Warning sounded on demoralized health care work force
■ Many medical work environments are unsafe for health professionals, adding stress and distraction that can expose patients to harm.
The experience of working in American health care is being drained of joy and meaning amid a rising rate of occupational injuries, episodes of verbal abuse and physical assaults from colleagues, and a seemingly relentless drive to provide more care in less time.
This toxic blend is setting back the effort to improve the quality of care and prevent patient harm, according to a recently published report produced by some of the most distinguished names in the field of patient safety.
“Production and cost pressures have reduced complex, intimate, caregiving relationships into a series of demanding tasks performed under severe time constraints,” said the report, released by the National Patient Safety Foundation's Lucian Leape Institute.
The institute is named for its chair, Lucian L. Leape, MD, a preeminent patient safety researcher. He said all health professionals deserve to be treated with respect, given the resources they need to do their jobs well, and be recognized for the work they do. Health care organizations where those basic needs are not met are impeding progress in patient safety.
“To the extent that people are unhappy in their work, or feel unappreciated or disrespected, they are less likely to be focusing entirely on patients and on making sure they do everything correctly, following the safe procedures and not cutting corners,” said Dr. Leape, adjunct professor of health policy at the Harvard School of Public Health in Boston.
The injury rate in health care is 5.6 per 100 full-time employees, 33% higher than the rate for all of private industry, said the institute's March report, “Through the Eyes of the Workforce.” Musculoskeletal injuries related to lifting and moving patients are the leading culprits. Many health professionals also are improperly exposed to infected patients and bloodborne pathogens.
“One of the ways you show respect for people working health care is by paying attention to the basic safety of the workplace,” Dr. Leape said. “It's really horrendous that the delivery of health care, in hospitals specifically, is one of the most hazardous places to work in the country.”
What causes disruptive behavior
The institute's report says health care organizations should track worker injuries carefully, find out what is causing them and aim to eliminate them. The report also highlights the lingering problem of disruptive behavior in health care, which can create a culture of fear and intimidation that inhibits safe, high-quality care.
Seven in 10 doctors see disruptive behavior at their institutions at least once a month, and 11% said such outbursts happen daily, according to a May 2011 survey released by the American College of Physician Executives and QuantiaMD, an online physician education provider. The physician respondents said the leading cause of disruptive behavior is a heavy workload, one of several recent examples illustrating how severe time constraints in health care are harming collegiality, quality and safety.
For example, a Feb. 25 study in JAMA Internal Medicine, formerly Archives of Internal Medicine, found that about 80% of misdiagnoses at five primary care clinics were related to problems in the patient encounter, such as errors during the physical exam and medical history-taking. The study's lead author said shorter office visits are a principal contributor to diagnostic errors.
Meanwhile, a May 2012 Agency for Health Care Research and Quality report found that more than 70% of doctors and others working in medical offices feel rushed when taking care of patients. Nearly half of physicians report experiencing at least one symptom of burnout, said a nationwide survey of 7,288 doctors in the Aug. 20, 2012, JAMA Internal Medicine.
Creating a culture of civility
Health care organizations hoping to prevent disruptive behavior, reduce physician stress and improve care quality should target heavy workloads and time-constrained care, said Alan H. Rosenstein, MD, who was not involved in the Leape Institute report.
“Over the years, physicians and nurses have worked harder and harder and nobody thought much about it, because they were able to do it without breaking. Now they're starting to break,” said Dr. Rosenstein, a leading researcher on disruptive behavior and medical director of Physician Wellness Services, a firm that provides employee-assistance programs to hospitals and health systems.
Health care leaders should offer extra help in the form of clerical assistance, nurse practitioners and physician assistants to stressed physicians, he said.
The Leape Institute report recommends that health care organizations commit to creating a culture that values civility and transparency. That includes using evidence-based management skills that improve an organization's reliability, communication and teamwork; offering wellness and peer-support programs; and sharing quality and safety data to encourage problem-solving instead of finger-pointing.
Some health systems are on the right track, the report said. Seattle's Virginia Mason Medical Center has employed car manufacturer Toyota's lean production model to cut waste that makes health professionals' jobs harder and distracts from patient care. Process changes cut steps walked per day from 10,000 to about 1,200 and increased the share of time nurses spend with patients from 35% to more than 95%. In 2012, Virginia Mason implemented a tool to track and quantify the costs related to health worker injuries.
“We have the means to create a positive work environment that then becomes a milieu where people can do their very best work on behalf of our patients,” said Gary Kaplan, MD, Virginia Mason's CEO and a member of the Leape Institute's board. “If we have staff including physicians and nurses feeling overwhelmed, burned out, beaten down, I think the ability to deliver we what we aspire to — zero-defect care — becomes very, very problematic.”