MEMO

Minimizing Error, Maximizing Outcome

The Physician Worklife Study II
Mark Linzer, UW, Principal Investigator
Mark Schwartz, NYU, Co-PI
Linda Baier Manwell, UW, Project Director
Learning Objectives
To better understand how the work
environment affects physicians and patients
To learn more about the MEMO project
To see how gender, race, and ethnicity
interact with working conditions
To realize the impact of a hectic or chaotic
work environment
Background
Physician Worklife Study I (PWS)
Funded by Robt Wood Johnson Found, 1995-1998
National, random sample of 5,704 MDs
Stratified by five specialties
Findings
Time pressure is major source of stress/dissatisfaction
Stress and dissatisfaction predict burnout and intent to
leave
Work control is powerful predictor of satisfaction
Burnout is 60% higher in women MDs
What is MEMO?
Funded by AHRQ, 2001-2005
Effect of primary care working conditions on MDs
and quality of care
Funded by Robt Wood Johnson, 2005-2006
Effect of workplace on health care disparities

101 clinics in Chicago, Madison, Milwaukee,
New York City, rural/small town Wisconsin
420 MDs, 1785 patients
MEMO Conceptual Model
Workplace
Characteristics

Structure
Culture
Workflow
Policies, processes
Patient demands
Patient
satisfaction

Quality of care

Medical errors
Burnout

Mental health
issues
MD Stress
MD Satisfaction
MEMO Data Collection Points
Time 1 Time 2
Jan-May/02 (Oct-Dec/02) (Jan-Jun/05)
Focus
groups
Clinic
recruitment
5 regions
MD survey #1
Clinic manager survey
Researcher clinic observation
Patient
recruitment
101 clinics
MD survey #2
Patient survey
Chart review
Measuring Quality
Up to 6 patients per MD with diabetes, HTN,
and/or CHF
Assess:
Patient satisfaction
Patient quality of life
Errors/omissions in care
Disease management
Preventive activities

Quality
Errors
Determining Errors
Clinicians reported errors in disease
management during past year
Clinicians rated their stress & predicted
likelihood of making future errors on the
OSPRE (Occupational Stress and
PReventable Error) instrument
Researchers performed confidential chart
reviews
420 primary care physicians (85.2% of target 500)
59.2% of those surveyed responded
51% GIM 49% FP
44% female
83% white
83% full-time
Age 44 (range 29-89)
Physician Participants
MEMO Results: Measures
Organizational Culture Domains
alpha
Quality emphasis (.86)
Leadership/governance (.86)
Organizational trust (.79)
Information/communic. (.68)
Cohesiveness (.66)

Stress Scale alpha (.84)
Feel stress due to to job
Few stressors at work
Job is extremely stressful
Almost never stressed at work
Prediction of Preventable Error
(OSPRE): alpha (.85)
High BPs & missed dx of HTN
No depression screen w/sympts
No ACE for diabetic
No aspirin for diabetes w/CAD
Missed drug-drug interaction
No diabetic eye exam referral
No alcohol screen for HTN
MEMO Results: MD Outcomes
Of 420 physicians...
79% highly satisfied with their jobs
61% said jobs were stressful
53% need more time for physical exams
27% burning out or burned out
31% moderately or more likely to leave job
within 2 years
MEMO Results: Organizational Culture
Predict job satisfaction:
Work control (.001)
Trust in the organization
(.001)
Resource availability (.001)
Less clinic chaos (.001)

Predict poorer MD mental
health:
Fewer resources (.001)
Less work control (.006)
More clinic chaos (.001)
Predict future error:
Less clinic emphasis on
information (.017)
Less clinic emphasis on
diversity (.001)

Predict intent to leave:
Less trust in the
organization (.001)
Fewer resources (.001)
Chaos ratings similar between MDs and their
clinic managers (r=0.30, p<.001)
46% of MEMO physicians rated their practices
as chaotic (4 or 5)
Describe the atmosphere in your office
Calm Busy, but Hectic,
reasonable chaotic
1 2 3 4 5
MEMO Results: Chaos in the Clinic
Chaotic offices are associated with:
More minority patients
More patients with public or no insurance
Fewer exam rooms
Fewer staff
Less practice emphasis on communication
Less practice emphasis on information
technology
MEMO Results: Chaos in the Clinic
67%
87%*
79%*
44%
41%*
14%
35%*
20%
0%
20%
40%
60%
80%
100%
Satisfaction Stress Burnout Leave
Practice
Hectic Not Hectic
Impact of Chaos on MDs

Perceived Leadership Integrity Index (PLII)
Attitudes of organizational leaders to (e.g.)
physicians core values
controlling costs vs. quality
Negative perceptions about perceived
integrity correlated with physician stress,
burnout, and intent to leave the practice
MEMO Results: Organizational Culture
MEMO Results: Gender Differences
Background
The 1995-98 Physician Worklife Study found
Women MDs have more
female patients
complex patients
managed care, uninsured, and Medicaid patients
Women MDs have less work control
All MDs need more time than allotted to see
patients, but women need a greater percentage
Burnout was 60% higher in women physicians
MEMO Results: Gender Differences


