PACT Implementation: Findings from primary care surveys 

Sandra Joos, Ph.D., 

Hector Rodriguez, Ph.D.

Lisa Meredith, Ph.D., 

Christian Helfrich, Ph.D., Chair, Organizational Function Working Group, 

PACT Demonstration Lab Coordinating Center, VA Puget Sound
VETERANS HEALTH ADMINISTRATION

Overview

• Second of two cyber seminars on findings on PC 

personnel experience from surveys

• January 16 - PACT Implementation: Findings from 

primary care surveys

– Michele Lempa, PhD, VISN 4 Demo Lab

• February 20 - Provider and Staff Experience with 

PACT: Results and recommendations from national 

and regional primary care surveys 
VETERANS HEALTH ADMINISTRATION

Participant question

• Do you have any involvement in PACT?

– No, and know virtually nothing about it

– No, but have some knowledge about the initiative

– Yes, am involved in researching or evaluating it

– Yes, am a clinician, staff member or administrator 

directly involved in implementing PACT

– Yes, involved in PACT in another capacity
VETERANS HEALTH ADMINISTRATION

Patient Aligned Care Team (PACT) initiative 

background

• VHA’s patient-centered medical home model

• Launched April 2010

• Multiple components

– Emphasis on team-based care

• PCP, RN care manager, clinical assoc. & clerical assistant 

• Share responsibility for defined panel of patients 

– Scheduling & alternatives to in-person visits; 

– Use of nurse care managers and additional health 

promotion support
VETERANS HEALTH ADMINISTRATION

Patient Aligned Care Team (PACT) initiative 

background

• Resources to support PACT implementation

– Funding to support the expanded staffing model

– Training, e.g., Regional Learning Collaboratives w/ VA 

Systems Redesign 

• 5 PACT Demonstration Laboratories: VISNs 4, 11, 20, 

22 & 23

• National Demo Lab Coordinating Center
VETERANS HEALTH ADMINISTRATION

2012 PACT Primary Care Personnel Survey:

Employee experience of PACT and burnout

Christian Helfrich, PhD

Emily Dolan, PhD

Organizational Function Working 

Group 

PACT Demonstration Lab Coordinating 

Center 

Survey fielded by the Healthcare 

Analysis and Information Group 

(HAIG)

Julie Kurutz – Project Manager

John Witzlib, MBA – Project 

Manager
VETERANS HEALTH ADMINISTRATION

Overview

• May 2012, PACT Demo Lab Coordinating Center 

fielded survey to all VA Primary Care personnel

• Goal was to help answer 3 questions:

1. To what extent has PACT been implemented?

2. What factors foster or hinder PACT implementation?

3. What’s PACT’s effect on employee burnout, 

satisfaction , perceived improvements in care, and 

training?
VETERANS HEALTH ADMINISTRATION

Survey methods

• Web-based survey 

• Fielded via e-mail from 10N through clinical 

leadership in Primary Care, Nursing, Pharmacy, Social 

Work, Nutrition

• Data collected from May 21, 2012 – June 29 , 2012

• 6,476 respondents, 5,404 are teamlet occupations

• Approximately 30% response rate
VETERANS HEALTH ADMINISTRATION

Respondent demographics for PACT survey

(n=6,476)

Age

30-49 years 46.9%

>= 50 years 48.3%

Tenure with 

VA

5-10 years 21.8%

> 10 years 36.3%

Supervisory 

level

No supervisory responsibility 62.9%

Some supervisory responsibility 37.1%

Teamlet

occupations

PCP, RN Care Manager, Clinical 

Associate or Admin Associate

78.2%
VETERANS HEALTH ADMINISTRATION

Burnout among PACT survey respondents 

compared to All Employee Survey (AES) 

respondents

Profession 

(categories

differ in AES)*

2012 PACT Survey 

Respondents 2012 All Employee Survey Respondents *

Primary Care only All VHA

Burnout n Burnout n Burnout n

Provider 45.4% 1,769 40.3% 2,565 28.1% 10,919

Nurse Care 

Manager 39.9% 1,135 -- -- -- --

Clinical 

Associate 30.7% 1,358 25.1% 2,934 25.3% 12,597

Administrative 

Associate 37.3% 557 33.9% 218 30.2% 3,948

RN (other than 

Care Manager) 33.8% 585 31.4% 3,699 30.4% 29,591

Total 36.6% 6,467 31% 11,674 28.1% 173,413
VETERANS HEALTH ADMINISTRATION

How do team members showing signs of 

burnout compare to those that don’t?

