Health  Vol.10 No.5 , May 2018
Addressing Human Factors in Burnout and the Delivery of Healthcare: Quality & Safety Imperative of the Quadruple Aim
Abstract: Human factors in the delivery of service are considered in many occupations of high impact on others such as airline industry and nuclear power industry, but not sufficiently in healthcare delivery. A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction (The Triple Aim). Many industries which support healthcare and healthcare administrators do not have firsthand knowledge of the complexities in delivering care. As a result, the experience and human factors of providing care are often overlooked at high level decision-making unless incorporated into the healthcare delivery framework, proposed as the fourth aim of The Quadruple Aim framework. Research is pointing to consequent negative effects on quality, safety, joy, meaning and sustainability of healthcare practice. High acute occupational stress and chronic occupational stress can cause direct and indirect effects on safety and quality of care. The biological, psychological and social consequences of burnout from excessive acute and chronic occupational stress are more of a threat to healthcare than commonly acknowledged. Patient safety, quality of care and clinician well-being are inextricably linked. This report will describe the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center. Developing the fourth aim of improving the experience of providing care, had high acceptability and aligned with other health system goals of optimization of safety, quality, and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations. The goal of HFE is to fit the healthcare system to the human instead of the human to the healthcare system. Concepts include removal of extraneous cognitive load, using clinician neural resource (brain power) optimally for highest order decision making in patient care. An integrative model of patient safety and clinician wellbeing is a product of this effort.
Cite this paper: R. Privitera, M. (2018) Addressing Human Factors in Burnout and the Delivery of Healthcare: Quality & Safety Imperative of the Quadruple Aim. Health, 10, 629-644. doi: 10.4236/health.2018.105049.

[1]   Shanafelt, T.D., Hasan, O., et al. (2015) Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 90, 1600-1613.

[2]   Epstein, R.M., Privitera, M.R. (2016) Doing Something about Burnout. Lancet, 5, 388, 2216-2217.

[3]   Privitera, M.R., Rosenstein, A.H., Plessow, F. and LoCastro, T. (2015) Physician Burnout and Occupational Stress: An Inconvenient Truth with Unintended Consequences. Journal of Hospital Administration, 4, 27-35.

[4]   Lin, Y.-W. (2013) The Causes, Consequences and Mediating Effects of Job Burnout among Hospital Employees in Taiwan. Journal of Hospital Administration, 2, 15-27.

[5]   Lyndon, A. (2016) Burnout among Health Professionals and Effect on Patient Safety. AHRQ PS Net. Perspectives on Safety.

[6]   ECRI (2017) Burnout in Healthcare Workers: The Elephant in the Room.

[7]   Rosenstein, A. and O’Daniel, M. (2017) A Survey of the Impact of Disruptive Behaviors and Communication Defects on Patient Safety. The Joint Commission Journal on Quality and Patient Safety, 34, 464-471.

[8]   Salyers, M., Bonfils, K., Luther. L., Firmin, R., et al. (2017) The Relationship between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. Journal of General Internal Medicine, 32, 475-482.

[9]   DeVoe, J., Fryer, G.E., et al. (2007) Congruent Satisfaction: Is There Geographic Correlation between Patient and Physician Satisfaction? Medical Care, 45, 88-94.

[10]   Friedman, T. (2016) Thank You for Being Late: An Optimists Guide to Thriving in and Age of Accelerations. Farrar, Straus & Giroux, New York.

[11]   Berwick, D.M., Nolan, T.W. and Whittington, J. (2008) The Triple Aim: Care, Health and Cost. Health Affairs, 27, 759-769.

[12]   Spinelli, W.M. (2013) The Phantom Limb of the Triple Aim. Mayo Clinic Proceedings, 88, 1356-1357.

[13]   Bodenheimer, T. and Sinsky, C. (2014) From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, 12, 573-576.

[14]   Sikka, R., Morath, J.M. and Leape, L. (2015) The Quadruple Aim: Care, Health Cost and Meaning in Work. BMJ Quality & Safety, 24, 1-3.

[15]   Carayon, P. and Wood, K.E. (2010) Patient Safety: The Role of Human Factors and Systems Engineering. Studies in Health Technology and Informatics, 153, 23-46.

[16]   Karwowski, W. (2005) Ergonomics and Human Factors: The Paradigms for Science, Engineering, Design, Technology and Management of Human-Compatible Systems. Ergonomics, 48, 436-463.

[17]   Muraven, M. and Baumeister, R.F. (2000) Self-Regulation and Depletion of Limited Resources: Does Self Control Resemble a Muscle? Psychological Bulletin, 126, 247-259.

[18]   Reason, J. (2005) Safety in the Operating Theatre—Part 2: Human Error and Organizational Failure. Quality & Safety in Health Care, 14, 50-60.

