinician burnout. Kroth et al. (2019), and Ommaya et al. (2018) discussed

regulatory requirements by CMS that mandate certain charting for billing, coding, and

reimbursement purposes, which add nonclinical workload for physicians. Ommaya et al. (2018)

proposed developing machine-captured data that could populate the required billing and coding

requirements without the need for physician input, whereas Kroth et al. (2019) proposed making

changes to CMS regulations to allow medical personnel to assist with documentation for

reimbursement purposes. Other issues related to clinical documentation rooted in EHR usability

were a common theme in each article such as click burden, redundant information, and interface

clutter. DiAngi et al. (2016), and Kroth et al. (2019), mentioned similar solutions requiring EHR

vendors to make changes to its functionality. DiAngi et al. (2016) went further and provided a

more in-depth solution requiring EHR vendors to use a federal rating system of EHR-user

interface usability to get certified to market the product. Solutions to the click-burden will be

discussed further in this paper.

Identified Solution

The technology hazard identified was the click burden caused by EHRs whereby multiple

clicks while using the interface are needed to accomplish a task. A solution that would minimize

the number of clicks is ideal to improving efficiency, lessening clinician burden, and burnout.

The solution identified to address this issue during placing orders is the implementation of

passive, soft, and hard stop alerts that would incorporate decision support, using best practice to
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curb unnecessary tests, and concurrently reduce clicks as discussed by Guo et al. (2017) in their

case study.

Implementing a clinical decision support (CDS) tool into the ordering interface of the

EHR that uses best practice would help avoid ordering of duplicate and unnecessary tests or

medications. A passive alert would offer information without interrupting the workflow. A soft

stop would be used to alert the physician to rethink ordering a test by requiring an override. A

hard stop would be used to prevent placing an order without approval from a third party (Powers,

E. M., Shiffman, R. N., Melnick, E. R., Hickner, A., & Sharifi, M., 2018). Using these decision

support tools streamlines EHR workflow, reduces the click burden for the health care provider,

and improves the delivery of care. It also improves patient safety by preventing potential harm

from unnecessary tests or medications ordered. Patients’ quality of care is improved through the

use of evidence-based provider guidance. Lastly, healthcare organizations experience cost

savings through improved patient outcomes supported by value-based care. A literature review

of 32 articles done by Powers et al. (2018) found that well-designed CDS workflows with hard

stops improved performance on process measures in 79% of studies, while outcomes improved

in 88% of the articles included in the sample.

Prior to the integration and implementation of the solution, a failure mode and effect

analysis (FMEA) was undertaken. First, the sequential steps of the solution were visually

depicted in a process map (see Appendix A). Second, potential errors were identified (see

Appendix B). Lastly, a FMEA was conducted to identify actions for eliminating or controlling

the potential causes of the error (see Appendix C).

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Quality Measurement Plan

The technology hazard identified was click burden resulting in physician burnout, which

leads to increased patient safety events. The solution identified was to use a customized CDS

tool incorporated into the Computerized Physician Order Entry (CPOE) system. The tool would

limit unnecessary clicks by using a tier system for alerts according to criticality (i.e., using

passive, soft, or hard alert stops). Using the plan-do-study-act (PDSA) cycle as discussed by the

institute for healthcare improvement (IHI, 2020) , the plan is to determine whether physician

burnout (outcome measure) will be improved by using a customized CDS tool to reduce click

burden in the CPOE system (process measure). The quality and risk management department of

the hospital will conduct this assessment quarterly (every 3 months) in collaboration with the

information technology (IT) department.

To assess the process measure, overridden alerts in the CPOE system will be tracked by

the IT department and reports generated every three months. This will determine which alerts are

overridden the low-level (passive and soft) or the high-level (hard) alerts. To assess physician

burnout, providers using the CPOE system will be surveyed online using the free abbreviated

Maslach Burnout Inventory (MBI), which comprises of nine questions divided into three

categories: emotional exhaustion, depersonalization, and personal accomplishment. The MBI

survey will be customized by the IT department to generate a link to be accessed by physicians

using the CPOE system via work email. The short survey will be mandatory and limited to one

response. It will be available for 1 month and will be distributed 2 months prior to implementing

the CDS tool and every 3 months (quarterly) after the rollout. Results of the overridden alerts

correlated to the results of the MBI collected prior to and after the CDS implementation will

determine the impact of using the tool to improve physician burnout.