No signs of 

burnout

Signs of 

burnout

Hours per typical day spent 

on: Mean # of hours (SD)

Teamlet Huddles 0.75 (1.70) 0.59 (1.36)

Face:face w/ patients 5.02 (2.63) 5.34 (2.79)

Telephone w/ patients 2.33 (2.55) 2.47 (2.80)

Electronic w/ patients 0.87 (1.82) 0.87 (1.69)

% reporting staffed to 3.0 ratio 57.3 38.3
VETERANS HEALTH ADMINISTRATION

How do team members showing signs of 

burnout compare to those that don’t?

No signs of burnout Signs of burnout

Working to top of license %

• Spends < 1/4 time doing work that 

could be done by someone else 4.8 9.6

• Spends > 3/4 time on work wellmatched to training 1.6 3.0

• Spends < 1/4 time doing work for 

which has too little training 45.4 29.8

Mean # of hours per day (SD)

Team functioning

• Communication 3.48 (0.64) 3.48 (0.63)

• Decision-making 3.26 (0.78) 3.25 (0.78)

• Chaos 3.34 (0.90) 3.34 (0.91)

• History of Change 3.48 (0.86) 3.43 (0.88)
VETERANS HEALTH ADMINISTRATION

Differences between team members showing signs 

of burnout/no burnout, in what % of them rely on 

their teamlet/team “a great deal” to complete tasks

Clinical task No burnout Showing 

burnout

Receive messages from patients 68 68

Resolve messages from patients 60.5 60.7

Screen patients for diseases 54.5 51.2

Encourage lifestyle modifications 51.4 45

Educate patients about disease-specific self-care 51.2 44.3

Respond to Rx refill requests 51.1 51.1

Assess lifestyle factors 50.8 47

Gather patient preventive services history 49.8 43.8

Educate patients about medications 43.5 37.7

Complete forms for patients 38.4 20.5

Evaluate patients and make decisions 31.6 30.5

Track diagnostic data 30 28.6

Respond to diagnostic and treatment data 29.9 28.9

Follow-up on referrals 25.7 25.6

Respond to requests for Home Health Care orders 24.4 24.4
VETERANS HEALTH ADMINISTRATION

Burnout and Job Satisfaction by PACT 

teamlet membership and staffing

Belong to at least one

teamlet

2012 AES

Staffed to 3.0 

ratio

Staffed <3.0 

ratio

n 2492 2121 11,674 (n/a)

Overall % reporting 

signs of burnout 29.9% 49.7% 31%

Mean Job Satisfaction 3.9(1.1) 3.4(1.2)
VETERANS HEALTH ADMINISTRATION

Comparing burnout, team functioning and job satisfaction 

among respondents based on how helpful they found regional or 

national PACT learning collaboratives

Not available/Not 

involved

(n=1070)

Not helpful

(n=1104)

Somewhat or 

very helpful

(n=3176)

Burnout (% of respondents

showing signs of burnout) 45.3% 58.6% 28.0%

Team functioning mean(SD)

Communication 3.5(0.6) 3.5(0.6) 3.5(0.6)

Decision Making 3.3(0.7) 3.3(0.7) 3.2(0.8)

Chaos 3.3(0.9) 3.3(0.9) 3.4(0.9)

History of change 3.5(0.8) 3.4(0.9) 3.5(0.9)

Job satisfaction mean(SD) 3.5(1.2) 3.2(1.2) 4.0(1.1)
VETERANS HEALTH ADMINISTRATION

Comparing burnout, team functioning and job satisfaction 

among respondents based on how helpful they found local 

education sessions specifically about PACT 

Not available/Not 

involved

(n=821)

Not helpful

(n=1148)

Somewhat or 

very helpful

(n=3753)

Burnout (% of respondents

showing signs of burnout) 44.8% 61.0% 28.9%

Team functioning mean(SD)

Communication 3.5(0.6) 3.5(0.6) 3.5(0.6)

Decision Making 3.3(0.7) 3.2(0.8) 3.3(0.8)

Chaos 3.3(0.9) 3.4(0.9) 3.4(0.9)

History of change 3.5(0.8) 3.4(0.8) 3.5(0.9)

Job satisfaction mean(SD) 3.5(1.3) 3.1(1.2) 4.0(1.1)
VETERANS HEALTH ADMINISTRATION

% reporting “much” or “a lot” of improvement in 

patient-centered primary care since PACT, by 

profession 

N %

Provider 1,769 19.5

Nurse Care Manager 1,135 25.9

RN (other than Care Manager) 585 24.1

Clinical Associate 1,358 29.1

Administrative Associate 557 27.6

Total 6,467 24.6
VETERANS HEALTH ADMINISTRATION

How do nurse care managers showing signs 

of burnout compare to those that don’t?

No signs of burnout Signs of burnout

Hours per typical day spent on: Mean # of hours (SD)

Teamlet huddles 0.70 (1.03) 0.74 (1.54)

Face:face w/ patients 3.65 (2.25) 3.79 (2.75)

Telephone w/ patients 3.45 (2.21) 3.91 (2.79)

Electronic w/ patients 0.95 (1.56) 0.99 (1.78)

% reporting staffed to 3.0 ratio 57.3 38.3
VETERANS HEALTH ADMINISTRATION

How do nurse care managers showing signs 

of burnout compare to those that don’t?

No signs of burnout Signs of burnout

Working to top of license %

• Spends < 1/4 time doing work that 

could be done by someone else 5.2 11.8

• Spends > 3/4 time on work wellmatched to training 1.8 3.5

• Spends < 1/4 time doing work for 

which has too little training 41.9 23.5

Mean # of hours per day (SD)

Team functioning

• Communication 3.46 (0.65) 3.47 (0.65)

• Decision-making 3.25 (0.79) 3.23 (0.81)

• Chaos 3.35 (0.90) 3.40 (0.90)

• History of Change 3.50 (0.87) 3.42 (0.87)
VETERANS HEALTH ADMINISTRATION

Differences between nurse care managers showing 

signs of burnout/no burnout, in what % of them rely 

on their teamlet/team “a great deal” to complete tasks

Clinical task No burnout Showing 

burnout

Receive messages from patients 83.8 88

Resolve messages from patients 83.5 90.2

Educate patients about disease-specific self-care 75.7 74.3

Encourage lifestyle modifications 71.6 69.4

Educate patients about medications 69.4 67.4

Assess lifestyle factors 64.9 67

Respond to Rx refill requests 64.3 71.2

Evaluate patients and make decisions 55 57.4

Screen patients for diseases 53.3 55.9

Gather patient preventive services history 46.2 45

Respond to diagnostic and treatment data 46 47.5

Track diagnostic data 42 45.4

Follow-up on referrals 37.9 40.1

Respond to requests for Home Health Care orders 36.5 39.3

Complete forms for patients 24.8 26.6
VETERANS HEALTH ADMINISTRATION

How do PCPs showing signs of burnout 

compare to those that don’t?

No signs of burnout Signs of burnout

Hours per typical day spent on: Mean # of hours (SD)

Teamlet huddles 0.57 (1.19) 0.51 (1.28)

Face:face w/ patients 6.03 (2.01) 6.51 (2.44)

Telephone w/ patients 1.15 (1.97) 1.15 (1.76)

Electronic w/ patients 0.66 (1.54) 0.71 (1.23)

% reporting staffed to 3.0 ratio 52.2 33.0
VETERANS HEALTH ADMINISTRATION

How do PCPs showing signs of burnout 

compare to those that don’t?

No signs of burnout Signs of burnout

Working to top of license %

• Spends < 1/4 time doing work that 

could be done by someone else 2.8 5.5

• Spends > 3/4 time on work wellmatched to training 0.7 1.6

• Spends < 1/4 time doing work for 

which has too little training 48.2 28.6

Mean # of hours per day (SD)

Team functioning

• Communication 3.48 (0.62) 3.48 (0.62)

• Decision-making 3.28 (0.76) 3.27 (0.76)

• Chaos 3.32 (0.91) 3.32 (0.90)