Workplace characteristics
Women
MDs
Men
MDs

p-value
Job control
(1=none, 4=great)
2.35 2.69 <.001
Trust in the organization
(1=none, 4=great)
2.47 2.69 <.001
Values aligned w/organization
(1=no, 4=great)
1.97 2.39 <.001

Physician characteristics

Women
MDs
Men
MDs

p-value
Stress
(1=low, 5=high)
3.45 3.23 <.003
Burnout
(1=none, 5=completely)
2.32 2.07 <.001
MEMO Results: Gender Differences

Despite widespread dissemination of similar
data, assessments of organizational climate and
worklife by women MDs continue to be lower
compared to males, and in many areas have
worsened.
Non-alignment of values may explain lower
perceptions of work control and higher levels of
stress and burnout among women MDs.
Women MDs and their patients remain at
higher risk for the effects of stress and poor
working climates.
MEMO Results: Gender Differences
MEMO Results: Effect of the
Workplace on Healthcare Disparities
Minority Practices
0
5
10
15
20
25
30
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
N
u
m
b
e
r

o
f

C
l
i
n
i
c
s

74 Non-minority clinics
27 Minority clinics
27 of 101 clinics had 30% minority patients
(average for these clinics =70% [95% CI: 60%, 81%])
MEMO Results: Disparities

CLINIC VARIABLES
Minority
clinics
Non-minority
clinics
Minority MDs 39% 12% p<.001
Adequate access to
supplies, equipment,
referral specialists

42%

70%

p<.001
Exam rooms per MD 2.1 2.7 p<.001
Staffing ratio:
RN+LPN+MA
MD+DO+PA+NP

0.9

1.2

p=.018
MEMO Results: Disparities

MD VARIABLES
Minority
clinics
Non-
minority
clinics
Feel time pressure 57% 39% p<.001
Burning or burned out 32% 23% p=.030
Clinic atmosphere
(1=calm, 5=chaotic)
3.8 3.2 p<.001
Amount of work control
(1=none, 4=great)
2.3 2.7 p<.001
MEMO Results: Disparities

PATIENT VARIABLES
Minority
clinics
Non-
minority
clinics
Average number of
medications per patient
2.7 2.1 p=.003
Uninsured and Medicaid
patients
58% 19% p<.001
Patient satisfaction with
care (1=very, 5=not at all)
1.44 1.40 p=.423
Patient trust in the
physician
(1= not at all, 5=complete)
4.54 4.47 p=.373
Clinics that serve many minority patients
have difficult working conditions that pose
a special challenge to our health care
system.

Improvements may be achieved if
remediable factors are addressed at the
organization, system, and policy levels.
MEMO Results: Disparities
Patient outcomes (n=1785, ave 4/MD)
Focus groups in minority clinics to identify
factors that create barriers to quality care and
exacerbate disparities
Focus groups in high quality clinics to identify
factors/processes that facilitate quality care
and minimize disparities.
Development of Office and Work Life (OWL)
tool
MEMO: Current Activities
From 2001-2005, your clinic took
part in a study, Minimizing Error,
Maximizing Outcome (MEMO).
This form reports results from MEMO.
Office & Work Life Feedback
WL
Physician data: Your clinic MEMO clinics
Job stress: highly stressed % %
Burnout: definitely % %
Organization data: Your clinic MEMO clinics
Staffing ratio n/n n/n
Nursing atmosphere calm/hectic calm/hectic
Patient survey data: Your clinic MEMO clinics
Satisfaction with provider: very % %
Depressive symptoms: yes % %
Chart audit data: Your clinic MEMO clinics
Score on error index 0-100 0-100
Score on quality index 0-100 0-100
Next Steps for MEMO
Analyses:
Patient outcomes
Regression analyses
Research: Practice Redesign
Preventing burnout
Ameliorating chaos
Improving work control
Facilitating communication (language, literacy)
Modifiable Factors
Find ways to better manage resources to
reduce disparities and improve physician
and patient health.
Assess methods to reduce clinic chaos.
Study practices that accomplish a lot with
few resources. Develop a tool kit for other
practices to use.
Upcoming MEMO Papers
MEMO main results paper!
Impact of the work environment on care quality and
errors
Other upcoming papers:
Errors in primary care: prediction & relationship to quality
Role of physician gender in quality & errors
Effect of physician burnout on quality & errors
Managing an ambulatory practice: lessons from MEMO
Separate but unequal: where minority and non-minority
patients receive primary care
MEMO Limitations
Only primary care practices enrolled
Only 5 regions included (NYC and upper
Midwest)
Self-reported data

Consultants
Eric Williams
Bob Konrad
Elianne Riska
Bill Scheckler
Stewart Babbott
JudyAnn Bigby
Peggy Leatt
Said Ibrahim
Jacqueline Wiltshire


MEMO Staff
Jim Bobula
Marlon Mundt
Roger Brown
Carolyn Egan

Chicago Region
Anita Varkey
Bernice Man
Elizabeth Arce

Milwaukee Region
Ann Maguire
Barb Horner-Ibler
Laura Paluch

Rural/Small Town WI
Mary Beth Plane
John Frey
Jessica Grettie
Mary Lamon-Smith
Madison Region
Julia McMurray
Jessica Sherrieb
James Gesicki
New York Region
Mark Schwartz
Joe Rabatin
Karla Felix
Debby Dowell
MEMO Team