Our clients report that addressing and preventing burnout for their physicians and other caregivers continues to be a critical priority in the aftermath of the pandemic. Healthcare organizations need high functioning, engaged clinicians to provide outstanding care and meet goals for quality patient outcomes. However, many grapple with how to create and maintain a robust organizational culture where physicians feel psychologically safe and well resourced, and in which they report lower rates of burnout. In light of ongoing physician shortages, particularly in primary care and high-demand specialties like radiology, effectively recruiting and retaining physicians is critical to delivering care, maintaining contractual staffing commitments, providing for more consistent revenue, and reducing associated costs. We hear often that physicians feel they are being asked to do more with less and adapt to a rapidly changing environment in terms of clinical care, medical record documentation, patient communication, mid-level supervision, and technological advancements. In response, many of our clients are actively exploring how to support providers, create and sustain a cohesive organizational culture, and reduce burnout rates. In this article, we discuss one piece of that larger puzzle – the importance of promoting psychological safety for physicians through both internal programming and participation in external opportunities.
A. How Psychological Safety Impacts Physicians’ Response to Workplace Stressors.
Providing front-line clinical care can be emotionally strenuous for providers, particularly if a patient suffers an adverse event and if the provider is subject to a peer review investigation or a medical board inquiry process. Providers need support and resources to manage emotional stress that comes with clinical work, including day-to-day patient interactions and relationships with other caregivers and administrative staff. As part of their efforts to combat provider burnout, organizations should assess the degree to which they provide psychological safety for team members. The Agency for Healthcare Research and Quality defines “psychological safety” as the degree to which physicians feel that their work environment supports them in efforts to seek help, develop new processes and techniques, and learn from mistakes.[1] Providers may be better equipped to navigate workplace stressors – such as tension between colleagues, changes in clinical or administrative workflows, or more serious issues like adverse patient events – if they believe they will receive appropriate protection and support in their efforts to deal with these situations.[2]
From a policy perspective, peer review and quality assurance processes receive protections from public disclosure in an effort to promote candid discussion of actual or potential risks and creative, proactive problem solving. However, even with legal protections for participation in these activities, providers may not fully disclose all facts or feel comfortable participating without a sense that the organization takes a systems-based, transparent, non-punitive, and collaborative approach in its patient safety, peer review, and quality efforts. Psychological safety is critical to ensuring that each of these processes functions in an optimal fashion.
B. Evaluating Your Organization’s Internal Processes.
As part of any effort to mitigate provider burnout, we suggest assessing the degree to which your organization’s internal peer review and/or quality assurance efforts provide psychological safety for providers. Ideally, physicians should be engaged in ongoing continuing medical education relevant to the organization’s safety goals. The organization’s quality metrics and expectations for physician performance should be clearly defined and prioritized (i.e., attending educational sessions and serving on committees), and strong performance may be rewarded through recognition, annual performance reviews, and if applicable, incentive compensation. In addition, for peer review and formal quality programming, organizations should assess existing degrees of physician participation, responsiveness to inquiries, and appropriate incentives to promote engagement. Organizations may also consider having their human resources team or an outside consultant assess elements of psychological safety associated with existing programming and ways to improve physicians’ experience of participation. Organizations may also consider offering providers other resources (e.g., professional coaching or internal education efforts) in addition to formal programming and/or engaging with peer organizations to learn how they address factors contributing to provider burnout.
C. Exploring Opportunities for External Collaboration.
Your organization may also benefit from adopting a Communication and Resolution Program (“CRP”) that provides an organizational framework for exploring the root causes of harm events, learning from mistakes, and identifying and adopting corrective actions for future quality assurance. CRPs may help combat burnout by promoting a culture of psychological safety among physicians and staff. They allow for providers to learn from harm events, build resiliency, and ultimately reduce the negative impacts that such events may have on their mental and emotional health. Additionally, CRPs are a helpful tool to restore patient trust, rebuild patient relationships, and help healthcare organizations learn from and prevent future mistakes.
If your organization has or would like to adopt a CRP, there are resources available that can help guide that process, like the Pathway to Accountability, Compassion and Transparency Collaborative (“PACT”).[3] PACT is a learning community committed to improving how healthcare organizations respond to, and learn from, patient harm events. PACT recently completed its first PACT Collaborative, an 18-month collaborative engagement with participating healthcare organizations, divided into cohorts of similar organizations (e.g., Acute/Ambulatory Care, Children’s Hospitals, or Senior Care Facilities).[4] The PACT Collaborative included virtual learning sessions for participants to explore CRP best practices. PACT helped participating organizations test, implement, and improve their CRPs, looking at five fundamental activities:
- Event management;
- Event review;
- Clinician engagement;
- Patient/family engagement; and
- Reconciliation/resolution.
D. Legal Considerations.
There are some legal considerations to think through when evaluating your peer review and quality assurance processes and when deciding to adopt a CRP or participate in a program like PACT. Specifically, organizations need to assess how state laws could impact the structure of, or physicians’ participation in, such programs, particularly with respect to medical malpractice liability and any related evidentiary protections. Consider California’s “Apology Law,” effective as of January 1, 2023, which extended California’s evidentiary protections to now include certain expressions or suggestions of fault relating to the suffering or death of a person, adverse patient safety event, or unexpected health care outcome. The law now protects statements if they relate to an act or omission in the provision of health care and were made to the affected person or their family/representative prior to the filing of a lawsuit. [5] With this change, those statements are treated as confidential, are not subject to subpoena, discovery, or disclosure, and may not be used or admitted into evidence in a civil proceeding (including civil lawsuits licensure hearings or disciplinary board actions). Previously, any suggestion that a sympathizer might be at fault for a person’s suffering or death were largely admissible (with only general expressions of sympathy or benevolence protected). [6] Protections like the Apology Law and California Evidence Code § 1157 (which bars the proceedings and records of peer review bodies from discovery in civil litigation) can give providers and organizations the space to transparently and candidly assess and improve patient safety and quality of care.[7]
While California is among many states to have adopted these types of protections, rules vary significantly by jurisdiction.[8] Your organization will need to evaluate the applicable laws of your state when establishing internal programming to improve physician psychological safety and quality of patient care and when choosing to participate in any external programs like the PACT Collaborative. Ultimately, solving for physician burnout requires a holistic approach that includes forward-looking solutions to support physicians during unexpected health outcomes or adverse patient safety events.
FOOTNOTES
[1] Agency for Healthcare Research and Quality, Creating Psychological Safety in Teams (Aug. 2018), Creating Psychological Safety in Teams (ahrq.gov).
[2] Id.
[3] The application deadline for the 2024-2025 PACT Collaborative is September 20, 2024 with the first event scheduled for October 16, 2024. Ariadne Labs, The PACT Collaborative Information Packet 9 (2024), PACT Collaborative 3.0 Information Packet 02.27.24.docx (ariadnelabs.org). Sheppard Mullin is not affiliated with PACT or any other CRP.
[4] Ariadne Labs, The PACT Collaborative Frequently Asked Questions (2021), available at PACT FAQ (ariadnelabs.org).
[5] Cal. Health & Safety Code § 104340.
[6] Cal. Evid. Code § 1160.
[7] Cal. Evid. Code § 1157.
[8] See William J. Naber, Several States Protect Physicians Who Apologize, But Be Careful, American College of Emergency Physicians (Nov. 23, 2021). See also Hicks & McCray, Don’t Regret Saying You’re Sorry: A Fifty-State Survey of “Apology Laws” and Their Effect on Medical Malpractice Suits, For the Defense: Med. Liab. and Healthcare Law (May 2021).
