Burnout and the role of authentic leadership in academic medicine.

BACKGROUND: Recently, there has been increasing evidence that reducing burnout in healthcare providers requires significant organizational efforts that include the integration of leadership strategies. METHODS: Focus groups were conducted across four health systems within the University of Colorado Department of Medicine in four affinity groups (administrative staff, medical trainees, research faculty, and clinical faculty). Authentic leadership theory was used for analysis to advance the understanding of the role of leadership style upon participants' work experiences and preferences, and to identify opportunities for translation of site-specific results to other academic medical settings. RESULTS: Study participants from each affinity group believed their clinical leaders lacked objectivity with decision-making (lacking "balancing processing"), which contributed to their overall feeling of powerlessness. The experience of increasing work demands was salient throughout all twelve focus groups, and participants identified leadership that interacted in a more open and self-disclosing manner ("relational transparency") as alleviating at least some of this burden. Strong preference discernable alignment between their leaders' decision-making and their internal moral compass of values (demonstrating "internalized moral perspective") was described, as was clinical leaders demonstrating "self-awareness" (having a self-reflective process that informs the leader's decision-making). Comparing affinity group experiences within each authentic leadership theory construct identified the relevance of contextual factors, such as work setting and roles, upon employees' perceptions and expectations of their leaders. CONCLUSIONS: Use of authentic leadership theory advanced the understanding of the association between leadership traits and experiences of burnout amongst a large group of academic clinicians, researchers, trainees, and administrative staff. Leadership styles that promoted relationship transparency, openness, and support were preferred and fostering these traits may help address the demands in academic medicine, including symptoms of burnout.

Implementation and operation of incident learning across a newly-created health system.

PURPOSE: The purpose of this work is to describe our experience launching an expanded incident learning system for patient safety and quality that takes into account aspects beyond therapeutic dose delivery, specifically imaging/simulation incidents, medical care incidents, and operational issues. METHODS: Our ILS was designed for a newly created health system comprised of a midsized academic hospital and two smaller community hospitals. The main design goal was to create a highly sensitive system to capture as much information throughout the department as possible. Reports were classified according to incidents and near misses involving therapeutic radiation, imaging/simulation, and patient care (not involving radiation), unsafe conditions, operational issues, and accolades/suggestions. Reports were analyzed according to impact on various steps in the process of care. Actions made in response to reports were assessed and characterized by intervention reliability. RESULTS: A total of 1125 reports were submitted in the first 23 months. For all three departments, therapeutic radiation incidents and near misses consisted of less than one-third of all reports submitted. For the midsized academic department, operational issues and unsafe conditions comprised the largest percentage of reports (70%). Although the majority of reports impacted steps related to the technical aspects of treatment (simulation, planning, and treatment delivery), 20% impacted other steps such as scheduling or clinic visits. More than 160 actions were performed in response to reports. Of these actions, 63 were quality improvement interventions to improve practices, while 97 were learning actions for raising awareness. CONCLUSIONS: We have developed an ILS that identifies issues related to the entire process of care delivery in radiation oncology, as evidenced by frequent and varied reported events. By identifying a broad spectrum of issues in a department, opportunities for improvement can be identified.

The Institute for Health care Quality, Safety, and Efficiency: A Comprehensive Approach to Improving Organization-Level Quality Performance.

Despite decades of effort to drive quality improvement, many health care organizations still struggle to optimize their performance on quality metrics. The advent of publicly reported quality rankings and ratings allows for greater visibility of overall organizational performance, but has not provided a roadmap for sustained improvement in these assessments. Most quality training programs have focused on developing knowledge and skills in pursuit of individual and project-level improvements. To date, no training program has been associated with improvements in overall organization-level, publicly reported measures. In 2012, the Institute for Health care Quality, Safety, and Efficiency was launched, which is an integrated set of quality and safety training programs, with a focus on leadership development and support of performance improvement through data analytics and intensive coaching. This effort has trained nearly 2000 individuals and has been associated with significant improvement in organization-level quality rankings and ratings, offering a framework for organizations seeking systematic, long-term improvement.

Perspectives on Patient Experience: A National Survey of Hospitalists.

Despite efforts to improve patient experience (PX), little is known about the perspective of hospitalists regarding PX initiatives and priorities. A survey was distributed to hospitalist groups across the country assessing involvement in PX initiatives and their perceived effectiveness, what PX means to providers, and facilitators/barriers in improving PX. Ninety-nine percent of respondents had encountered some improvement activity around PX. The most prevalent were communication training, group Hospital Consumer Assessment of Healthcare Providers and Systems data, and interdisciplinary bedside rounding. Respondents rated most initiatives a 5 to 6 out of 10 for their effectiveness, with the perception of effectiveness increasing with respondents' assessment of patient experience priority. Learning about others' experiences in improving PX and learning about potential collaborations for quality improvement or research in these areas were areas of interest for future work. Qualitative work highlighted potential barriers in improving PX such as workload and staffing constraints, uncontrollable environmental factors, and unrealistic patient expectations. Improving PX is a priority, and there are many initiatives in place with perceived variable success and perceived barriers in improving PX.

Optimization Sprints: Improving Clinician Satisfaction and Teamwork by Rapidly Reducing Electronic Health Record Burden.

OBJECTIVE: To evaluate a novel clinic-focused Sprint process (an intensive team-based intervention) to optimize electronic health record (EHR) efficiency. METHODS: An 11-member team including 1 project manager, 1 physician informaticist, 1 nurse informaticist, 4 EHR analysts, and 4 trainers worked in conjunction with clinic leaders to conduct on-site EHR and workflow optimization for 2 weeks. The Sprint intervention included clinician and staff EHR training, building specialty-specific EHR tools, and redesigning teamwork. We used Agile project management principles to prioritize and track optimization requests. We surveyed clinicians about EHR burden, satisfaction with EHR, teamwork, and burnout 60 days before and 2 weeks after Sprint. We describe the curriculum, pre-Sprint planning, survey instruments, daily schedule, and strategies for clinician engagement. RESULTS: We report the results of Sprint in 6 clinics. With the use of the Net Promoter Score, clinician satisfaction with the EHR increased from -15 to +12 (-100 [worst] to +100 [best]). The Net Promoter Score for Sprint was +52. Perceptions of "We provide excellent care with the EHR," "Our clinic's use of the EHR has improved," and "Time spent charting" all improved. We report clinician satisfaction with specific Sprint activities. The percentage of clinicians endorsing burnout was 39% (47/119) before and 34% (37/107) after the intervention. Response rates to the survey questions were 47% (97/205) to 61% (89/145). CONCLUSION: The EHR optimization Sprint is highly recommended by clinicians and improves teamwork and satisfaction with the EHR. Key members of the Sprint team as well as effective local clinic leaders are crucial to success.

Training Residents in Hospital Medicine: The Hospitalist Elective National Survey.

As the field of hospital medicine expands, internal medicine residency programs can play a role in preparing future hospitalists. To date, little is known of the prevalence and characteristics of hospitalist-focused resident rotations. We surveyed the largest 100 Internal Medicine Residency Programs to better understand the prevalence, objectives, and structure of hospitalist-focused rotations in the United States. Residency leaders from 82 programs responded (82%). The prevalence of hospitalist-focused rotations was 50% (41/82) with an additional 9 programs (11%) planning to start one. Of these 41 rotations, 85% were elective rotations and 15% were mandatory rotations. Rotations involved clinical responsibilities, and most programs incorporated nonclinical curricular activities such as teaching, research, and work on quality improvement and patient safety. Respondents noted that their programs promoted autonomy, mentorship, and "real-world" hospitalist experience. Hospitalist-focused rotations may supplement traditional inpatient rotations and teach skills that facilitate the transition from residency to a career in hospital medicine.

What Is Career Success for Academic Hospitalists? A Qualitative Analysis of Early-Career Faculty Perspectives.

BACKGROUND: Understanding the concept of career success is critical for hospital medicine groups seeking to create sustainably rewarding faculty positions. Conceptual models of career success describe both extrinsic (compensation and advancement) and intrinsic (career satisfaction and job satisfaction) domains. How hospitalists define career success for themselves is not well understood. In this study, we qualitatively explore perspectives on how early-career clinician-educators define career success. METHODS: We developed a semistructured interview tool of open-ended questions validated by using cognitive interviewing. Transcribed interviews were conducted with 17 early-career academic hospitalists from 3 medical centers to thematic saturation. A mixed deductiveinductive, qualitative, analytic approach was used to code and map themes to the theoretical framework. RESULTS: The single most dominant theme participants described was "excitement about daily work," which mapped to the job satisfaction organizing theme. Participants frequently expressed the importance of "being respected and recognized" and "dissemination of work," which were within the career satisfaction organizing theme. The extrinsic organizing themes of advancement and compensation were described as less important contributors to an individual's sense of career success. Ambivalence toward the "academic value of clinical work," "scholarship," and especially "promotion" represented unexpected themes. CONCLUSIONS: The future of academic hospital medicine is predicated upon faculty finding career success. Clinician-educator hospitalists view some traditional markers of career advancement as relevant to success. However, early-career faculty question the importance of some traditional external markers to their personal definitions of success. This work suggests that the selfconcept of career success is complex and may not be captured by traditional academic metrics and milestones.

Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline.

BACKGROUND: Hospital medicine (HM) is rapidly evolving into new clinical and nonclinical roles. Traditional internal medicine (IM) residency training likely does not optimally prepare residents for success in HM. Hospital medicine residency training tracks may offer a preferred method for specialized HM education. METHODS: Internet searches and professional networks were used to identify HM training tracks. Information was gathered from program websites and discussions with track directors. RESULTS: The 11 HM tracks at academic medical centers across the United States focus mostly on senior residents. Track structure and curricular content are determined largely by the structure and curricula of the IM residency programs in which they exist. Almost all tracks feature experiential quality improvement projects. Content on healthcare economics and value is common, and numerous track leaders report this content is expanding from HM tracks into entire residency programs. Tracks also provide opportunities for scholarship and professional development, such as workshops on abstract creation and job procurement skills. Almost all tracks include HM preceptorships as well as rotations within various disciplines of HM. CONCLUSIONS: HM residency training tracks focus largely on quality improvement, health care economics, and professional development. The structures and curricula of these tracks are tightly linked to opportunities within IM residency programs. As HM continues to evolve, these tracks likely will expand to bridge clinical and extra-clinical gaps between traditional IM training and contemporary HM practice. Journal of Hospital Medicine 2017;12:173-176.

Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety.

PROBLEM: The morbidity and mortality (M&M) conference is a vital event that can affect medical education, quality improvement, and peer review in academic departments. Historically, M&M conferences have emphasized cases that highlight diagnostic uncertainty or complex management conundrums. In this report, the authors describe the development, pilot, and refinement of a systems-based M&M conference model that combines the educational and clinical missions of improving quality and patient safety in the University of Colorado Department of Medicine. APPROACH: In 2011, a focused taskforce completed a literature review that informed the development of a framework for the redesigned systems-based M&M conference. The new model included a restructured monthly conference, longitudinal curriculum for residents, and formal channels for interaction with clinical effectiveness departments. Each conference features an in-depth discussion of an adverse event using specific quality improvement tools. Areas for improvement and suggested action items are identified during the conference and delegated to the relevant clinical departments. OUTCOMES: The new process has enabled the review of 27 adverse events over two years. Sixty-three action items were identified, and 33 were pursued. An average of 50 to 60 individuals participate in each conference, including interprofessional and interdisciplinary colleagues. Resident and faculty feedback regarding the new format has been positive, and other departments are starting to adopt this model. NEXT STEPS: A more robust process for identifying and selecting cases to discuss is needed, as is a stable, sufficient mechanism to manage the improvement initiatives that come out of each conference.

Current issues in patient adherence and persistence: focus on anticoagulants for the treatment and prevention of thromboembolism.

Warfarin therapy reduces morbidity and mortality related to thromboembolism. Yet adherence to long-term warfarin therapy remains challenging due to the risks of anticoagulant-associated complications and the burden of monitoring. The aim of this paper is to review determinants of adherence and persistence on long-term anticoagulant therapy for atrial fibrillation and venous thromboembolism. We evaluate what the current literature reveals about the impact of warfarin on quality of life, examine warfarin trial data for patterns of adherence, and summarize known risk factors for warfarin discontinuation. Studies suggest only modest adverse effects of warfarin on quality of life, but highlight the variability of individual lifestyle experiences of patients on warfarin. Interestingly, clinical trials comparing anticoagulant adherence to alternatives (such as aspirin) show that discontinuation rates on warfarin are not consistently higher than in control arms. Observational studies link a number of risk factors to warfarin non-adherence including younger age, male sex, lower stroke risk, poor cognitive function, poverty, and higher educational attainment. In addition to differentiating the relative impact of warfarin-associated complications (such as bleeding) versus the lifestyle burdens of warfarin monitoring on adherence, future investigation should focus on optimizing patient education and enhancing models of physician-patient shared-decision making around anticoagulation.

Bleeding talent: a lesson from industry on embracing physician workforce challenges.

Shortages of both generalist and specialist physicians are intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures, including an aging population, the retirement of thousands of baby-boomer physicians, the growth of nonpractice opportunities for MDs, and physician demands for greater work-life balance. This work posits that the medical profession might benefit from recognizing how progressive nonmedical companies systematically approach similar "talent shortages" through a recruiting and retention strategy called "talent facilitation." It highlights the 4 actions of talent facilitation (attract, engage, develop, and retain) and provides examples of how each action might be utilized to address medicine's recruitment and retention challenges. Although other policy maneuvers are needed to address overall physician workforce shortages (such as the planned opening of more medical schools and changes in the payment system to promote primary care), the talent facilitation approach can help individual organizations meet their needs and those of their patients.

Trends in catheter ablation for atrial fibrillation in the United States.

BACKGROUND: There are few data on the use of catheter ablation for atrial fibrillation (AF) in the United States. We analyzed data from the National Hospital Discharge Survey (NHDS) to examine trends in the rate of catheter ablation for hospitalized patients with AF over a 15-year period. OBJECTIVE: To examine rates of catheter ablation in patients with AF over time. DESIGN: All adult patients in the NHDS with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for AF from the years 1990 to 2005 were identified and assessed for the presence of a cardiac catheter ablation procedure code. Clinical characteristics associated with ablation were identified and multivariable logistic regression used to determine trends in the rate of ablation therapy over time. RESULTS: We identified 269,471 adults with AF. The rate of catheter ablation in AF patients increased from 0.06% in 1990 to 0.79% in 2005 (P < 0.001 for trend). Compared to those not undergoing ablation, ablated patients were younger (mean age 66 versus 76 years; P < 0.001), more likely to be male (57% versus 43%; P < 0.001), have private insurance (22% versus 11%; P < 0.001), and have a none of the following stroke risk factors: congestive heart failure, hypertension, age >75 years, diabetes mellitus, or stroke/transient ischemic attack (37% versus 16%; P < 0.001). Catheter ablation in AF patients increased by 15% per year over the time period (95% confidence interval [CI], 13%-16%) and across all age groups, including in patients age > or =80 years (0.0% in 1990 and 0.26% in 2005; P < 0.001 for trend). CONCLUSIONS: The rate of catheter ablation in patients with AF is increasing significantly over time, even in the oldest patients. Medicine.