• History of Change 3.45 (0.84) 3.49 (0.84)
VETERANS HEALTH ADMINISTRATION

Differences between PCPs showing signs of 

burnout/no burnout, in what % they rely on their 

teamlet/team “a great deal” to complete tasks

Clinical task No burnout Showing 

burnout

Receive messages from patients 61.6 55.3

Screen patients for diseases 51.9 46.9

Resolve messages from patients 47.5 41.4

Gather patient preventive services history 45.1 39.9

Respond to Rx refill requests 41.3 37.3

Assess lifestyle factors 38.2 35.8

Encourage lifestyle modifications 36.4 31.3

Educate patients about disease-specific self-care 36.4 29.5

Educate patients about medications 29.1 23.9

Evaluate patients and make decisions 23.6 21.4

Respond to requests for Home Health Care orders 23.1 18.7

Track diagnostic data 21.2 17

Respond to diagnostic and treatment data 21.2 19

Follow-up on referrals 20 17

Complete forms for patients 17.9 15.7
VETERANS HEALTH ADMINISTRATION

Limitations

• Response bias; no true denominator

– Comparisons to AES demographics positive

• Not possible to link observations to teamlets (only 

clinics)

– Limits ability to test for convergence at teamlet level and 

test associations

• Associations are cross-sectional & subject to method 

bias
VETERANS HEALTH ADMINISTRATION

Conclusions

• High levels of burnout among PACT occupations; 

similar to other recently published rates

• PACT staffing and training support negatively 

associated with burnout

• PCPs delegation of clinical responsibilities negatively 

associated with burnout for PCPs, but depends on 

activity for nurses

• Team functioning not associated with burnout

• Results should be viewed as descriptive and 

preliminary
VETERANS HEALTH ADMINISTRATION

Thoughts? Questions? Suggestions?

• We welcome your input now and later:

• Christian.helfrich@va.gov, 206-277-1655

• Emily.dolan@va.gov, (206) 277-4771
VISN 20 PACT Demonstration Lab:

staff experiences and associations 

with burnout

David Hickam, MD, MPH

Sandra Joos, PhD

Anais Tuepker, PhD

Jesse Byrd, BS

Melinda Leng, BS

Eleni Skaperdas, BA
Survey of Primary Care Clinic Staff

• Opted out of the national survey, modified 

administration and content

• Distributed to all clinic staff during an on-site visit, with 

one mail and 2 email reminders

• Completed in 11 clinics Aug ‘11- May ‘12

– 3 facility-based clinics (one in academic med center)

– 3 urban CBOCs within 15 miles of a VA hospital 

– 2 CBOCs in urban areas 50 &150 mi from VA hospital

– 3 CBOCs in rural areas 

● Overall response rate = 72%; Clinics = 58-100%
Respondent Characteristics

N Response 

Rate (%) % Femalea % at VA 

< 3 years

% at VA

> 11 Years 

% Hours 

per week 

> 40

PCP 60 70 52 31 40 68

NCM 60 87 89 27 52 63

Clinical Asso. 54 73 80 41 19 45

Clerical Asso. 18 37 79 33 17 65

Other Clinical 19

75

80 6 50 42

Other 

Clerical/Admin 14 57 36 57 50

Overall 226 72 74 31 38 58

a. 17% didn’t report
Teamlet Role Characteristics

PCP NCM Clinical

Associate

Clerical

Associate

% Assigned to teamlet 95 92 96 78a

% Staffed to 3.0 ratio 33 42 63 79

Median hours/day on:

 Huddles 0.40 0.40 0.50 0.20 n.s

 Face to face w/pts 6.00 1.25 5.00 4.00 p<.01

 Telephone w/pts 1.00 4.80 2.00 3.00 p<.01

 Electronic w/pts 0.50 0.50 1.00 1.00 n.s.

 Electronic not w/pts 2.00 2.00 1.00 1.00 p<.01

% who spend >75% of time 

on work well-matched to 

training

61 29 69 81 p<.000

a. 12% said “don’t know”
 Percent who endorse each level 

of burnout by role

Single item

level of burnout PCPs NCMs ClinicalAssociate

Clerical

Associate

1-2 (no 

 symptoms) 50 44 60 53

3 (burning out,

 > 1 symptom) 37 25 23 17

4 (symptoms

 won’t go away) 5 17 11 17

5 (completely 

 burned out) 8 14 6 12
Job Satisfaction by Teamlet Role

PCP NCM Clinical Assoc. Clerical Assoc.