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Conclusion

Physician burnout related to click burden while using CPOE system can result in

increased patient safety events (ECRI, 2018). To mitigate this technology hazard, a CDS tool

would be implemented into the CPOE system to manage alerts by customizing them according to

criticality, thus reducing click burden from unnecessary low priority notifications. Conducting an

FMEA prior to implementation revealed possible failure points (see Appendix B) in introducing

this solution. For the CDS tool to be successful, it should involve primary users in its

development, reflect current best practice guidelines, and optimize workflows that supports user

needs (Powers et al., 2018). Additionally, ongoing training and feedback should be provided.

Resources should also be allocated for development, implementation, and future updates. Failure

to address these potential issues can result in an inefficient CDS tool that creates nonintuitive

workflows that increase physician burden and ultimately result in patient harm.
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References

Comerford, J. (2016, December). Burnout in healthcare: The elephant in the room. ECRI

Institute. Retrieved from https://www.ecri.org/components/HRC/Pages/RMRep1216.aspx

DiAngi, Y. D., Longhurst, C. A., & Payne, T. H. (2016). Taming the EHR (electronic health

record): There is hope. Journal of Family Medicine, 3(6), 1072. Retrieved from https://w

ww.ncbi.nlm.nih.gov/pmc/articles/PMC5098336/

Elmore, L. C., Jeffe, D. B., Jin, L., Awad, M. M., & Turnbull, I. R. (2016). National survey of

burnout among US general surgery residents. Journal of the American College of

Surgeons, 223(3), 440–451. doi:10.1016/j.jamcollsurg.2016.05.014

ECRI Institute. (2018). 2019 top 10 health technology hazards. Retrieved from https://www.ecri.

org/Resources/Whitepapers_and_reports/Haz_19.pdf

Guo, U., Chen, L., & Mehta, P. H. (2017). Electronic health record innovations: Helping

physicians – One less click at a time. Health Information Management Journal, 46(3),

140–144. doi:10.1177/1833358316689481

IHI (2020). How to improve. Retrieved from http://www.ihi.org/resources/pages/HowtoImprove/

default.aspx

Kroth, P., Morioka-Douglas, N., Veres, S., Babbott, S., Poplau, S., . . . Linzer, M. (2019).

Association of electronic health record design and use factors with clinician stress and

burnout. JAMA Network Open, 2(8), 1–14. doi:101001/jamanetworkopen.2019.9609

Ommaya, A. K., Cipriano, P. F., Hoyt, D. B., Horvath, K. A., Tang, P., . . . Sinsky, C. A. (2018).

Care-centered clinical documentation in the digital environment: Solutions to alleviate

burnout. National Academy of Medicine, Perspectives: Expert voices in health & health
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care. Discussion paper. Retrieved from https://nam.edu/care-centered-clinical-

documentation-digital-environment-solutions-alleviate-burnout

Powers, E. M., Shiffman, R. N., Melnick, E. R., Hickner, A., & Sharifi, M. (2018). Efficacy and

unintended consequences of hard-stop alerts in electronic health record systems: A

systematic review. Journal of the American Medical Informatics Association, 25(11),

1556–1566. doi:10.1093/jamia/ocy112

Shin, A., Gandhi, T., & Herzig, S. (2016, April). Make the clinician burnout epidemic a national

priority. Health Affairs. Retrieved from http://healthaffairs.org/blog/2016/04/21/make-

the-clinician-burnout-epidemic-a-national-priority/

Sinsky, C., Colligan, L., Li, L., Prgomet, M., Reynold, S., Goeders, L., . . . Blike, G. (2016).