[19]   Duthie, E.A. (2010) Application of Human Error Theory in Case Analysis of Wrong Procedures. Journal of Patient Safety, 6, 108-114.

[20]   Plessow, F., Fischer, R., Kirschbaum, C. and Goschke, T. (2011) Inflexibility Focused under Stress: Acute Psychosocial Stress Increases Shielding of Action Goals at the Expense of Reduced Cognitive Flexibility with Increasing Time Lag to Stressor. Journal of Cognitive Neuroscience, 23, 3218-3227.

[21]   Plessow, F., Schade, S., Kirschbaum, C. and Fischer, R. (2012) Better Not to Deal with Two Tasks at the Same Time When Stressed? Acute Psychosocial Stress Reduces Task Shielding in Dual-Task Performance. Cognitive, Affective and Behavioral Neuroscience, 12, 557-570.

[22]   Savic, I. (2015) Structural Changes of the Brain in Relation to Occupational Stress. Cerebral Cortex, 25, 1554-1564.

[23]   Blix, E., Perski, A., Berglund, H. and Savic, I. (2013) Long-Term Occupational Stress Is Associated with Regional Reductions in Brain Tissue Volumes. PLoS ONE, 8, e64065.

[24]   Deligkaris, P., Panagopoulou, E., Montgomery, A.J. and Masoura, E. (2014) Job Burnout and Cognitive Functioning: A Systematic Review. Work & Stress, 28, 107-123.

[25]   Reason, J. (2008) The Human Contribution. Ashgate Publishing Company, Burlington.

[26]   Sinsky, C.A. and Privitera, M.R. (2018) Creating a “Manageable Cockpit” for Clinicians: A Shared Responsibility. JAMA Internal Medicine.

[27]   Sweller, J. (1988) Cognitive Load during Problem Solving: Effects on Learning. Cognitive Science, 12, 257-285.

[28]   van Merrieboer, J.J.G. and Sweller, J. (2010) Cognitive Load Theory in Health Professional Education: Design Principles and Strategies. Medical Education, 44, 85-93.

[29]   West, C.P., Dyrbye, L.N., Erwin, P.J. and Shanafelt, T.D. (2016) Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis. The Lancet, 388, 2272-2281.

[30]   Panagioti, M., Panagopoulou, E., Bower, P., et al. (2016) Controlled Interventions to Reduce Burnout in Physicians. A Systematic Review and Meta-Analysis. JAMA Internal Medicine, 177, 195-205.

[31]   West, C.P., Dyrbye, L.N., Sloan, J.A. and Shanafelt, T.D. (2009) Single Item Measures of Emotional Exhaustion and Depersonalization Are Useful for Assessing Burnout in Medical Professionals. Journal of General Internal Medicine, 24, 1318-1321.

[32]   Mind Garden, Inc.

[33]   de Beer, L., et al. (2013) Linking Employee Burnout to Medical Aid Provider Expenditure. South African Medical Journal, 103, 89-93.

[34]   Anagnostopoulous, F., et al. (2012) Physician Burnout and Patient Satisfaction with Consultation in Primary Health Care Settings: Evidence of Relationships from a One-with-Many Design. Journal of Clinical Psychology in Medical Settings, 19, 401-410.

[35]   Michel, A. (2016) Burnout and the Brain. Association for Psychological Science.

[36]   Alkadhi, K. (2013) Brain Physiology and Pathophysiology under Mental Stress. ISRN Physiology, 2013, Article ID: 806104.

[37]   Golkar, A., et al. (2014) The Influence of Work Related Chronic Stress on the Regulation of Emotion and Functional Connectivity in the Brain. PLoS ONE, 9, e104550.

[38]   Erickson, S.M., et al. (2017) Putting Patients First by Reducing Administrative Tasks in Healthcare. Position Paper of American College of Physicians. Annals of Internal Medicine, 166, 659-661.

[39]   Berwick, D.M., et al. (2017) Breaking the Rules for Better Care. JAMA, 317, 2161-2162.

[40]   Merlino, J. (2015) The Responsibility Matrix: A Strategy for Stronger Physician/Administrator Partnerships.

[41]   Disconnects in Transforming Health Care Delivery. How Executives, Clinical Leaders, and Clinicians Must Bridge Their Divide and Move forward Together.

[42]   Shanafelt, T.D., Dyrbye, L.N. and West, C.P. (2017) Addressing Physician Burnout. The Way Forward. JAMA, 317, 901-902.

[43]   Wallace, J.E., Lemaire, J.B. and Ghali, W.A. (2009) Physician Wellness: A Missing Quality Indicator. The Lancet, 374, 1714-1721.