Ease of Work and Practice Efficiency
Burnout among physicians, advanced practice providers, registered nurses and other clinicians is an occupational syndrome driven by the realities of our work environment. According to data collected by the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience, over one-half of clinicians experience symptoms of burnout during their careers. In order to tackle burnout, we must recognize it is not primarily a personal resiliency issue, but instead woven into the conditions of work. Personal resilience and attention to one’s individual health are critically important to overcoming burnout, but this is only part of the well-being equation.
Work efficiency — our ability to do the jobs we are meant to do with the least amount of wasted time or effort — has a big impact on our overall well-being in the workplace. Its absence leads to frustration, delays, lower-quality care and burnout.
Below is the first of a series of conversations across JHM with colleagues who are tackling barriers to efficient work. In all cases, they seek to combat unwanted outcomes and promote greater professional fulfillment and high-quality care. This first conversation is with Pamela T. Johnson, MD, FACR, Vice President of Care Transformation.
In order to address the factors that contribute to burnout for our own clinicians, the Johns Hopkins Office of Well-Being is collaborating with partners across Johns Hopkins Medicine to look at systems, processes, and practices that promote the well-being of our clinical faculty and staff. And we are working to mitigate the things that get in the way of professional fulfillment and work life balance.
In addition to our work within Johns Hopkins Medicine, we have joined the Healthcare Professional Well-being Academic Consortium (PWAC), which enables us to collaborate, share interventions and benchmark data with peer institutions across the country. We are also part of the Leadership & Working Group for the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.
Efficiency of Practice Resources
The Steps Forward program contains a diverse set of toolkits addressing the organizational and individual factors affecting health worker well-being. The toolkits offer strategies to engage health system leadership, understand and address health worker burnout, as well as plans for developing a culture that supports well-being.
The NAM Clinician Well-Being Collaborative is working urgently to deliver a National Plan for health workforce well-being, and recently released a draft plan for public input. The National Plan will build on almost six years of collective work among NAM’s network of 200 organizations committed to reversing trends in health worker burnout.
The Institute is partnering with worldwide experts to offer online courses and coaching to combat the epidemic of health worker burnout. The course shares quality improvement methods to create positive work environments that stimulate collaboration and equity among health professionals while delivering high-quality care, even in stressful times.
This Advisory contains steps that different stakeholders can take together to address health worker burnout. It calls for change in the systems, structures, and cultures that shape health care. Given the nature and complexity of the challenges outlined, this Advisory is not intended to be comprehensive in its recommendations.
Highlighted Projects and Collaborations at Johns Hopkins
A work efficiency initiative that brings Epic experts to individual hospital clinics for two weeks of focused team-based and one-to-one training. The Sprints are designed so that people are get relevant training in the production environment, with solutions tailored to their needs. The program, modeled after one at the University in Colorado, was piloted in General Internal Medicine at Green Spring Station in June 2021, and will be rolled out in Neurology in the coming months.
The Office of Care Transformation directs performance improvement programs across Johns Hopkins Health System designed to increase the effectiveness, efficiency, consistency, and affordability of health care delivery for patients and providers. Through a programmatic and disciplined strategy, the Vice President of Care Transformation engages front-line health care providers to implement initiatives that eliminate barriers to care delivery, facilitate evidence-based practice, and harmonize system-wide practice standards.
Care Transformation programs include the Providers Aligned in Care Transformation (PACT) initiative. Through PACT, the Office of Care Transformation and Armstrong Institute engage multidisciplinary clinical teams to design and implement performance improvement solutions to “make Hopkins easy”, with resources that include evidence-based guidelines fully integrated in the EHR. The craniotomy and cardiac catheterization services recently participated in PACT. During their eight-month partnership, the clinical teams redesigned their care to increase effectiveness, which included scheduling and performing procedures more efficiently, providing better outcomes through patient education, and improving the patient and provider experience. If your clinical team is interested in leveraging PACT, contact Pamela Johnson and Rebecca Stone.
Learn more (JHED required)
The medical transcription software was one of the first initiatives announced by JHMto improve work efficiency, and now has about 1,500 consistent users. Clinicians say the voice recognition tool seamlessly transcribes in Epic in real time, creating a work day that is more efficient and focused on patients.
The volume of in-basket messages has grown exponentially over the past few years, and has become a source of burnout. To address this, Johns Hopkins created the Great 8 optimization initiative, providing training for clinicians to help them more efficiently manage MyChart communication. Over a one hour training clinicians learn how to categorize common Basket tasks into 8 efficient workflows to improve collaboration among teams and accuracy of patient responses. Current goals aim for all ambulatory physicians/practitioners, department managers and leaders, and clinical/nonclinical staff who use Epic to be trained in the Great 8 process by December of 2022.
