Long-term impact of evidence-based quality improvement for facilitating medical home implementation on primary care health professional morale

Delivering patient-centered accountable care across enrolled populations requires high functioning primary care practice teams as the basis for prevention, chronic disease care, and links to specialty, hospital, and long-term care [1]. Burnout among primary care providers (PCPs) (defined here as internal medicine and family physicians, physician assistants, or nurse practitioners) and their team members (often referenced as staff) can impede achievement of high functioning primary care [2, 3]. High levels of burnout in clinical teams are associated with poorer quality healthcare and decreased patient safety [4, 5]. In the work presented here, we test an approach, termed evidence-based quality improvement (EBQI), for accelerating change and maintaining morale in six engaged primary care sites during large scale implementation of a new team-based, patient centered primary care model (the patient centered medical home).

Burnout is a complex multi-dimensional condition characterized by emotional exhaustion (EE, the sense of being overwhelmed and exhausted), cynicism (feeling depersonalized and detached from the job), and professional efficacy (the lack of a sense of personal accomplishment related to work goals) [6, 7]. EE is considered to be the most central of the three components, is the most widely reported, and in some studies is the first domain that manifests when the full burnout syndrome is developing [8]. Burnout, and its EE component in particular, can be associated with lowered job satisfaction and increased job turnover [9, 10]. We assess EBQI outcomes based on PCP and staff EE and job satisfaction; we refer to these two concepts as indicators of PCP and staff morale.

Patient-centered medical home models can improve both patient outcomes [11] and provider morale [12, 13]. The model enhances the capabilities of primary care practices by linking all patients to both a continuity PCP and the PCP’s team. In the model, the patients work closely with their assigned PCP and team staff including e.g., a registered nurse, a health technician or licensed practical nurse, and a clerk. They also have access to extended team members that serve several PCP teams, such as a social worker, dietitian, and pharmacist. The model challenges traditional primary care disciplinary roles substantially by depending on strong team integration and functioning, with each member working “at the top of his or her license” [10, 11, 14].

Despite the enthusiasm for the medical home model, the stress inherent in transforming into high functioning, accountable primary care teams [10] runs the risk of increasing provider and staff burnout [9, 10] and reducing morale, thus impeding successful model implementation. The stresses are due not only to new working relationships, but to the many administrative challenges of adapting or replacing administrative systems such as scheduling, information systems, or performance monitoring. Yet it is particularly critical to maintain morale during transformation; falling levels can result in a vicious cycle of higher turnover within a primary care practice, less care continuity for patients, and greater burdens on continuing providers and staff. Just when expertise is most needed, trained team members may be replaced by less experienced professionals, causing continued turnover due to a poor work environment [6].

While much literature has examined the prevalence of burnout [15, 16] and its potential causes, very little has been written about how healthcare organizations might work to reduce it [9, 17]. Engagement in quality improvement has the potential to ease transformation by supporting development of local innovations for addressing transformation problems and for achieving needed care redesigns. Engagement might also empower teams to problem-solve in general, thus reducing feelings of stress, helplessness, and apathy [3] that can lead to burnout. Job satisfaction, in turn, is typically reduced when burnout occurs [18].

The Veterans Health Administration implemented its medical home model (termed Patient Aligned Care Teams, or PACT) nationally beginning in 2010 across its over 900 primary care sites [19, 20]. In addition to continuity team care, the implementation emphasized visit modalities other than face-to-face care, advanced or “open access” appointment scheduling, and new electronic performance measures accessible to sites on dashboards [21]. By engaging practices transforming into the new model in EBQI, a method tested both inside and outside the Veterans Health Administration [22], we aimed both to promote development of a high morale primary care quality improvement culture and to support systems re-engineering during transformation [22‐30]. We previously documented high adherence to the EBQI model among the engaged sites [24]. We also found enhanced adoption of non-face-to-face care in EBQI compared to comparison sites [28]. We know of no prior work examining the impact of EBQI or similar approaches on morale.

EBQI aims to engage front-line clinical teams in developing innovations that reflect interdisciplinary input and are aligned with multi-level healthcare system leadership priorities. In this study, EBQI-engaged primary care sites developed quality councils [25] and participated in workgroups that generated proposals for innovations directed at medical home implementation; innovations are reviewed by regional leaders. Innovation teams discuss their approved projects in across-site telephone meetings and during yearly in person conferences that also engage regional leaders.

We addressed two questions: (1) Was transformation to the patient-centered medical home model associated with improved primary care practice morale (measured as emotional exhaustion and job satisfaction) over time? (2) Did engagement in EBQI improve morale among primary care practice’s providers and staff?

Experts agree that high functioning primary care teams, such as those featured in patient-centered medical home models, are essential for delivery of high value accountable care across enrolled patient populations. Yet achieving transformation to these models is challenging. We examined whether EBQI [24] was effective in reducing PCP/staff burnout [33, 34] or increasing satisfaction during national transformation to the Veterans Health Administration’s medical home model. We used a rigorous quasi-experimental design that compared change over time in intervention clinics (EBQI in the context of the medical home) vs. comparison clinics (medical home alone) within the first five years of transformation. We found a significant EBQI effect on reducing burnout among PCPs, but no significant effect for early EBQI-PACT practices or for late EBQI-PACT practices relative to comparison practices.

