June 15, 2023

CareEx: Enhancing clinical experience for higher productivity

Tldr;

  • Care organizations are facing a clinical talent war and need to prioritize Care Experience (CareEx) to attract and retain clinicians.
  • CareEx encompasses how clinicians feel about, think about, and value their work.
  • The five dimensions of CareEx are cognitive load, flow state, feedback loops, emotional and psychological stress and control and autonomy.
  • Improving CareEx could lead to higher clinician productivity, satisfaction, engagement and retention, and overall higher profitability of the organization.
  • Care organizations should measure CareEx, reduce cognitive lead, enhance the flow state, improve feedback loops, address emotional stress, and foster balanced control and autonomy to build high-performing care teams.

Why should CareEx be mission critical?

Note: The backbone of the ideas shared in this newsletter are based on developer productivity frameworks such as DORA, SPACE and DevEx.

Care organizations are in the middle of an unprecedented clinical talent war. As the industry grapples with rising provider shortages, alarmingly high burnout rates and an increasing number of clinicians that are calling it quits. But that’s not all. The advent of virtual care and the newfound geographical flexibility of jobs are upping the ante. Now, a decent paycheck isn’t enough - clinicians are on the funt for better work environments too. 

To win the clinical talent war, care organizations who want to attract and retain clinicians need to go beyond ensuring there are enough patients to fill up capacity and level up the experience for their clinicians. In this article we advocate why a proper approach to  Care Experience or CareEx is rapidly becoming a must have for any organization that delivers care, with Patient experience on the other side of the same coin.

But boosting CareEx isn’t just about winning the talent war - it’s also a key to unlocking care team productivity and achieving sustainable profitability. In a world where nearly half of U.S. hospitals wrapped up 2022 in red and tech-enabled care organizations are scratching their heads over what path will lead them to profitability, this couldn’t be more welcome. The evidence backs it up - numerous studies show that improving the employee experience leads to higher productivity, better organizational performance, and yes, even profitability. There’s no reason to assume that what holds true for non-care organizations wouldn’t hold true for care organizations.

It’s glaring to see how CareEx has basically forever been ignored. Core healthcare industry concepts of the last decade like the “triple aim” and “patient centricity” all assume our clinician workforce doesn’t need specific attention. It’s about time this changes.

Finally, good CareEx is a direct result of a good CareOps practice. While implementing and continuously evolving care flows is essential for CareOps success, in the end the activities in those care flows are still performed by humans. CareEx is a cornerstone of successful CareOps - it’s not about the software, tools and process, but about how they impact and enhance CareEx.

What is CareEx?

CareEx encompasses how clinicians feel about, think about, and value their work. 

As far as we know, CareEx is a new field, akin to well-established fields of Employee Experience (EmployeeEx) and Developer Experience (DevEx). These existing concepts provide a valuable model for understanding CareEx, as they have demonstrated a significant impact on organizational effectiveness. 

In contrast to the common misconception that these experiences are primarily affected by tools, research shows that human factors such as having clear goals for projects and feeling psychologically safe on a team have a substantial impact on performance. Improving CareEx increases not only productivity but also satisfaction, engagement and retention. 

The Five Dimensions of CareEx 

Note: Given the complexity of healthcare work, the number of dimensions is likely even higher than five. If you reckon I’ve missed something, don’t be shy - send me a note.

CareEx can be distilled into five dimensions: 

  1. Cognitive Load
  2. Flow State
  3. Feedback loops
  4. Emotional and psychological stress
  5. Control and autonomy

Cognitive load

Care delivery is inherently complex, and the increasing pace of medical research being published is adding even more cognitive load to the work of clinicians. Cognitive load encompasses the amount of mental processing required for a clinician to perform a task. For example, cognitive load typically increases when taking care of a multimorbidity patient, when there is a language barrier or when providers need 26.7 hours per day to provide guideline-recommended care

Cognitive load also varies according to how external information is presented to clinicians and how much information they need to digest. At the point of care, you’re not given a relevant snapshot of a patient’s journey but you get to digest an entire film reel - every medical moment, every detail ever recorded, all at your fingertips. The value of this information is undeniable, but there’s a snag - it’s like trying to find a specific scene in a movie without a fast-forward button. As a provider, you’re not just navigating a sea of information, you’re wading through an ocean of irrelevance. What a provider needs is not every detail, but the right detail.