Allocation of physician time in ambulatory practice: A time and motion study in 4

specialties. Ann Intern Med, 165(11), 753–760. doi:10.7326/M16-0961

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Appendix A

Implementation Process of CDS Tool into CPOE

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Appendix B

Potential Failures Associated with Implementation of CDS Tool into CPOE

Process Step 1 Process Step Right information – implement CDS alert tool into
#1 CPOE that uses evidence based and best practice data

2 Potential Failure CDS tool does Creation of CDS tool does

Mode not reflect inefficient not reflect
current best workflow current needs
practice potentiating and guidelines
guidelines errors to support
increasing patient safety
patient safety
issues
Process Step 1 Process Step Right people – inform physicians on benefits of CDS
#2 tool and how to incorporate it into their decision
making
2 Potential Failure Workarounds/de Pushback and Increased
Mode viations from conscious patient safety
best practice decision not to events from
that can lead to use CDS tool, implementing a
patient harm which can lead CDS tool
to patient harm without
established
goals or
objectives
Process Step 1 Process Step Right intervention format – Use customized EHR alert
#3 thresholds or tier system i.e. passive, soft, and hard
stop alerts
2 Potential Failure Ignoring critical Delay in care Overriding
Mode notifications alerts for critical
that can lead to issues can lead
patient harm to patient harm
Process Step 1 Process Step Right monitoring tool – CPOE CDS tool evaluation
#4
2 Potential Failure Users not using CDS tool does Lack of buy-in
Mode CDS tool to not reflect user from users who
improve patient needs and choose not to
safety therefore does use the CDS
not promote tool potentially
patient safety negating patient
safety
Process Step 1 Process Step Right maintenance of CDS tool – Regular upgrades to
#5 reflect specific needs and best practice

2 Potential Failure CDS tool does Users reject CDS tool

Mode not reflect CDS tool upgrade does
specific needs not reflect
or best practice ongoing user
that supports needs
patient safety
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Appendix C

Failure Modes and Effects Analysis (FMEA)

Table C1

Process step #1 of FMEA

Process Step 1 Process Step Right information – implement CDS alert tool into
#1 CPOE that uses evidence based and best practice data
2 Potential Failure CDS tool does Creation of CDS tool is
Mode not reflect inefficient outdated
current best workflow
practice potentiating
guidelines errors
increasing
patient safety
issues
3 Potential Difficulty Lack of Lack of
Cause(s) incorporating customization of resources to
extensive CDS tool to maintain and
quantity of support the user update the CDS
research being needs tool to reflect
published on an current needs
ongoing basis and guidelines
4 Severity 3 5 5
5 Probability Uncommon Frequent Uncommon
6 Hazard Score 2 8 4
7 Action Accept Control Control
(Eliminate,
Control, or
Accept)
8 Description of -There will -The CDS tool -Foresight when
Action always be new should be implementing
research and customized to the CDS tool
guidelines reflect current should include
emerging that safety issues planning for
cannot be -CPOE users future upgrades
immediately should be and making sure
incorporated involved in the resources
into the CDS building the required are
tool. CDS tool to available
-Current best support creation -The
practice of an intuitive effectiveness of
guidelines tool the tool in
should be -Minimizing improving
utilized upon workflow clinician
rollout of the interruptions by workflow and
CDS tool. using a tier patient safety
-Future updates system for alerts can result in
can be made on or notifications more available
a later basis will eliminate resources e.g.
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which will alert fatigue. cost savings
incorporate from patient
newer research safety events
and guidelines. can be utilized
to upgrade the
tool.
- If resources to
maintain the
tool are not
available and
renders it to be
inefficient and
not meeting the
set objectives,
then the CDS
tool should be
rescinded.
CDS – Clinical Decision Support; CPOE – Computerized physician order entry
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Table C2

Process step #2 of FMEA

Process Step 1 Process Step Right people – inform physicians on benefits of CDS
#2 tool and how to incorporate it into their decision
making
2 Potential Failure Workarounds/de Pushback and Increased
Mode viations from conscious patient safety
best practice decision not to events from
that can lead to use CDS tool, implementing a
patient harm which can lead CDS tool
to patient harm without
established
goals or
objectives
3 Potential Resistance from Lack of user Lack of clear
Cause(s) physicians to involvement in goals and
change/ lack of the design and objectives of
buy-in implementation using CDS tool
process
4 Severity 5 5 3

5 Probability Occasional Frequent Occasional

6 Hazard Score 6 8 3

7 Action Control Control Eliminate

(Eliminate,
Control, or
Accept)
8 Description of -Ongoing -Elicit user -CPOE users
Action training feedback should be
-Elicit user -Involve CPOE involved in
feedback users in the building the
-Use peer development, CDS tool and
influence to implementation establishing the
support for the and future goals and
tool updates of the objectives
CDS tool to -CDS tool
foster a sense of should be
ownership customized to
- Use super- reflect current
users who can safety needs that
influence their require
coworkers to improvement
avoid conscious -Ongoing
deviation from training will
adherence to help reeducate
using an users on the
evidence-based goals and
tool objectives of the
tool
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Table C3