Our findings are important because burnout and dissatisfaction are associated with adverse consequences for patient care [21, 36] and with increased job turnover across industries [2, 15, 37, 38]. Worsened burnout and job satisfaction can become acute during transformation to the patient-centered medical home [2], threatening the success of the new model. Only PCPs had significantly reduced EE burnout but not staff. Conversely, job satisfaction was better over time only for staff but not for PCPs. A possible explanation for this finding is that because PCPs have overall responsibility for creating and leading functional teams, their role in PACT is inherently more stressful than for staff which makes them more prone to burnout. This longitudinal observational study is the first to test whether a systematic approach to engaging front-line primary care practices in inter-professional medical home-related quality improvement innovation might ameliorate or reduce burnout and increase job satisfaction during the difficult work of implementing the medical home model.

This study followed PCPs and staff for nearly five years after national patient-centered medical home implementation in Veterans Health Administration, far longer than in previous studies of change in burnout and satisfaction, and began over a year after medical home implementation was nationally mandated in Veterans Health Administration. The study thus spanned the initial five years of medical home transformation. Additionally, unlike most prior work, this study assessed PCPs and staff separately, given that medical home implementation role and task changes are substantially different for PCPs compared to staff [39, 40]. Further, we do not know if the innovation efforts were initiated by PCPs, other types of providers and staff, or with equal input across type of provider/staff. It is possible that the reason we found a positive impact on PCP burnout but not staff burnout is that because most of the innovations were spearheaded by PCPs, the psychological investment was greater for them. Greater psychological investment is likely associated with more engagement in change. Heavier investments, particularly by enthusiastic employees, have been found to have positive associations with a number of work characteristics including less role ambiguity and greater autonomy [41]. Although a few studies have found reductions in burnout over time post-medical home implementation, these have been limited to one or two years [11, 13]. Two years may be too short; one study found that practices that were relatively more successful at implementing the medical home model did so only after more than two years of implementation [42]. Adopting new models of care requires changing the culture of practice and getting past initial change fatigue as well as having an infrastructure that enables transformation [43]. Health systems should consider tracking provider engagement and well-being (including burnout levels) along with standard institutional measures such as cost, quality, and patient satisfaction) [17] following medical home implementation.

Major change takes time and resources, particularly at the organizational level. This is possibly why we did not observe a statistically significant difference between early EBQI and the comparison group for either EE or job satisfaction. National Veterans Health Administration PACT implementation, experienced by both intervention and comparison groups in this study, included a well-documented care model, mandated changes in staffing, time-limited increases in special funding for implementation, data resources including a national dashboard with primary care practice level PACT process measures, web-based tools, redesign collaboratives, and substantial PACT training opportunities for providers and staff. Nevertheless, without EBQI, burnout increased for comparison practices. EBQI appeared to have a protective effect, avoiding significant worsening of morale (burnout and satisfaction) among the early EBQI group and improving it in the late EBQI group.

In a recent meta-analysis of interventions to prevent and reduce physician burnout, West and colleagues [44] identified a total of 15 randomized trials and 37 cohort studies that were relevant. They found that interventions that were focused on the individual as well as interventions that were focused on structural changes or at the organizational-level were associated with clinically meaningful reductions in burnout. The statistical review of these studies is the first step toward understanding how to engage the healthcare workforce in strategies to boost morale and prevent or minimize burnout and improve morale under hyperkinetic circumstances. The EBQI approach used here includes both individual and organizational strategies (i.e., interdisciplinary leadership participation, management assistance from quality council coordinators, and technical assistance from improvement laboratory researchers) by engaging individual providers as well as administrators and leadership in the transformation process. The approach emphasizes psychological factors that can make adaptation to change a more positive experience [45, 46]. It also emphasizes using systematic, interdisciplinary, organizationally aligned redesign to solve the inevitable issues arising from transformation. The redesign efforts used local innovation, formal quality improvement methods, outcome measures, and tool-based spread. Our findings suggest that the EBQI approach holds promise for putting the joy back into practice [3], as well as for more rapid implementation of medical home features [28].

Our study has a number of important limitations warranting caution in interpreting results. First, our design was quasi-experimental; participating medical center-based network leaders chose EBQI practices for a variety of reasons. Our repeated measures analyses and covariates control for major differences between EBQI and comparison practices at baseline. However, our sample size limited our ability to control for all possible differences and effects of unmeasured variables cannot be ruled out. Our restricted sample size also prevented disaggregating the sample staff to examine specific experiences of mental health providers or pharmacists. Also, while our self-report burnout measure could be biased, we would expect this effect to influence baseline as well as follow-up results. Additionally, we measured burnout based on only the emotional exhaustion subscale of the Maslach burnout inventory; we did not administer the other two subscales at waves 2 and 3. Our previous analyses of wave 1 data indicated that the emotional exhaustion subscale was highly correlated with the other two Maslach subscales (cynicism and professional efficacy) and more sensitive to variations in PACT.

Engaging PCPs and staff in EBQI reduced burnout over time during medical home transformation. Observed effects may have been due to more rapid solving of medical home-related problems and challenges through system redesign or the other types of quality improvement innovations undertaken by EBQI practices, including innovations directly aimed at addressing burnout. They may also have been due to increased engagement of PCPs and staff in medical home implementation. Healthcare systems should consider EBQI as a systematic method for assisting with large organizational changes, such as medical home implementation.