% Somewhat or Very 

Satisfied with:

 Type of work 71 58 81 69 ns

 Relationships with 

 coworkers 65 62 75 59 ns

 Job overall 57 52 71 64 p = .02

 Amount of work 41 37 52 29 ns

 Working conditions 39 28 51 24 ns

 Opportunities for 

 promotion 22 25 26 6 p = .024

% somewhat or 

much less satisfied 

vs. 2 years ago

49 48 38 47 ns

% would leave if able 41 39 28 37 ns
Burnout and Job Satisfaction

 Symptoms of Burnout

% Somewhat or very

 satisfied with: Not present Present

 Type of work 81 56 p=.000

 Amount of work 56 24 p=.000

 Relationships w/ coworkers 77 53 p=.003

 Promotion opportunities 34 10 p=.000

 Working conditions 52 22 p=.000

 Quality of work provided 52 34 p=.010

 Job overall 85 34 p=.000

% Overall satisfaction greater 

vs. 2 years ago 61 10 p=.000

% Would leave if able 16 59 p=.000
Time spent on activities, staffing ratio 

and burnout

Burnout

not present

Burnout 

present

Hours/day spent on: Mean (SD) Mean (SD)

 Teamlet huddles 0.52 (.55) 0.44 (.52) ns

 Face to face w/ pts 3.89 (2.28) 3.94 (2.54) ns

 Telephone w/ pts 2.66 (2.15) 2.89 (2.22) ns

 Electronic w/ pts 0.69 (0.90) 1.07 (1.36) p = .015

 Electronic not w/ pts 2.12 (1.73) 2.73 (1.88) p = .014

% reporting staffed to 3.0 53.8 41.1 p = .086 

% who spend >75% of time

 on work well-matched to

 training

62 47 p = .04
% Who Perceive Barriers to Patient 

Care Differs by Level of Burnout

Factor limits ability to 

deliver patient-centered 

care "a great deal":

Burnout

not present

Burnout 

present

 Lack of support from 

 clinical leadership 13 37 p=.001 (NCMs)

 Lack of control over my

 schedule

21 39 p=.042 (PCPs)

 Lack of team members’

 responsiveness to my

 requests for assistance

8 23 p=.001 (NCMs)

 Inadequate time for pt.

 counseling or education 34 53 p=.05

 Inadequate time for

 follow-up care

26 52 p=.003 (PCPs & 

NCMs)

 Patient panels too large 50 68 p=.09 (PCPs)
Perceptions regarding PACT

Vary by Level of Burnout

Percent who: Burnout 

not present

Burnout 

present

Understand PACT

very well 66 64 ns

Confident they are 

capable of 

implementing PACT

54 42 p=.005

Confident team is 

capable of 

implementing PACT

59 37 p=.015

Confident PACT will 

improve care 60 44 p=.006

Have seen 

improvement 24 15 p=.021
Perception of team functioning & workplace

Burnout

not present

Burnout 

present

SOAP-C subscales: Mean (SD) Mean (SD)

 Communication/

 relationships 3.52 (.76) 2.93 (.77) p = .000

 Decision making 3.68 (.73) 2.95 (.79) p = .000

 Stress/work demands 3.40 (.75) 4.08 (.64) p = .000

 History of change 3.42 (.69) 3.10 (.72) p = .003

Some people lack skills they

 need to do team’s work 3.20 (1.1) 3.46 (1.1) p = .10

Some people do not carry 

 fair share of workload 3.43 (1.2) 4.10 (.89) p = .000

How seriously ideas taken 

 depends on who person is 3.24 (1.1) 3.60 (.91) p = .05
Summary

• Symptoms of burnout were present in a 

relatively high proportion of employees

• More dissatisfaction with amount of work and 

work conditions than with type of work, 

relationships or job overall

• Burnout and job satisfaction are strongly 

associated
Summary (continued)

• Burnout and satisfaction are strongly 

associated with:

– perceptions of barriers

– perceptions of PACT

– perceptions of team functioning and workplace 

environment
HSR&D CyberSeminar: 

Provider Perceptions and 

Experiences

Lisa Meredith

February 20, 2013
VAIL 

Evaluation

Patient Surveys

Electronic 

measures

Teamlet

effectiveness

evaluation

Clinician & Staff 

Surveys

Economic 

Evaluation

Implementation 

Evaluation

Practice 

Surveys

2
• VA

– Lisa Rubenstein, Becky Yano, Lisa Altman (Co-PIs)

– John McElroy

– Jill Darling

– Barbara Simon

– Susan Stockdale

– Kristina Cordasco

• RAND

– Lisa Meredith

– Nicole Schmidt

– Tania Gutche, Bas Weerman, Bart Orriens (MMIC)

