Clinician Turnover and the EHR Experience

At the beginning of 2020, KLAS began asking clinicians in our Arch Collaborative survey how likely they are to leave their organization in the next two years. More than 59,000 clinicians have responded to date. Using this data, we hope to shed light on which clinicians are likely to leave and what related factors healthcare organizations can influence to improve clinician retention and resolve clinicians’ concerns. This report focuses on physicians, advanced practice providers (APPs), nurses, and allied health professionals; physician residents and fellows are excluded since they are generally not expected to stay at one organization long term.

An Overall View: What Clinicians Are Most Likely to Leave?

The percentage of clinicians reporting they are likely to leave their organization has fluctuated somewhat over the two years the question has been asked; it was highest overall in the Q3 of 2021. Compared to other clinical backgrounds, nurses are the most likely to have plans to leave in the next year. In Q1 of 2021, 26% of surveyed nurses reported plans to leave (the period with the highest reported percentage). This spike could be attributable to a number of factors, including the increase in acute COVID-19 cases at the time, more prevalent cultural and political antagonism toward healthcare, and the resulting strain on healthcare workers. Clinician burnout similarly grew in Q1 of 2021.

Beyond clinical background, the Arch Collaborative also asks about other factors such as burnout, training, and various aspects of the EHR experience. By breaking clinicians into groups based on their answers to these and other survey questions, the Arch Collaborative has identified the clinician cohorts most likely to leave.

The rest of this report takes a closer look at each of these cohorts, including providing resources and insights for organizations trying to improve the experience of these highly vulnerable clinicians. Some of the most actionable factors are discussed in this Executive Insights section; see the Expanded Insights section of the full report for insights on additional factors.

A Deeper Dive on Actionable Factors That Contribute to a Clinician’s Likelihood of Leaving

All Levels of Burnout Associated with Attrition Risk; When Completely Burned Out, Clinicians More Likely to Leave Than Stay

Burnout is the indicator most strongly correlated with how likely clinicians are to leave their organization in the next two years. KLAS’ 2021 Clinician Burnout report found a link between burnout and attrition, especially among nurses. This report has identified that as burnout increases, so does likelihood to leave—suggesting that addressing the problems of burned out clinicians could help reduce turnover. Attrition could also be lowered by preventing clinicians from becoming severely burned out in the first place—while clinicians who are completely burned out are most likely to leave, attrition likelihood grows rapidly beginning with those who report definite symptoms of burnout. This, coupled with the sheer number of clinicians who report they are under stress or definitely burning out, suggests that there is real opportunity to reduce turnover by addressing burnout in early stages and preventing it from getting worse. To learn more about how other healthcare organizations are tackling burnout, see the case studies from UW Health (on their strategy for using virtual scribes to help reduce burnout) and Spectrum Health (on how they prioritize clinician wellness). (For more insights on burnout and other contributing factors, see KLAS’ reports on COVID-19 related burnout and nurse burnout.)

Clinicians Likely to Leave Often Cite Organization-Level Problems as Contributors to Burnout

Clinicians planning to leave are twice as likely to report a lack of shared values with organization leadership as a contributor to burnout (compared to those who are not likely to leave—35% versus 17%). Other factors with large gaps include lack of effective teamwork (38% to 23%), chaotic work environment (47% to 35%), and lack of autonomy in the job (23% to 12%). The common attribute of these contributors, along with several other leading responses, is that they can all be influenced by the organization’s governance structure. KLAS has previously reported that clinician perceptions of their organization are correlated with their level of burnout (see also the section below on trust in IT).

Low Trust in Organization and IT Leadership Correlated with Likelihood to Leave

Among clinicians who strongly disagree their organization has implemented, trained on, and supported the EHR well, more than one-third say they are likely to leave their organization in the next two years—a larger proportion than any other clinician cohort. In collaboration with several healthcare leaders, the Arch Collaborative published an article in the Journal of the American Medical Informatics Association (JAMIA), which shared that agreement that the organization delivers well is also correlated with lower burnout. Measures aimed at increasing clinician trust in the organization could have a positive effect on burnout and reduce clinicians’ desire to leave the organization. For instance, establishing a system of two-way communication between end users and the organization/IT leadership can help improve clinicians’ perception of their organization. More insights on how to achieve this can be found in the Clinician Trust in Organization/IT Leadership report. Some Collaborative organizations have also shared the strategies they used to improve clinician trust in the organization—demonstrating expertise, establishing a reliable support structure, and improving communication.

Satisfaction with other EHR stakeholders (vendors and end users themselves) is similarly correlated with likelihood of leaving—see additional details in the Expanded Insights section of the full report.

Users Who Are Satisfied with the EHR Are More Likely to Stay

Overall EHR satisfaction^† is also correlated with the likelihood that a clinician is planning to leave their organization. Those who are very dissatisfied with the EHR have almost three times the proportion reporting they are likely to leave compared to clinicians who are very satisfied with the EHR. When clinicians feel the EHR is a help rather than a hindrance, they are more likely to want to stay at their organization. Healthcare leaders should focus on improving the areas of EHR satisfaction with the most room to improve. At a foundational level, organizations need to ensure their EHR has solid reliability (i.e., uptime) and quick response time, as these issues can overshadow even an otherwise good EHR experience. Additional insights on EHR satisfaction can be found in a number of other Arch Collaborative reports including the 2020 Arch Collaborative Guidebook and The Science of Improving the EHR Experience.

Less Afterhours Charting Can Improve the Clinician Experience

One strategy to improve EHR satisfaction is to reduce providers’ and allied health professionals’ afterhours charting time. While some clinicians chart after hours by choice, those who are efficient enough in the EHR to complete most of their charting during business hours tend to be more satisfied with the EHR and less burned out. Charting efficiency can also be improved by implementing personalizations that are the most appropriate for each clinician’s workflow. More details can be found in the Immediate Chart-Closure Rates report.

Unproductive or Duplicative Charting by Nurses Is Correlated with Attrition

30% of nurses who report spending five or more hours doing duplicative or unproductive charting per week also say they are likely to leave their organization in the next two years. Reducing charting burden can have a dramatic impact on nurse satisfaction. After Sutter Health, an Arch Collaborative participant, optimized their nursing workflows and drastically reduced nurse charting requirements, they saw a 44.7% increase in their Net EHR Experience Score (see their case study for more details).

Tailoring Training to Specific Workflows Could Help Lower Turnover

Just because a clinician has learned the EHR’s functionality does not mean they will be successful or satisfied with the EHR. One of the best practices found in Arch Collaborative research is that case-based (or workflow-specific) training—where clinicians learn to use the EHR in the context of their specific role—is highly effective. Clinicians who strongly disagree their training was specific to their workflow are more than twice as likely to report planning to leave their organization compared to those who strongly agree training matched their workflows. Additional insights can be found in the Expanded Insights section of the Clinician Training 2021 report, which dives deeper into workflow-specific training.

Among clinicians who are likely to leave, 49% agree or strongly agree EHR training matched their workflows, compared to 61% of clinicians not likely to leave. Updating training programs to be more tailored to clinician workflows could help decrease attrition rates.

What Is the KLAS Arch Collaborative?

The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 250 healthcare organizations have surveyed their end users and over 240,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR. To participate in the Arch Collaborative, go to https://engage.klasresearch.com/klas-arch-collaborative/.