Reducing Burnout among VA PCPs Using Evidence-Based Quality Improvement

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Background: Burnout, a long-term psychological response to chronic workplace stress, is highly prevalent among providers and staff in VA primary care. Healthcare worker (HCW) burnout is not only detrimental to affected individuals, but also to the organizations that they work in. High rates of HCW burnout are linked to increased medical errors, worse quality of care, and worse patient experience. Burned out HCWs also work fewer hours and are more likely to leave their organization. Organizational interventions to reduce burnout are more effective than individual interventions, but no single organizational intervention is applicable to all settings. We propose to use evidence-based quality improvement (EBQI) to utilize collaborative leadership and PACT teamlet input to develop and pilot test a burnout reduction intervention, informed by evidence and facilitated by experts, that is tailored to the specific needs of participating primary care clinics. Findings from this work will inform strategies for implementing burnout interventions in other VA facilities, adapted to local organizational contexts. Significance/Impact: In VA, 31-55% of providers, nurses, clinical associates, and administrative associates in patient-aligned care team (PACT) teamlets consistently report burnout. Strong primary care models are essential to the VA’s integrated delivery system. High burnout, and subsequent turnover, could erode that strength by decreasing primary care staffing, team function and PACT fidelity, thereby impairing Veteran access and shifting more care to the community. Addressing burnout in primary care before it leads to larger downstream effects is essential to preserving Veteran health and the integrity of the VA healthcare system. In addition, addressing burnout in primary care meets the HSR&D and ORD research priorities of primary care practice and complex chronic disease management, and of increasing substantial real-world impact of VA research. Innovation: EBQI is an effective and well-evaluated strategy that aided in the implementation of PACT, Women’s Health PACT, depression collaborative care, and smoking cessation guidelines. The strategy also reduced provider and staff burnout during PACT implementation, but has never been used in tandem with burnout interventions to optimize impacts. This CDA is the first endeavor to combine EBQI as an implementation strategy with evidence-based burnout interventions, adapted for local organizational contexts. Through EBQI, a multi-level, collaborative approach that empowers frontline HCWs, we may increase the feasibility and impact of burnout reduction interventions. Specific Aims: In this CDA, I aim to: Aim 1: Understand facility- and clinic-level drivers of burnout in VA primary care; Aim 2: Develop burnout reduction interventions using an EBQI approach; and Aim 3: Evaluate feasibility, acceptability, and effectiveness of the pilot EBQI-facilitated burnout reduction interventions. Methodology: For Aim 1, I will measure burnout and identify burnout drivers using surveys and interviews, which will serve as the foundation for stakeholder-engaged priority setting processes using EBQI to design locally-tailored evidence-based burnout reduction interventions. Aim 2 will involve integrating the key drivers of burnout and intervention activities identified in Aim 1, and developing EBQI-facilitated burnout interventions (using stakeholder panels, quality improvement training, formative feedback, and practice facilitation). Aim 3 will entail evaluation of the feasibility, acceptability, and effectiveness of the EBQI-facilitated burnout interventions in a pilot stepped wedge design among five VA medical centers and community-based outpatient clinics in VISN 22. During Aim 3, I will also use interviews to identify intervention barriers and facilitators. Next Steps / Implementation: In Years 3 and 5 of this CDA, respectively, I will prepare and submit IIRs to conduct a national organizational survey to identify and study the impact of burnout drivers in VA primary care, and a larger multi-site cluster randomized controlled trial to fully evaluate the effectiveness and impacts of EBQI-facilitated burnout reduction. Findings will also be shared with national and local stakeholders to inform future implementation.