Adding to the challenge of processing a deluge of information, healthcare providers are often stuck using tools that are about as cutting-edge as a stone tablet. Most care processes and guidelines are buried in mountains of paper, and operations are tangled up in Excel spreadsheets. These outdated methods aren’t just a hassle, they’re time-sucking, error-prone nightmares. 

To improve the care experience, care organizations should aim to reduce cognitive load by finding ways to eliminate unnecessary hurdles in the care delivery process. Emphasis should be placed on building and evolving flexible care processes and clinical workflows into your software applications, balancing information overflow and making sure care teams and patients are prompted at appropriate times along the care journey on what the next steps are.

Flow state

Sometimes called being in the ‘zone’ a flow state is associated with deep, productive work, but it’s a challenging feat for clinicians providing care. Nevertheless, it’s crucial for care organizations to invest time and resources to get clinicians into a Flow state, a mental state in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment. 

Frequent experiences of Flow state at work lead to higher productivity, innovation, provider satisfaction and employee development. An overall bad UI/UX of the systems they use, interruptions, regulator changes in team composition and information spread out across +20 different systems are things that will hinder a clinician’s ability to experience a Flow state. 

To improve the Flow state, care organizations should improve the overall UI/UX of the systems they use, reduce context switching between different UIs & patients, cluster meetings, avoid unplanned work and foresee “downtime” where clinicians can perform non-care delivery related activities (e.g. providing product feedback). The recent advent of AI scribes is a major advance in reducing soul crushing work like manually completing charting notes, with a potentially positive impact on Flow state for clinicians.

Feedback loops 

“Software organizations commonly look for ways to optimize their value stream by reducing or eliminating delays in software delivery. This allows faster feedback and learning about what is being built, which in turn allows for more rapid course correction.” - Abi Noda (DX)

In healthcare, two primary feedback loops play a critical role in effective care delivery, yet they are frequently broken.

The first is the intra-workflow feedback loop. This is the immediate feedback loop involved in care delivery, like “I ordered a lab test, now I need the results to make a treatment decision for my patients”. These feedback loops are typically more complex in healthcare than in other industries, often due to the volume and complexity of data points required for decision-making.

The second feedback loop is the outcomes feedback loop. This is the longer-term feedback loop relating to relevant patient outcomes after treatment. Has my patient recovered? Are they still alive? Can they play tennis again? The State of CareOps indicates that less than 36% of care providers measure Patient Reported Outcome Measures (PROMs), meaning this feedback loop is entirely missing for over 60% of providers.

"Doctors assume that when a patient never shows up again it is because the issue/problem was fixed. But it often means the patient doesn’t want to go through the effort of setting up another appointment that they don’t think will yield any benefit." Lina Colucci

To succeed, care organizations need to find ways to ensure both feedback loops are in place and bottlenecks are continuously removed.This is the goal of mastering the CareOps lifecycle. By doing so, they will scale and continuously improve care processes faster, than their peers and create a sustainable competitive advantage in the form of better outcomes delivered at lower cost.

So, what has this to do with CareEx? Well, a typical provider’s day consists of numerous tasks relying on feedback from both tools and people. For example, a clinician could have already been waiting six weeks for an engineer to make a small change to an internal workflow. Later, they may wait for approval from a doctor to administer certain medication. All of these things block their ability to make progress. 

Fast feedback loops allow clinicians to complete their work quickly with minimal friction. Slow feedback loops, by contrast, interrupt the care delivery process, leading to frustration and delays as clinicians wait or decide to switch tasks.

To improve feedback loops, care organizations should improve the “hit rate” of these feedback loops (ensuring that accurate information is available) and speed up these feedback loops (e.g. by automating the health insurance verification). 