Survey Team

3
• Track changes in clinician and staff knowledge, 

attitudes, and reported behaviors related to 

PACT and VAIL implementation

– Important for efficient redesign of care 

processes, identification of “best practices”

• Two waves: “early” and “later”

– Early wave (11/29/11-3/9/12) replaced PACT 

National Survey

– Formative feedback, pre-post changes, VAIL vs. 

no VAIL, factors associated with changes

VISN 22 PACT Surveys

4
• By Health Care System:

Response Rates

Health Care System Sample Size RR

GLA 201 67%

LOMA LINDA 89 60%

LONG BEACH 75 66%

SAN DIEGO 118 61%

SOUTHERN NEVADA 32 55%

Overall 515 63%

5
• By Demo Site Groups:

Response Rates

6

Demo Site Groups Sample Size RR

NON-DEMO 234 63%

PHASE 1 (3 sites) 85 60%

PHASE 2 (3 sites) 196 65%

Overall 515 63%
PCC PC Staff

Provider

Characteristic

MD

(n=131)

NP / PA

(n=60)

RN

(n=108)

LPN / 

LVN

(n=114)

Other 

Staff 

(n=102)

% Female 36 85 83 80 67

% Latino 5 5 10 25 23

% Non-White 

Non-Latino 50 46 56 69 71

Mean (SD) Age 49 (10.3) 52 (9.9) 48 (10.4) 43 (11.9) 43 (12.7)

Mean (SD) Years 

in Clinic 12 (8.8) 10 (7.8) 6 (7.5) 6 (6.3) 6 (6.8)

Demographics and Years in Clinic

7
8
Burnout has consequences

• Negative mental and physical health 

outcomes

• Reduced work performance

–Lower productivity and effectiveness

• Lower organizational commitment

–Absenteeism

–Turnover/intention to quit

9
Some factors may be linked to burnout

• Dissatisfaction with work

• Unsupportive learning environment

• Not ready for change

• Insufficient time

• Lack of respect/support by leadership

• Poor communication

• No control over schedule

• “Difficult encounters”

10
Components of Burnout

Emotionally drained from work

Feel used up at end of workday

Working w/people all day is a strain

Burned out from work

Fatigued when get up in morning to 

face another day at job

Frustrated by job

Working too hard on job

Working with people directly is too 

stressful

End of my rope

Doubt significance 

of work

Less enthusiastic 

about work

Just want to do 

job and not be 

bothered

Exhilarated when 

accomplish 

something at work

Have 

accomplished 

many worthwhile 

things on the job

Good at job

Emotional Exhaustion Cynicism Professional Efficacy

α=.92 α=.68 α=.59

α=.90 (total scale)

11
0

5

10

15

20

25

30

35

40

All PCCs Staff

Average 

Burnout

Non-VAIL

Demo Phase 1

Demo Phase 2

Burnout: No Differences by Demo but 

Differences Across Respondent Type

12

p < .01

Cronbach’s Alpha = .90
0

5

10

15

20

25

30

35

40

Average

Burnout

Burnout Differs By Job Type

p<.001

(Total burnout scores can range from 0 to 90)

13
0 % 20% 40% 60% 80% 100%

MD

PA/NP

RN

LPN/LVN

MH/SW

Dietician/Nutritionist

Pharmacist

Health/Med Tech

Low Med High

Emotional Exhaustion Differs By Job Type

14
0 % 20% 40% 60% 80% 100%

MD

PA/NP

RN

LPN/LVN

MH/SW

Dietician/Nutritionist

Pharmacist

Health/Med Tech

Low Med High

Cynicism Differs By Job Type

15
0 % 20% 40% 60% 80% 100%

MD

PA/NP

RN

LPN/LVN

MH/SW

Dietician/Nutritionist

Pharmacist

Health/Med Tech

Low Med High

(Lack of) Professional Efficacy Differs By 

Job Type

16
0 % 20% 40% 60% 80% 100%

GLA

LOMA LINDA

LONG BEACH

SAN DIEGO

SOUTHERN NEVADA

Low Med High

Burnout differs by Medical Center

17
0 % 20% 40% 60% 80% 100%

National Sample of MDs

VA Sample PCCs

VA Sample Other Staff

Low Med High

Comparing VA and National Sample of MDs 

(Shanafelt)

