Ten Ways to Help Reduce Frustration and Burnout

Hi fellow CMIOs, CNIOs, and other Clinical Informatics and HealthIT friends,

With all of the recent discussions about 'burnout' (moral injury) among clinicians and other struggles with healthcare technology, I thought I'd take a moment to share some lessons about what you can do to help reduce frustration and burnout, based on my own experiences and lessons I've learned (sometimes the hard way!) over the last sixteen years I've worked in Applied Clinical Informatics. 

10. Worry about the details.

Most providers are acutely aware of the effect of the problem, but not the cause. So when you are looking at workflow problems, try hard to resist the temptation to get overwhelmed with the details - they are very important. You can sometimes tell when people get overwhelmed, because they sometimes say things at meetings like : 

• "You can't boil the ocean!"
• "We can't get too into the weeds here."
• "Let's just look for some quick wins / low-hanging fruit!"
• "Don't fall victim to analysis paralysis!"
• "Perfection is the enemy of good!"
• "We don't have time to plan!"

Unfortunately, anything that prevents important details from being reviewed and discussed can lead to workflow problems, so it helps to set expectations early and accept that details are important - and so you should always look for ways to discuss them easily, openly, and honestly.

9. Have organized, well-developed project intake and project management processes. 

Healthcare is complicated. The need for change could come from any one of a number of different directions: 

... so you will need to plan for how to manage all of these stakeholders above. Developing an organized project intake, prioritization, and management process for all of your stakeholders to participate in will help them to see the big picture, better negotiate conflicts when they arise, and provide transparency to end-users.

8. Have an organized, well-developed change management process. 

People like predictable outcomes. While it might take some time and resources to do :

• formal evaluations of change/project requests, along with...
• the necessary policy/regulatory searches, 
• identification of best practices (e.g. through literature search, site visits, and interviews), 
• current-state/future-state ('gap') analysis, 
• design of organized blueprints, and ...
• proper identification of stakeholders and deliverables, 

... but it always pays off in smooth workflows, smooth implementations, predictable outcomes, and happy users/patients. So the answer is not to skip these necessary analysis and planning steps - The answer is to have a clear, consistent, well-developed, and well-supported change management process that - not unlike a factory assembly line - lets you accomplish all of these important steps in a smooth, well-oiled process throughout the intake, analysis, design, build, approval, training, implementation, and support phases of your projects.

7. Have standardized definitions and templates for common tools (both inside and outside the EMR).

Creating an organizational glossary (with policy-grade definitions!) and developing standardized templates for common tools will decrease training and development times, increase standardization and functionality, increase predictable outcomes, and improve user satisfaction. A common source of workflow inconsistency happens when development teams focus on developing only the tools inside the EMR (on the right below), while letting someone else worry about the tools outside of your EMR (on the left below) : 

You can help avoid those unnecessary workflow inconsistencies by using both the red and grey lists above (as a checklist!) when identifying the deliverables necessary for your requested clinical workflow implementations/updates. 

6. Worry about document control and standardized document management. 

At first, it might seem like a trivial detail. Most people don't give it much thought, but having a single, centralized catalog (source-of-truth) for all of your important operational documents (policies, procedures, guidelines, protocols, forms, etc.) can help create a great deal of clarity, understanding, and collaboration. As the saying goes, "Control your documents, before they control you." - Without good document control and management, it's easy for project implementations to be delayed and/or result in unexpected outcomes. 

5. For those who write Federal/State regulations - You can help save time and frustration by fully understanding the subject matter, working from clear policy-grade definitions, and writing clearly and succinctly.

Some of the administrative complexities of modern healthcare can result from Federal / State agencies sometimes writing vague regulations, using vague definitions, sometimes with a vague understanding of the clinical workflows and subject matter. So if you write regulations, you can help organizations to save time and reduce administrative costs by using standardized, federal policy-grade definitions and writing regulations that are clear, short, and succinct. You could even help organizations to succeed by writing more than just regulations - Consider other tools necessary for success, such as sample workflows, best practices, educational curriculum, and sample policies : 

Finally, always have a plan for expiring/retiring or updating your regulations - Regulations with no planned expiration date may not get the necessary attention and updates they deserve.

4. Always have clearly written operational policies and procedures. 

Your operational policies are the standards of your organization, and your associated procedures describe how you will achieve those standards. Not only do good policies and procedures create clarity, harmony, and understanding - but they can be used to educate staff, answer questions, and even help plan/design workflows. While some believe the mantra 'don't paint yourself into a corner' , always remember - Good policies help to create clarity, improve understanding, improve accountability, encourage teamwork, and reduce risk of harm or unexpected outcomes.

3. Have an Applied Clinical Informatics team. 

When budgeting for technology, details are important. Total Cost of Ownership (TCO) and Return-on-Investment (ROI) are crucial to make smart business decisions. Applied Clinical Informatics professionals specialize in the analysis, planning, budgeting, design, development, implementation, and monitoring/support of technology implementations. So it's very helpful - if not essential - to have a multidisciplinary team of them available to help you with your most common clinical and business needs : 

... through not just your purchasing decisions, but also for your clinical workflow analysis/designs (#BlueprintsBeforeBuild), complex tickets/projects, special event planning, compliance, maintenance, and other strategic clinical and business needs.