The Johns Hopkins Medicine Office of Well-Being is pleased to offer a small grant/practice innovation program to address workplace efficiency challenges and help our teams decrease the burdens that get in the way of joy in health care. The purpose of this program is to support clinician-driven, organization-directed interventions that support efficiency of practice.
Johns Hopkins Medicine Well-Being Research
Joy in Medicine Task Force
Learn about the Joy in Medicine Task Force and Access the Report (JHED required)
Office of Care Transformation - Priorities to Improve Clinician Experience and Productivity:
- Facilitate evidence-based practice through point-of-care guidance
- Reduce workflow disruptions & deficiencies ("pain points")
- Partner with health plans to ease prior authorization burdens
What is the role of the Office of Care Transformation?
The Office of Care Transformation directs various initiatives that enable care delivery teams to improve clinical effectiveness and efficiency. The mission is to facilitate consistent, evidence-based practice, deliver better patient outcomes at a lower cost, enhance the patient and clinician experience, reduce barriers to care delivery and harmonize practice standards across the system.
What are one or two challenges your team has taken on so far?
Advancing evidence-based imaging across Johns Hopkins.
In 2014, the Center for Medicare and Medicaid Services (CMS) mandated that all ordering clinicians in the emergency medicine and outpatient clinics use an approved clinical decision support, or CDS, tool when ordering advanced imaging. Johns Hopkins Medicine piloted a commercial tool for several years but it added workflow burden for our providers without improving patient care. In response, the care transformation team designed an ambitious initiative to allow Johns Hopkins clinicians to control our standard of care for advanced imaging while minimizing workflow disruptions.
After obtaining the necessary designation by CMS, we engaged a large team of Johns Hopkins clinicians to create evidence-based guidelines embedded in Epic workflow for CMS’ eight priority clinical areas —headache, neck pain, low back pain, shoulder pain, hip pain, coronary artery disease, pulmonary embolism and lung cancer. Clinicians can consult guidelines to aid in management decision making. For direct imaging orders, our solution reduced interruptions during the ordering process from 100% for CT and MRI orders to under 10%. Now, when alerts do fire, they are actionable, substantive, and based on high caliber evidence curated by Johns Hopkins clinicians.
In early 2020 when we rolled out the advanced imaging CDS platform in the ambulatory setting, Johns Hopkins Employer Health Programs (EHP) decided to sunset their utilization management program for imaging and rely on our new system for CT and MRI. Doing so helped eliminate the need for prior authorization requirements for those imaging modalities. This is a big win for EHP members and their care providers. Data so far shows that allowing our clinicians to make decisions in conjunction with high quality, point-of-care guidance delivered by the CDS tool has been an effective utilization management program.
What is the next “pain point” that your team is hoping to address?
The advanced-imaging CDS tool that we described above assists with ordering regardless of a patient’s health plan; however, only EHP has allowed use of the tool to eliminate the need for traditional prior authorization. For other health insurance plans, prior authorization is still required, which can result in delays and denials of necessary care. To address this problem, we partnered with Johns Hopkins Health Plans to understand the requirements of traditional plans as pertains to prior authorization and medical necessity, and we are working to enhance the functionality of our CDS platform to meet the expectations of commercial payor processes in real time. Our goal is to create an end-to-end, real-time prior authorization tool* embedded in Epic, eliminating the inefficient prior authorization process for these imaging studies entirely, and then broaden the scope to all other resource utilization (infusions, procedures, etc.).
Who might that impact and how? When will people notice a difference?
Real-time, automated prior authorization coupled with the Johns Hopkins evidence-based guidelines would improve the care experience for patients, first and foremost. Automating this process will also decrease the burden on providers and generate more time for them to directly care for their patients. Approval denials often result from insufficient information transfer to the health plan rather than a test or treatment being unnecessary, which precipitate the request for a peer-to-peer review in the middle of a busy clinical day. Our hope is to ameliorate these barriers through collaboration with the health plans to harmonize rules, point-of-care feedback to clinicians, and more robust means of transmitting clinical data from Epic to the health plan.
For those who might want to learn more about this project or partner with your team on other efforts, where and how can they learn more?
*Disclosure Statement: Under a license agreement between AgileMD and the Johns Hopkins University, Dr. Pamela Johnson and the University are entitled to royalty distributions related to the the AgileMD electronic prior authorization platform. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies