Can DPI™ Reduce Provider Burnout?
Improving Provider Satisfaction by Sharing the Care
Significant Contributions from:
Cynthia Countryman, NP
Deanna Renoiso, MD
Timothy Spurrell, MD
Fewer and fewer medical students are choosing to enter practice as primary care providers. One article, entitled In Search of Joy in Practice, citing research on 23, high-performing primary care practices states:
Although waning interest in adult primary care careers is multifactorial, driven by such forces as the primary care – subspecialty income gap, medical schools’ devaluing of primary care and the unsustainable primary care work life issue — one study suggests that the difficult work life may be the most influential factor discouraging medical students from primary care careers.
The article references studies such as Shanafelt’s “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population”.
Pediatrician and Chief Physician Executive, Dr. Deanna Renoiso, stated:
I think a big part of burnout is when you’re ineffective at doing what you thought you would love to do. This can be from the lower level of care you’re giving to your patients or the stress of the day because patients are upset with long cycle times and worse, can’t get in for an appointment. It’s very demoralizing over time. DPI™ helps you sustain the joy in practicing medicine for your entire career.
Coleman Associates’ Dramatic Performance Improvement™, or DPI™, works to improve professional life and provide what is missing in in a physician’s day. We target four main categories where DPI™ can positively influence professional life and thus reduce provider burnout.
- Sharing the Care: building up the working roles of the entire Patient Care Team and medical assistant (MA) as Shepherd of Flow
- Reduction of medical errors
- Focus on goals associated with quality care
- Team communication
1. Sharing the Care
First, DPI™ helps a Patient Care Team Share the Care. This is accomplished through better integration of ancillary staff, such as social workers and dieticians, and amplification of the role of an MA within a team. Shared care allows physicians to move efficiently through patient visits. DPI™ tactics also help train MAs or LVNs (Licensed Vocational Nurses) to be active shepherds of their physician’s day; Dr. Deanna Renoiso stated, “Dramatic Performance Improvement™ deemphasizes the provider-portion of the visit. DPI™ helps you share the visit amongst the entire team to make the day go better.”
The following are the ways in which providers feel most impacted by the elevated roles of their support staff through Sharing the Care.
- MAs Manage Provider Schedule Flow
In order to offer the best care possible, providers need the freedom to be present with and focus on each patient they see. As such, DPI™ places the MA in the role of managing the provider’s day and adjusting the provider’s schedule to allow for additional patients (or not) based on how the flow of the provider’s day. In this way, the MA acts as a “shepherd”, directing the provider based on patient needs and input and information from support staff.
Dr. Timothy Spurrell states:
DPI™ gives providers the freedom to have a predictable day. DPI™ offers clinicians more patient face time. And, the new process keeps doctors away from agonizing clinical decisions. For example, before, I would run an hour late and a patient comes in, they’re complex, and I decide to see them. Then I get out late and miss my kid’s soccer game. Next time, a patient walks in, they’re sick and I decide I can’t see them today. I feel awful, but I get out on time.
DPI™ keeps me away from making that decision. DPI™ keeps me running with a team who supports me and helps you run my day. The team keeps me away from making that decision by figuring it out for me, moving patients around, working in the tricky patients without it getting me behind. DPI™ gives the team ownership and keeps me, as the provider, focused on my patients.
- MAs Help Providers Chart in Real Time
Provider burnout and imbalance between work and personal life can be dramatically impacted by how much work the provider takes home. One of the big advantages of training the MA on your team to be a provider’s shepherd is that the MA becomes the driving force ensuring that the provider charts in real time. This can mean checking in with the provider before they move on to the next patient: “Dr. Jones, are you done with your last chart and ready to hear about your next patient?” If the provider states, “No, not yet,” then the MA states, “Ok, I’ll let you work on that and then come back in a few minutes to tell you about your next patient.” It becomes the team’s responsibility to ensure that timely, daily documentation occurs. This allows the team to end their day together, versus a provider staying to complete their notes long after the MA has left.
2. Reduction of Medical Errors
In the MEMO Study, aka Minimizing Error and Maximizing Outcomes investigation, 420 physicians responded from general and family medicine practices. This longitudinal study drew from physicians in New York, Chicago, and the state of Wisconsin. 38% of respondents described their work as stressful, 27% noted burnout symptoms, and 31% of respondents said they were at least moderately likely to leave their job within two years. The study concluded that “physician stress is prevalent in primary care and stress and the tendency to err are associated with different aspects of organizational climate and the pace of the office environment.” Further, “the tendency to make mistakes was associated with a lack of emphasis on quality, information and communication.”
Quality is strongly influenced and improved when multiple sets of eyes are on each patient and their medical record. Further, an MA’s involvement in pre-visit planning tees the provider up to perform exams and authorize referrals and other laboratory testing associated with preventative care.
Pre-visit planning and the Patient Care Team Daily Huddle decrease the amount of work a provider must do to organize their day and instead relies on the MA to report out patient needs each morning. This positions the provider to add input, give instructions, and ask follow-up questions. Better yet, providers get a head start on visit notes, lab orders, and medication refills at the beginning of the day.
3. Focus on Goals Associated with Primary Care
In the MEMO Study, physicians were more likely to report prior year errors in offices where quality was not emphasized. DPI™ focuses strongly on quality and operational metrics. Data is reviewed daily and reported weekly on banners publicly hanging in clinic walls as well as in newsletters disseminated to the organization. The data focus on metrics associated with quality care–such as patient satisfaction, access to care, and specific quality metrics such as well-controlled diabetics by way of A1C scores. This focus on quality, in turn, leads to a more focused and effective practice.
One Indian Health Services (IHS) clinic in Northern California, trained by Coleman Associates in 2014, vastly improved their quality metrics measures, referred to as GPRA (Government Performance and Results Act), amongst IHS clinics. The clinic publicly posted a summary of weekly quality data for all patients being seen that week. They focused on three measures: cervical cancer screening, tobacco cessation education, and pneumococcal vaccination for adults over the age of 65. Each week, the clinic posted the results of the three measures, which were displayed as a percentage score. The numerator showed the number of patients who received the service or screening, and the denominator showed the total number of patients coming in that week who were due for each service. The Patient Care Team with the highest overall percentage score received free lunch the following week. This public posting of quality data vastly improved this IHS clinic’s GPRA measures and catapulted them as one of the premier Indian Health Clinics in California.
4. Team Communication
The combination of strategic visit planning and an increased MA role not only supports quality care, it helps reduce medical errors through increased and structured verbal communication, thereby reducing the risk of overlooking a medication refill, abnormal lab result, or unaddressed symptom. While more research exists in studies about the failure of hospital communication during handovers, the same principles apply to outpatient care.
In an evaluation by the Joint Commission in 2005, it was found that “more than 3,000 root-cause analyses of reported error data revealed that nearly 70 percent of sentinel events in accredited healthcare entities result from communication failures” (Joint Commission International Center for Patient Safety, 2006). While this is an extreme case of inpatients being transferred across providers or medical teams, the same can be true of the transfer of information between MA to provider, provider to nurse, or provider back to MA. Each handoff increases the likelihood that critical information will be missed, leading to possible error.
In Indianapolis, one large, hospital-based organization went through a DPI™ Collaborative over the course of 10 months, spanning 2017-2018. One year after the Collaborative, Cynthia Countryman, NP said:
Now I trust my team to carry me through the day and help take care of patients. If my team can contribute their piece, it’s taking a piece off of my plate. Now I can focus on what is really important. The Robust Intake, the Robust Confirmation Calls, if those are done, I can now pick the top three things that I need to focus on because my team has taken care of the rest of it.
The following structured communication tactics of Robust Intake, 30-Second Reports, Midway Knocks, and Red Carpet Exits can reduce the likelihood of medical error through handoff in out-patient primary care between support staff and the provider. This can reduce provider burnout and the toil that errors take on a provider’s overall wellbeing and performance.
- Robust Intake: A robust workup of the patient by the MA or support staff before the provider enters the room. Rather than simply taking vitals, asking for preferred pharmacy, or reconciling medications, the MA goes a step further, obtaining additional information from the patient to help prep the provider prior to entering the exam room. For example, often an MA will ask, “I see you’re coming in for your physical, is there anything else you want to tell Dr. Kay?” The Patient answers, “I fell and have some arm pain.” Instead of simply adding an additional chief complaint, the MA asks follow-up questions: “When did you fall? Which arm? Can you show me where you hurt your arm? Did you go to the ER? Which one? Do you have pain? On a scale of 1-10, how much pain? Do you take anything that relieves the pain?” Now the MA is armed with a wealth of information with which to prep the provider within the HPI (History of Present Illness) portion of the visit notes or during the 30-Second Report.
- 30-Second Report: A brief, expected communication between MA and provider serving as a debrief about the patient before the provider enters the exam room. Instead of beginning the visit with, “What brings you here today?” the provider can pick up right where the MA left off with the patient: “I hear that you need a refill of your blood pressure medication today. Olga also shared that you fell and have some lingering right arm pain. I’m so sorry that happened and that it hurts so much. Can I take a look?”
- Midway Knock: Often, providers come out of exam rooms searching for their MA. Sometimes it is because the provider needs labs drawn, or a vaccine performed but at other—less fortunate—times it is to request a missing instrument, such as a speculum or an oversized BP cuff. The Midway Knock helps prevent embarrassing occurrences like these, which can damage a provider’s image in terms of bedside manner. The Midway Knock comes at roughly the halfway point in the visit and provides a timely check-in to ensure that both provider and patient can successfully complete their visit. Per protocol, the MA knocks briefly, waits for an ‘ok’, and then enters the exam room to receive instruction on what the patient and provider need before stepping back out.
- Red Carpet Exit: A structured, customer-experience-driven exit for the patient that leaves them feeling as though all questions were answered, follow-up appointments made, and referrals explained. Rather than have the patient leave the room after the provider is through, the MA or nurse returns to escort the patient out. During the exit, the MA or nurse clarifies what the patient has understood during their visit with the provider and articulates next steps to ensure that the patient leaves with a thorough understanding of the visit, and with answers to any outstanding questions. The Red Carpet Exit promotes referral compliance and reduces the number of patient phone calls associated with medical questions following a visit.
When asked about provider burnout following DPI™, Dr. Deanna Renoiso asked us to share a big piece of advice with providers:
Providers’ jobs will only change for the better. But providers must be on board to allow others to grow. To realize the benefits of a team, it takes trusting in your team. A provider can’t expect their MA to be able to support them at a high level unless the provider helps them grow into that. Help your MA enjoy the reason why they got into medicine as well. Share the joys of what it is to practice medicine.
Primary care provider numbers are dwindling, but the number of patients requiring primary care is not. We need to continue to foster the health and well-being of providers in America to prevent the loss of more good clinicians to burnout, frustration with chaotic work environments, and poor systems. Doing so is vital to our patients’ safety and well-being. DPI™ reduces provider burnout when care is shared amongst the team, and when support staff roles are elevated to support the management of a provider’s day.
 Sinksy, Christine, MD. Willard-Grace, Rachel, MPH. Schutzbank, Andrew, MD. “In Search of Joy in Practice: A Report of 23 High Functioning Primary Care Practices.” Annals of Family Medicine. www.annfammed.org Vol 11, No. 3, May/June, 2013.
 Linzer, Mark, “Organization Climate, Stress, and Error in Primary Care: The Memo Study.”
 Linzer, Mark, “Organization Climate, Stress and Error in Primary Care: The Memo Study.”
 Institute of Medicine (US) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety; Ulmer C, Miller Wolman D, Johns MME, editors. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington (DC): National Academies Press (US); 2009. 8, System Strategies to Improve Patient Safety and Error Prevention.