CRASH 2019 The Relationship Between Wellness, Resilience and Quality Alison Brainard MD, Norah Janosy MD, Melanie Donnelly MD February, 2018

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1 Objectives CRASH 2019 The Relationship Between Wellness, Resilience and Quality Alison Brainard MD, Norah Janosy MD, Melanie Donnelly MD February, 2018 Understand burnout the features, risk factors, signs and symptoms Understand the connection between provider wellness, quality and safety culture Experience resilience techniques that are shown to decrease burnout and increase resilience Investigate the national and regional available resources surrounding quality improvement and wellness Develop an unexpected event algorithm for your own institution Using the tools, develop an outline of an initial PDSA cycle meant to address the problem of burnout 1 2 Overview Introductions Literature Overview of Burnout, 2 nd Victim, and Quality Improvement Use of Root Cause Analysis /Fishbone, PDSA cycle to address Burnout Individual Assessments, Institutional Algorithms Individual Resilience Techniques 3 4 Acknowledgments How do you define burnout? Jenny Reese, MD Abbie Beacham, PhD Vesna Jevtovic Todorovic, MD, PhD, MBA 5 6

2 Burnout Burnout is the sum total of hundreds of tiny betrayals of purpose, each one so minute that it hardly attracts notice. Richard Gunderman, MD, PhD Broader consequences of working in a stressful environment Emotional Exhaustion Depersonalization Reduced sense of accomplishment and achievement 7 8 Maslach et al. Maslach Burnout Inventory Manual, 3 rd edn. Palo Alto, CA: Consulting Psychologists Press 1996 Impact of Burnout in Health Care Medical Error and Mortality 1 3 Impaired professionalism 5,6 Reduced patient satisfaction 7 Staff turnover and reduced hours 8,12 Depression and Suicidal Ideation 9,10 54% of Physicians report at least one symptom of burnout 1 Prevalence 50% of nurses are emotionally exhausted 2 2 in 3 have difficulty sleeping 1 in 4 are clinically depressed Motor vehicle crashes and near misses 11 1 JAMA 296:1071, 2 JAMA 304:1173, 3 JAMA 302:1294, 4 Annals IM 136:358, 5 Annals Surg251:995, 6 JAMA 306:952, 7 Health Psych 12:93, 8 JACS 212:421, 9 Annals IM 149:334, 10 Arch Surg146:54, 11 Mayo ClinProc2012, 12 Mayo ClinProc Shanafelt et al. Mayo Clin Proc Sexton et al. Palliative Care % Reporting burnout % Satisfied with Work Life Balance Figure 1 Mean burnout increased from 45.8% to 54.4% Satisfied with work life balance decreased from 48.5% to 40.9% Mayo Clin Proc Dec 2015; 90(12): Copyright 2016 Mayo Foundation for Medical Education and Researc Shanafelt et al. Mayo Clin Proc. January 2017;92(1):

3 Key Drivers of Burnout and Engagement Executive Leadership and Physician Well being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Workload and Job Demands What is a second victim? First described by Albert Wu in 2000 Efficiency and resources Meaning in Work Control and Flexibility although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims. Organization culture and values Work life integration Social support and community at work Shanafelt et al. Mayo Clin Proc. January 2017;92(1): Formal definition: A health care provider involved in an unanticipated adverse patient event, medical error and/or a patient related injury who becomes victimized in the sense that the provider is traumatized by the event. (Scott et al., 2009) Schwappach, D L B; Boluarte, T A (2008). The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Medical Weekly, 138(1 2): The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33: Gazoni, Farnaz; Amato, Peter; Malik, Zahra; Durieux, Marcel; MD, PhD Anesthesia & Analgesia. 114(3): , March International Anesthesia Research Society. Published by International Anesthesia Research Society.

4 What happens at your institution? Have you ever? Worked Tired? Not given your patient on the table your full attention? Worked when under family stress? Worked Sick? Had a near miss and done the next case? Asked for help when you were not at your best? Taken call when sick? Had a death in the OR and done the next case? You are in good company we all have...but should we??? So now what. We know that burnout is an adverse outcome for health care providers which we need to address Lets figure out what how to approach this problem in a systematic way First steps.. Step 1: Overall what is our goal. reduce burnout in ourselves and colleagues, focus on improving provider wellness in achievement of the quadruple aim in healthcare, etc Step 2: Literature Review to better understand the problem Step 3:What is current culture surrounding this problem and provide a better definition of the problem. Define problem better: What is the problem exactly and why is it a problem? what is burnout and why do you consider it a problem at all? What is the evidence that this is a problem, local or based on literature? Who are the stakeholders who may have something to gain or lose by addressing this problem? 23 24

5 Leadership Personal Factors Culture/work environment Support Systems/Relationships Resources Stressors Policy and Procedure Personality/Biology Clinical Demands Organizational/ Systemic Factors Individual Factors Next. So 1 we know the problem, 2 we have some literature about the problem 3 we have engaged our stakeholders in defining what factors contribute to the problem What do we want to do to fix the problem.or at least begin to address the problem Step 5:SMART AIM Specific, Measurable, Achievable, Relevant and Time based To do this we need to figure out: What changes can we make which will will result in improvement of the problem based on what we have discovered about the problem and the literature? How will we measure success? What outcome will you use? more to come. SMART AIM We will increase mindfulness by doing 30 minute experiential mindfulness exercises before work once a week for 8 weeks. We will evaluate the impact of this intervention by measuring the Cognitive and Affective Mindfulness Scale (CAMS R) before and after the intervention Step 6: PDSA (plan do study act) How can we measure success in the arena of wellness and burnout? 29 30

6 Subjective Rating of Sleep Quality Please rate your sleep quality over the previous month 0 Very Good Very Bad Buysse, D. J., Reynolds III, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, Perceived Stress Scale 10 Item MINI Z BURNOUT SURVEY AMA STEPS Instructions: The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with a check how often you felt or thought a certain way burnout survey 34 What is Resilience? Resilience Resilience is the process of negotiating, managing and adapting to significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and bouncing back in the face of adversity. Across the life course, the experience of resilience will vary. Windle et al. A methodological review of resilience measurement scales. Health and Quality of Life Outcomes 2011, 9:

7 INDIVIDUAL RESILIENCE Books/Websites/Ted Talk Recommendations Books Kitchen Table Wisdom by Dr. Rachel Naomi Remen Getting Grit by Caroline Angela Miller Grit by Angela Duckworth Websites Soul Pancake Happy MD Ted Talks Angela Duckworth Grit Shawn Achor The Happiness Advantage Kelly McGonigal How to Make Stress Your Friend Recommended Resources CENTILE Rochester Mindfulness Training medicine/mindfulpractice/presentations workshops.aspx International Conference on Physician Health assn.org/events/international conference physician health Georgetown Faculty Training in Mind Body Medicine classes/professionals/faculty training mind bodymedicine/ Culinary Institute of America Mindfulness (Napa)