18
Organizational Functioning Measures

Measure Description

Team skills and process Members of the clinical team have enough 

experience and skills, and share information

Psychological safety Staff and clinicians are comfortable expressing 

their thoughts about work and owning up to 

mistakes 

Openness to new ideas Staff and clinicians are encouraged to explore 

novel approaches 

Decision-making Clinicians, nurses, and other staff are 

encouraged to be involved in decision-making, 

taking initiative, and making improvements

Communication Clinic team members have constructive work 

relationships and are able to resolve conflict 

and reduce tension

Cross-discipline 

communication

Co-workers from different clinical and 

administrative backgrounds work together 

effectively

Leader norms and 

readiness to change 

Leadership and management work 

cooperatively to make changes and understand 

implementation challenges 

19

Learning

Climate

Organizational

Communication
Correlate of Burnout

Overall 

Burnout

Emotional 

Exhaustion

Cynicism Professional 

Inefficacy

Satisfaction -0.63 -0.57 -0.59 -0.30

Teamlet Satisfaction -0.39 -0.32 -0.37 -0.27

Individual Readiness -0.36 -0.29 -0.33 -0.29

Team Skills & Process -0.37 -0.29 -0.34 -0.32

Psychological Safety -0.45 -0.40 -0.44 -0.21

Open to Ideas -0.36 -0.33 -0.32 -0.16

Decision making -0.46 -0.40 -0.46 -0.25

Communication -0.44 -0.38 -0.41. -0.26

Cross-discipline

Communication -0.39 -0.31 -0.39. -0.29

Leadership Norms &

Readiness -0.40 -0.33 -0.39 -0.26

All of the hypothesized factors are significantly 

negatively associated with burnout

20 All p<.01
Model

Demos & 

Prof Chars.

Clinic Chars. Org. 

Climate

Individual

Experiences

Intercept 24.80 28.17 51.68 60.56

Age -0.04 -0.06 -0.03 0.01

Male -3.80*** -3.69** -4.03*** -3.06**

Latino -7.24*** -7.70*** -6.16*** -6.44***

Non-white, non-Latino -1.15 -1.19 -0.22 0.30

Primary care clinician 4.25*** 4.31*** 3.85*** 1.39

Years at clinic -0.13 -0.11 -0.10 -0.04

Miles to nearest VAMC -0.01 0.01 0.01

Panel size 0.00 0.00 0.00

Number of providers -0.08* -0.06 -0.03

Learning climate -0.32 -0.30

Organizational communication -0.47* -0.14

Decision-making -0.37 -0.13

Leadership -0.20 0.01

Job satisfaction -5.13***

Teamlet satisfaction 1.30*

Team skills and process -0.15

Individual readiness -0.45*

R2

. 07 .09 .27+ .40

Summary of Regression Models for EE (n=344)

21
0 10 20 30 40 50 60

Inadequate visit time: counseling or education

Inadequate visit time: follow-up care

Lack of support for patient behavioral change ...

Lack of responsiveness to requests for teamlet ...

Limited patient benefits (ns)

Preferred medication difficult to obtain (p<.05)

Lack of respect for clinical expertise by ...

Difficulty accessing specialist care

Poor communication with specialists

Lack of control over schedule

Lack of clinical leadership support

Lack of system leadership support

Limits a great deal Limits somewhat Does not limit

All significant at p<.001, except as noted. 

Burnout is lowest among those who do not 

experience barriers

22
0 5 10 15 20 25 30 35 40 45 50

New measurement tools***

Teamlet huddles**

Information systems**

Feedback on performance***

New scheduling approaches**

Small tests of change**

Very helpful Somewhat helpful Not at all helpful

Burnout is lower among those who find 

PACT helpful

*p<.05; **p<.001; ***p<.001 23
• To prevent and reduce burnout among primary care staff, 

create an environment that:

– Appropriately recognizes special skills

– Provides staff with a sense of psychological safety

– Leverages cross-disciplinary communication

– Encourages all staff to participate in decisions

– Has leadership that champions the change

– Minimizes barriers to providing optimal care

Implications for Burnout in VA 

Primary Care

24
Lisa S. Meredith, Ph.D.

Senior Behavioral Scientist

Associate Director, Behavioral and Policy Sciences Research Department

Professor, Pardee RAND Graduate School

Research Scientist, VA HSR&D Center for the Study of Healthcare Provider Behavior

RAND Corporation

1776 Main Street

Santa Monica, CA 90407-2138

Phone: 310.393.0411, x7365

FAX: 310.260.8152

Email: lisa_meredith@rand.org

Questions

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