Center for Improvement in Healthcare Quality Newsletter
December 2021

CIHQ-ARS Article

Burnout, Patient Safety, and the Quality Professional

An article provided by Beth Guyton, CEO of Interactive Quality
No matter your role in healthcare, be it a quality professional, an administrator, or a frontline caregiver, there is a united and common goal of delivering safe and effective care of the highest quality. In 2008, the Institute for Healthcare Improvement identified the Triple Aim as a framework for improving the quality of United States healthcare system. It included enhanced patient experience, improved population health, and reduced cost. In 2014, a fourth dimension, improved caregiver work life, was added. Each of these aspects of care is seen as critical to optimizing our U.S. healthcare system (Sikka et al., 2015).

A question to ponder.

If the caregiver’s work life experience is central to quality healthcare, what knowledge, skills, and abilities should a quality professional have in this arena?
Although caregiver burnout has gained visibility as a result of the pandemic, it is not a new problem. Prior to the pandemic it was estimated that clinician burnout was a seventeen-billion-dollar annual problem with significant impact on patient safety and quality of care as well as detrimental effects to physicians and nurses (National Taskforce for Humanity in Healthcare, 2018). Prior to the pandemic, 54% of physicians and 63% of nurses reported experiencing signs of burnout (Medical Specialties with the Highest Burnout Rates, n.d.; Employee Burnout Crisis, 2017).
As early as 2006, research connecting work stress and burnout to compromised patient safety began to surface. A landmark publication, Through the Eyes of the Workforce was published in 2013 by the National Patient Safety Foundation. This comprehensive paper connected emotional and physical work stressors to patient safety concerns. In 2017, the Institute for Healthcare Improvement introduced its Joy in Work Framework offering the following rationale (Institute for Healthcare Improvement, n.d.).
“Burnout leads to lower levels of staff engagement, patient experience, and productivity, and an increased risk of workplace accidents. Lower levels of staff engagement are linked with lower-quality patient care, including safety, and burnout limits providers’ empathy - a crucial component of effective and person-centered care.”
Below are a handful of findings that show a negative relationship between caregiver burnout and patient safety, meaning when burnout increases, patient safety decreases.
  • There is a significant negative relationship between burnout and quality of care in meta-analysis of 82 studies (Salyers, et al., 2016)
  • Burnout and stress lead to decreased patient safety (Laschinger and Leiter, 2006)
  • Burnout is a predictor of medical error (Shanafelt et al., 2010)
  • RN burnout is associated with higher infection rates (Cimiontti et al., 2012)
  • Burnout is a predictor of both clinician-related and objective patient safety (Welp et al., 2016)
  • There is a bi-directional relationship between burnout and medical error (Dyrbye et al., 2017)

What can quality professionals do to make a difference?

First, let’s give credit where credit is due. Just Culture and Second Victim programs support caregivers when things do go wrong and this support is important. Recently a nurse leader at a Dallas Health System shared that they found a direct correlation between their AHRQ Safety Culture results and respondents that had accessed various types of support when a safety incident had occurred. Considering that once a mistake is made, stress and burnout escalate, which in turn increases the likelihood of additional errors, these types of programs are critical.

Four significant ways that quality professionals can make a difference:

  1. Know what burnout is and how to recognize it
  2. Use process improvement knowledge to identify and improve organizational causes of burnout
  3. Use data science knowledge to assess the connection between employee data and patient safety data and influence positive change for both the caregiver and the patient
  4. Learn about and promote evidence-based methods for enhancing individual resiliency resources

Know About and Recognize Burnout

It is interesting that burnout is identified on an individual basis, but caused at an organizational or team level. Individuals get burnout, but individuals don’t cause burnout. Burnout is the result of a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions; exhaustion, cynicism with detachment, and inefficacy. It occurs at the intersection of the work environment and the worker (Maslach, 2011).
Signs and Symptoms of Burnout
Overwhelming Exhaustion
  • Most obvious symptom
  • Direct result of stress
  • Causes behavior changes to self-preserve
Cynicism with Detachment
  • We begin to feel negative towards work and others
  • We detach and distance ourselves emotionally
  • We begin to see patients as objects, ignoring their uniqueness and engaging qualities
Feeling Ineffective
  • Our sense of self-efficacy and accomplishment diminish
  • Our work becomes less fulfilling

Apply PI Knowledge to Improve Organizational Factors

Organizational factors related to burnout have been well-studied and are identified as:
  • Workload and job-demands
  • Efficiencies and resources
  • Meaning in work
  • Culture and values
  • Control and flexibility
  • Social support and community at work
  • Work-life integration (Shanaflet et al., 2017)
Quality professionals can help their organization measure these drivers and identify which factors are more tightly connected to burnout on units with patient safety concerns. Process improvement expertise can be a valuable asset to organizations striving to address root causes of burnout.

