Evidence-Based Quality Improvement to Reduce VA Primary Care Burnout

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. The investigators 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.

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 project 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, the investigators may increase the feasibility and impact of burnout reduction interventions.

The investigators will conduct a pilot, modified stepped wedge trial of EBQI for primary care burnout in 5 primary care clinics (based in 2 VA Medical Centers and 3 community-based outpatient clinics) in 2 VA healthcare systems in 1 Veterans Integrated Service Network. Three intervention sites will implement EBQI-facilitated interventions to reduce burnout, while 2 control sites will receive usual care. Survey data on burnout, drivers of burnout, turnover intent, intervention feasibility and acceptability, and other survey respondent individual and workplace characteristics will be collected annually through the trial period.

• Turnover intent [Time frame: Annually, from enrollment until the end of the study, three years later (4 survey administrations).]
• Workplace drivers of burnout [Time frame: Annually, from enrollment until the end of the study, three years later (4 survey administrations)]
• Depression [Time frame: Annually, from enrollment until the end of the study, three years later (4 survey administrations)]
• Anxiety [Time frame: Annually, from enrollment until the end of the study, three years later (4 survey administrations)]