Emotional and psychological stress

“Physician burnout affects more than three in five physicians, and one in five physicians intend to leave practice in the next two years. Contributing factors include stress, staffing shortages, bureaucratic tasks and documentation requirements.” - American Medical Association

During my nursing internship in the oncology department, I was confronted with the immense pain and suffering of patients battling cancer. Witnessing lives slipping away and facing the harsh reality of cancer took a toll on me.

While much attention is given to the impact of increased workload on burnout, emotional burnout is often overlooked. It’s simply hard for human beings to face death repeatedly without it affecting their outlook on life. This becomes especially apparent when I look at my nursing friends - they clearly show signs of “compassion burnout”. The constant exposure to suffering has caused them to lose their sense of compassion for their patients, leading to a more mechanical and detached approach to delivering care.

Beyond negatively impacting clinicians, burnout also has consequences for patients. A 2018 Mayo Clinic study found that physicians experiencing burnout were more likely to make medical errors, while other research has linked burnout to increased rates of healthcare-associated infections. 

To decrease emotional and psychological stress, care organizations should first start by reducing the cognitive load. Additionally, fostering a workplace culture that openly discussed mental health and provided a supportive space for providers to share their experiences and emotions is crucial. A good example is Vitalize Care, a platform where healthcare professionals can connect with certified coaches and peers who have walked in their shoes before, providing a valuable support network. 

Control and autonomy 

Control and autonomy are essential ingredients in the CareEx recipe. They instill a sense of purpose, enabling clinicians to fully harness their expertise to enhance patient care. If you’ve spent time in healthcare, you’ll know that losing control and autonomy is a source of huge frustration for clinicians.

This is not just anecdotal but also backed by science. A 2019 study revealed that high levels of autonomy and job control have a positive impact on the relationship between physician job satisfaction and guideline adherence. Furthermore, autonomy is one of the three pillars of motivation according to the Self-Determination Theory (SDT). When clinicians have a high degree of autonomy, it enhances their motivation, resulting in a more positive CareEx. 

To improve control and autonomy, care organizations need to strike the right balance between being prescriptive, not tolerating variation when science is clear and leaving room for expert decision making in the face of ambiguity. In the end, this is where a clinician’s ability is still uniquely valuable. To help strike this balance, we propose to change the perspective from efforts around standardization to continuous improvement. Standardization means a clinician loses agency once decisions on “the standard” have been made. This could be a crucial aspect why so many standardization efforts fail. By organizing the care organization around continuous improvement, this agency is safeguarded and the participating clinicians will have a higher degree of control & autonomy. 

Furthermore, autonomy is closely tied to evolution of professional skills and knowledge. It’s important to offer education and training opportunities that empower clinicians to build autonomy in their work. Additionally, fostering a supportive work environment plays a significant role in cultivating autonomy. This includes establishing clear roles and responsibilities and adopting a leadership style that encourages independence and self-direction.

Getting started

CareEx is a new field that requires further research and exploration. However, waiting for additional research is not a viable option, as neglecting attention to CareEx today puts care organizations at a competitive disadvantage. 

By conducting Net Promotor Score (NPS) or employee satisfaction surveys that take the five dimensions of CareEx into account, you can already gain valuable insights into the current state of CareEx at your organization. Additionally, conducting sample tests of clinicians' calendars can help identify specific areas that may require improvement. 

Care organizations should begin measuring care experience now, even if they don’t plan a formal CareEx investment yet. Measurement plays a crucial role in CareOps initiatives. It allows organizations to grow, spot and understand trends and decide the right time to begin making investments. 

CareEx plays a vital role in driving business performance by enhancing clinical efficiency, care quality, and employee retention. While a comprehensive view of clinical efficiency is difficult to capture, measuring and focusing on care experience provides a proven path towards building a high-performing care organization.

Rik Renard & Thomas Vande Casteele

Twitter: @rikrenard

LinkedIn: Rik Renard / Thomas Vande Casteele

Special thanks to Dr. Ben Bergman, Hal Levy, Dr. Jared Dashevsky, Kate Schlag, and Dr. Manan Shah for their valuable feedback and contributions to this article. 

I would also like to give a special shoutout to Abi Noda, the author of DevEx, for providing inspiration and insights that have creatively contributed to the development of this article.

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