Use Data Science to Connect Burnout to Patient Safety

Another way quality professionals can assist is through data gathering and analysis. Organizations are tracking engagement, and more and more are beginning to monitor wellbeing, burnout, and resiliency. Looking for relationships in caregiver data that maybe gathered by human resources and safety culture and patient safety data gathered by quality can offer valuable insights. Drilling down to the unit level can lead to specific interventions that can benefit both the patient and the caregiver.

Know and Promote Evidence-based Strategies for Building Resiliency

Taking a more proactive stance, quality professionals can promote wellbeing through evidence-based strategies such as mindfulness and journaling.
Mindfulness has been demonstrated to enhance every aspect of wellbeing. It is one of the most scientifically sound practices for enhancing emotional regulation and cognitive function. Highly relevant to patient care, mindfulness improves human connection, empathy, and compassion (Holzel, et al., 2017). If you are reading something about “empathy training” or “compassion training” you are reading about mindfulness; most likely a mindfulness Loving Kindness meditation (Seppala, et al., 2014). It is also worth noting the link between mindfulness and high reliability (Weick & Sutcliffe, 2007).
Journaling is a reflective exercise that has also been demonstrated to enhance every aspect of wellbeing. It helps individuals who have experienced traumatic events, release emotion, absorb the event, and effectively move through the hardship. It is a powerful tool for sense-making, meaning making, and gaining self-knowledge (Dimidroff et al., 2017)
Beth Guyton, MAIOP, CPHQ
Let’s connect on LinkedIn. I would love to learn more about you and your work.
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References

American Medical Association, (n.d.), Medical Specialties with the Highest Burnout Rates, ama-assn.orgs
Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care associated infection. American journal of infection control, 40(6), 486-490.
Dimitroff, L. J., Sliwoski, L., O’Brien, S., & Nichols, L. W. (2017). Change your life through journaling–The benefits of journaling for registered nurses. Journal of Nursing Education and Practice, 7(2), 90-98.
Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., & Meyers, D. (2017). Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM perspectives.
Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on psychological science, 6(6), 537-559
Institute for Healthcare Improvement. (n.d.) IHI Framework for Improving Joy in Work. Retrieved from ihi.org
Kronos, (2017), “The Employee Burnout Crisis: Study Reveals Big Workplace Challenge in 2017” (Jan. 9, 2017), kronos.com
Laschinger, H. K. S., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout engagement. JONA: The Journal of Nursing Administration, 36(5), 259-267.
Lucian Leape Institute National Patient Safety Foundation. (2013). Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care. National Patient Safety Foundation.
Maslach, C. (2011). Burnout and engagement in the workplace: New perspectives. The European Health Psychologist, 13(3), 44-47.
National Taskforce on Humanity in Healthcare. (2018, April 25). The business case for humanity in healthcare [Position paper]. Retrieved from View
Seppala, E. M., Hutcherson, C. A., Nguyen, D. T., Doty, J. R., & Gross, J. J. (2014). Loving kindness meditation: A tool to improve healthcare provider compassion, resilience, and patient care. Journal of Compassionate Health Care, 1(1), 1-9.
Sikka, R., Morath, J. M., & Leape, L. (2015). The quadruple aim: care, health, cost and meaning in work.
Salyers, M., Bonfils, K., Luther, L., Firmin, R., White, D., Adams, E., & Rollins, A. (2016). The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. Journal of General Internal Medicine: JGIM, 32(4), 475–482. doi.org
Weick K, Sutcliffe K. (2007). Managing the Unexpected: Resilient performance in an age of uncertainty, San Francisco, CA: Josey Bass.
Welp, A., Meier, L. L., & Manser, T. (2016). The interplay between teamwork, clinicians’ emotional exhaustion, and clinician-rated patient safety: a longitudinal study. Critical Care, 20(1), 110.