2. Build clear, complete, and consistent order sets.

Physicians spend a lot of time ordering. Order sets connect all of the orders they need for all of their common clinical scenarios. Having inconsistent, incomplete, or unclear order sets only creates frustration, clicks, and unnecessary pages for your physicians. So to help reduce clicks, reduce frustration, and reduce unnecessary pages - you can help ensure your order sets are always clear, complete, and consistent by : 

• Making sure you have a standardized order set template for developing your ordering tools (in a consistent manner).
• Making sure you have the terminology necessary to clearly distinguish your order sets from your other common clinical tools like protocols, guidelines, templates, and clinical pathways.
• Making sure your organizational order set development, approval, implementation, monitoring/support, and update processes are clear, well-defined, and well-supported.
• Making sure you have organized naming conventions for all of your order set types.

1. Empower your clinical leaders. 

Supporting your Physician, Advanced Practice Providers (APPs), Nursing, and Pharmacy leaders might take time, planning, and resources - but expanding their skill set with helpful information about governance, committee chairing, policy writing, operations, finance, and/or project and change management will : 

• give your clinical leaders more satisfaction, understanding, and control of their workflows, while also ...
• empowering them them to play a more active role in problem solving, project development, and project implementation.

Remember - With the necessary Clinical Informatics support, support for/from your clinical leaders, and change and project infrastructure - you too can help create the clarity, harmony, efficiency, and predictable outcomes needed to help fully see the return on your technology investments. 

I hope this blog post helps spur some discussions with your own teams on how to help reduce frustration, reduce burnout, improve planning, improve analysis/design, improve usability, improve participation, and perhaps most importantly - improve patient satisfaction and patient care. 

Remember : This blog is for educational and discussion purposes only - Your mileage may vary! Have any other helpful suggestions for reducing frustration and burnout? Please feel free to leave them in the feedback section below!

Blueprints Before Build

Hi fellow CMIOs, CNIOs, HealthIT, and Clinical Informatics friends,

I'm writing today to talk about burnout, or what's also sometimes referred to as "moral injury".  

In the bigger discussion about healthcare reform, burnout is a hot topic, largely because of the multiple problems it's causing. A number of physicians are leaving the medical field, usually after about 10-15 years in practice, to find non-clinical jobs. 

And it's not just physicians - Nurses, pharmacists, and other clinical staff are feeling the same way. Healthcare is becoming 'too much'. 

When clinical staff leave either their position, or the field entirely, this creates problems for everyone : 

• There is the personal (emotional and sometimes physical/financial) injury to the provider/nurse/pharmacist themselves (and their family)
• There is the replacement cost for that provider/nurse/pharmacist, including a recruiting cost, credentialing/onboarding cost, and training cost, which industry estimates show, together, can cost over $50-$75k to replace a provider.
• There is the industry loss of a talented and hard-working clinical staff member, one that could be helping to care for patients as our country ages and the demand for providers in the next ten years goes up.

I know this topic well because, as a physician, I've been there myself, and personally understand the pain of bad workflows. This is one of the reason I blog about clinical workflow design. While the EMR is often maligned for its contributions to provider burnout, I'd like to share a deeper clinical informatics understanding of where these workflow issues can stem from. 

A. WHAT IS WORKFLOW?

I usually tell people - Workflow is a lot like carbon monoxide. It's silent, invisible, and odorless, but if you don't know about it, it can kill you. 

When discussing workflow with clinical staff, I often get questions like : 

• By workflow, do you mean the way this button in the EMR makes this window open?
• By workflow, do you mean the registration policies of the organization?
• By workflow, do you mean the documentation policies, that are often shaped by payor/insurers?

Workflow is all of the above. 

I've shared this once before, but one of the most well-known leaders in the national discussion about clinical workflow and Business Process Management (BPM) is Charles Webster, MD ( Twitter : @wareflo ) who in 2016 offered this great definition of workflow in his post, "Task workflow and interoperability definitions: Pragmatic interoperability part 2" : 

"Workflow is a series of tasks, consuming resources, achieving goals."

When I train people on workflow design, I usually offer a slightly different definition, that I think still fits with Dr. Webster's definition above, but has a few small distinctions. My definition is below : 

"Workflow is a series of ordered tasks that uses people, time, and resources to achieve a desired goal."

I expanded the definition because I feel it's important to show the relationship between workflow and another important definition - procedures. From Google's definition of procedure : 

What you start to see is that workflows and procedures are, largely, the same thing - They are both essentially your 'recipe for getting things done'. 