Process step #3 of FMEA

Process Step 1 Process Step Right intervention format – Use customized EHR alert
#3 thresholds or tier system i.e. passive, soft, and hard
stop alerts
2 Potential Failure Ignoring critical Delay in care Overriding
Mode notifications alerts for critical
that can lead to issues can lead
patient harm to patient harm
3 Potential Desensitization Increase in Lack of
Cause(s) to critical alerts time-to-order customizing
from low- and time-to- alerts to
priority completion for distinguish
notifications specified tasks simple
reminders or
notifications
from critical
ones
4 Severity 6 7 6

5 Probability Frequent Frequent Frequent

6 Hazard Score 8 12 8

7 Action Control Control Control

(Eliminate,
Control, or
Accept)
8 Description of -Use a tier -Monitor the -Ongoing
Action system and efficiency of the training to
customize tool to make educate CPOE
alerts/notificatio improvements users on usage
ns to the degree that support of the CDS tool
of criticality to more efficient to support
help decrease patient informed
alert fatigue and management decision-making
desensitization -Customize -Use a tier
-Improve the notifications to system to
CPOE interface lessen workflow customize
to support interruptions notifications to
features that do -User feedback the degree of
not interrupt will help criticality
workflow determine how -Monitor the
-Elicit user the tool can be tool to
feedback to improved to determine which
improve the tool support task alerts are
completion and commonly
efficiency overridden to
revise or
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improve on the
notification
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Table C4

Process step #4 of FMEA

Process Step 1 Process Step

#4 Right monitoring tool – CPOE CDS tool evaluation

2 Potential Failure Users not using CDS tool does Lack of buy-in
Mode CDS tool to not reflect user from users who
improve patient needs and choose not to
safety therefore does use the CDS
not promote tool potentially
patient safety negating patient
safety
3 Potential Lack of user Lack of specific Different
Cause(s) feedback goals and visions or ideas
objectives on the function
during CDS tool of the CDS tool
implementation
4 Severity 4 4 4

5 Probability Occasional Occasional Frequent

6 Hazard Score 3 3 4

7 Action Control Control Control

(Eliminate,
Control, or
Accept)
8 Description of -Eliciting user -Monitor -Involve the
Action feedback on an effectiveness of CPOE users in
ongoing basis the tool on the CDS tool
- Ongoing current patient development
training on the safety and updates to
goals and -Elicit user help promote
objectives feedback to buy-in of the
-Using super- customize the tool
users to provide tool -Use super-users
peer influence -Create user to provide peer
friendly and influence
intuitive -Ongoing
workflow with training and user
customized feedback
alerts
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Table C5

Process step #5 of FMEA

Process Step 1 Process Step Right maintenance of CDS tool – Regular upgrades to
#5 reflect specific needs and best practice
2 Potential Failure CDS tool does Users reject CDS tool
Mode not reflect CDS tool upgrade does
specific needs potentially not reflect
or best practice increasing ongoing user
that supports patient safety needs and
patient safety events negates
improving
patient safety
3 Potential Inadequate Change Poor user
Cause(s) resources resistance from feedback and
too many or inefficient
constant updates monitoring of
CDS tool
negates making
worthwhile
updates
4 Severity 7 6 4
5 Probability Frequent Occasional Occasional

6 Hazard Score 12 6 6

7 Action Eliminate Control Control

(Eliminate,
Control, or
Accept)
8 Description of -Monitor tool -Elicit user -Provide a
Action effectiveness on feedback to variety of
patient safety determine areas feedback tools
-Perform regular requiring (e.g.,
updates improvement anonymous
incorporating -Involve users report or peer
user feedback in maintaining discussion) to
and patient the tool can help elicit adequate
safety needs determine the response
-If the CDS tool ideal frequency -Monitor CDS
does not reflect of updates to tool effect on
best practice and avoid patient safety
does not support information events and
current patient overload initial goals and
safety issues -Provide objectives
and resources ongoing training -Use CPOE
remain sessions that are users in making
unavailable, easily changes to the
then the tool accessible, brief, tool
should be and concise
rescinded.