How exactly does a healthcare organization get things done? This is an interesting topic. Healthcare operations is a complex dance between people (staff) and their environments. People often think of the EMR as the sole purveyor of workflow issues, but environments and clinical workflows are actually shaped by tools both inside and outside of the EMR : 

Experienced Clinical Informatics professionals know that, when analyzing and fixing workflows, that half of the work is inside the EMR, and half of it is outside the EMR. Alternatively, it's easy to create workflow inconsistencies by only focusing on the tools inside the EMR, or only focusing on the tools outside the EMR. Good workflow depends on synchronizing the tools on both sides of this technology fence. 

B. WHAT IS 'BAD WORKFLOW'?

Bad workflow feels inconsistent. As I started to explain above, bad workflow happens when the procedures of an organization don't fit as seamlessly as they could or should. Especially in healthcare, this can be difficult to manage, since patient care depends on the timely delivery of quality care, 24/7, no holidays or exceptions. In most industries, a 2-hour delay or downtime is tolerable. In healthcare, it is not. 

Bad or incomplete workflow is not easy to find electronically or on paper, but it's easy to spot through clinical staff interviews, or just listening to conversations. Some clinical staff understand workflows enough to recognize workflow issues (and complain about them), but more often you will hear statements like : 

• "Who made that decision?"
• "Why does it take so long to get things done?"
• "Why is it so hard to do the right thing?"
• "I can't keep up."
• "I stay after my shift to get things done."
• "I'm constantly getting paged." (or, "I'm constantly having to page the doctors.")

These are all symptoms of problematic or incomplete workflows. If it takes more than one phone call to schedule a patient, or more than one order to obtain a medication, lots of clicks to get through an order set, or lots of extra documentation to ensure reimbursement from a payor - These are all signs of workflow problems. 

Because so few people talk about workflow design, it's easy to unknowingly create workflow issues by either : 

• Only focusing on tools inside the EMR, or only focusing on tools outside the EMR (as described above)
• Incompletely addressing the workflow (e.g. Only having 80% of the orders needed to admit a patient in your admission order set.)
• Some combination of the above.

C. WHAT IS 'GOOD WORKFLOW'?

Good workflow just feels right. It gives clinical and administrative staff confidence that the right thing is happening. It feels like someone with your specialty configured your EMR, wrote your policies, and trained you. I've even heard it described as a 'leisurely walk down a street, where the things you need pop up in front of you just when you need them - not before, and not after.'

Technically speaking, good workflow means : 

• All of your tools, both inside and outside the EMR, support the same good, evidence-based, best-practice, efficient, and user-friendly workflows. 
• The workflows are completely built out. (Note : Incomplete workflows generate extra telephone calls and pages!!) 

Generating consistently smooth and complete workflows can be difficult, due to the large number of stakeholders that all healthcare organizations have to interact with, all of whom have an impact on the local workflows and configuration : 

Again, it's important to remember that configuration isn't just the tools inside the EMR - The tools outside the EMR are just as important, and should be roughly half of the deliverables of any clinical workflow project.

D. HOW TO BUILD 'GOOD WORKFLOW' 

Building good, smooth, and user-friendly clinical workflows consistently requires strategy, planning, and infrastructure. 

First, you'll want to propose a consistent change-management process, one that has a single point-of-entry (intake process), and follows all the way through to delivery of services and the monitoring and support required after your implementation. I recently started the Twitter hashtag #Blueprintsbeforebuild to try to create awareness of the importance of this change management process : 

The above process shows the sort of rigor and discipline that's needed to help ensure all of the current- and future-state workflows are well-understood, best-practice, cost-effective, and planned for - and that all of the stakeholders and deliverables have been properly identified during the project planning stage. 

Next, you'll need leadership support for this change management process, as well as agreement, both inside and outside of IT, to use the new process - as well as agreement on how to address complex project management situations like urgent or emergent projects that come up from time-to-time.

You'll also need governance, to help balance the needs of the many stakeholders who play a role in shaping your configuration and your workflows, and prioritize projects after they have been properly evaluated, analyzed, and scoped. 

Finally, you'll need a good project intake process, one that helps your directors to submit projects that get evaluated, analyzed, and scoped in a timely basis, before they get prioritized by your agreed-upon governance and leadership.

E. CONCLUSION

If the above seems complicated, you're right - It is a lot of work. Clinical Informatics professionals are constantly working on building out this sort of governance, prioritization, change management, and project management, all with the goal of delivering smoother and more complete configurations (both inside and outside the EMR), that then help improve workflows, and : 

• Increase stakeholder engagement
• Increase provider satisfaction
• Reduce variation in practice
• Increase consistency
• Increase quality of care
• Reduce clicks
• Reduce unnecessary pages / phone calls
• Reduce training time
• Reduce burnout

You can start by asking your Clinical Informatics team about your current- and future-state workflows, supporting them in these important operational discussions, and sharing your knowledge about the relationship between good change management, solid governance, great configuration (both inside and outside the EMR), and great workflow - the kind that makes both clinical and administrative users smile. :-)

Remember, this discussion is for educational purposes only - Your mileage may vary. Always check with your clinical leadership, legal team, and clinical informatics leadership, before you consider any changes to your change management strategy. 

Have any project management or change management tips to share? Feel free to leave them in the comments below!