HealthManagement, Volume 22 - Issue 5, 2022

Frontline clinicians are emotionally exhausted, mentally fatigued, and pessimistic about the future, often due to the complex, inefficient environments they work in each day. Solving this requires a systems-based approach to creating highly reliable systems in healthcare. One good place to begin is by making it easier for the frontline to know what they are expected to do, how to do it, and where to find it. A standardised approach to organising the documents that guide care (the 6Ps of Clinical Practice) is outlined in this article.

Key Points

  • Clinician burnout began long before the pandemic and has only worsened in recent years.
  • The root causes of burnout are system factors that can be addressed by creating highly reliable systems.
  • There is often a disconnect between work as imagined (WAI) and work as done (WAD). Making expectations clear, easily accessible, and easy to follow can help to eliminate this disconnect.
  • Burnout is reduced in organisations that make it easy for the frontline to understand and follow expectations.


The COVID-19 pandemic pushed many health workers across the world to their breaking point, as they faced severe fatigue, high mortality, and fear for their own families. The resulting emotional exhaustion and moral distress has led to unprecedented levels of burnout, but it’s important to remember that this is a problem that began a long time ago. The pandemic just highlighted a crisis that we have ignored for years.

In 2019, the National Academies of Medicine (NAM) in the U.S. released the report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, and called out clinician burnout as a major, alarming problem that required immediate action. Needless to say, the pandemic that occurred the following year only worsened this already significant problem in healthcare. Clinicians everywhere are now more emotionally exhausted, mentally fatigued, and pessimistic about the future than ever. Many healthcare organisations have responded to this crisis through a mental health lens, providing free psychological help, establishing meditation rooms, or providing free chair massages. These are all wonderful ideas and quite necessary in some circumstances, but most hospitals have still not addressed the real root cause of burnout: the complex, inefficient environments that most clinicians work in each day.

Ever since the Institute of Medicine (now NAM) report, To Err is Human: Building a Safer Health System was published in 1999, healthcare leaders have been working towards using a systems-based approach to redesign care (Kohn 2020). We have implemented lean management systems, focused on improving safety cultures, and advanced technology in many areas. But despite twenty years of this dedicated effort, the 2019 report found that the root cause of clinician burnout remained system factors that make a healthcare organisation a very difficult place to work. The pandemic only worsened this, as many of the systems-based solutions that had been put into place crumbled under the pressure of this extraordinary crisis. With bedside caregivers now leaving the profession at unprecedented rates, staffing shortages have magnified the difficulty of meeting the expectations of providing safe, high-quality care.

Creating the systems-based approach we need to become more reliable in healthcare is not an easy fix. It requires a culture of transparency, honest reporting of errors, the effective use of data to drive decision-making, a clear framework for improvement, and leaders who are skilled in managing change. If your organisation is already on this journey, then you are on the right track, so keep going! If you are not, begin by learning more about high reliability organisations (HROs) in healthcare and get started. Either way, you can begin improving the work environment today, by making it really easy for the frontline to know what they are expected to do.

The 6Ps of Clinical Practice

In most organisations, there is a disconnect between what the executives think is happening and what is really happening on the frontline. “Work as imagined” (WAI) is created by leaders who know the best practice standards in the form of various “documents” (electronic or paper) that guide care. These documents can be summarised into six categories, which I refer to as the6P’s of Clinical Practice:

  1. Practice guideline summaries
  2. Policies, procedures, and standard work
  3. Protocols, pathways, and order sets
  4. Patient education material
  5. Patient care documentation requirements
  6. Professional development and training modules

These documents exist in some form in every healthcare organisation and are intended to provide clear expectations for practice. However, “work as done” (WAD) often does not follow the guidance outlined in the 6Ps, for several reasons. Consider whether any of these scenarios are true in your organisation:

  • The sheer number of these documents is overwhelming, numbering in the thousands, and making it very difficult for the frontline to keep up. In many cases, they don’t even know the documents exist.
  • There is duplicate and/or conflicting information between the policy, protocol, or another document, leading to care variations and distrust that any of the information is accurate.
  • There is no central location where all of these documents are stored. Policies and procedures are located in an online manual that is difficult to navigate and time consuming to search. Standard work documents were created by performance improvement teams and saved on a shared drive outside of the policy management system. Some protocols are outlined in a policy, others are embedded in the EHR or on paper. Professional development is in the form of online powerpoint modules that are outdated yet still available. And none of these are in the same place.
  • There is no standard that outlines whether guidance is provided in the form of a policy, protocol, powerpoint presentation, or wall art in the bathroom. Each team/individual that develops them decides the best way to deliver the information, so the policy may not even be consistent with the protocol.
  • The policy, procedure, etc. is not followable: the care processes, physical environment, or staffing levels make it difficult or impossible to do what is expected.

Some aspects of the above scenarios are true in nearly every healthcare system, adding to the burden of providing clinical care today. Healthcare organisations can begin addressing the issue of burnout just by focusing on how to make it easier for the frontline to know what is expected of them, and then engaging them in process improvement work that makes it easier for them to meet those expectations. You can start by gathering an improvement team that includes frontline leaders and clinicians, and apply the five-step methodology tool known as “5S” to all of the documents that provide guidance for care.

5S Your 6Ps

  1. Sort all of the documents (paper or electronic) that exist in your organisation according to the 6Ps. How many of each do you have? What outdated documents still exist in various departments that are posted, saved in personal drives, or copied and stored in file drawers? Combine content that is duplicative and eliminate conflicting information.
  2. Straighten (or set in order) by determining the best location to maintain the documents. Ensure that any online manuals can be easily searched, and that all content related to a specific patient population is retrieved at the same time. For example, when searching for guidance on the care of the patient with restraints, congestive heart failure, or diabetes, all related policies, procedures, protocols, etc. are displayed together. If that is not possible, consider creating links to documents that reside in different systems.
  3. Shine the documents by building an analysis of WAI (work as imagined) vs WAD (work as done) into the current state assessment of every improvement project. Teams should examine all of the 6Ps that outline organisational expectations and then build process maps that outline what is actually happening. The solution plans that result from the improvement project should include action items to further “shine” the documents. Each team should continually keep in mind the questions, “Is this easy for the frontline to understand? To find? To do?”
  4. Standardise the process by aligning this work with all committee work and your policy management review schedule. Ensure that all improvement teams are communicating with each other so that any newly developed or revised content to any of the 6Ps is aligned.
  5. Sustain the new document management process by aligning improvement efforts with your educational processes. Ensure that the objectives for all training incorporate the 6Ps into the content. For example, locate the documents that guide care, demonstrate applicable clinical skills, discuss relevant protocols, verbalise appropriate education material, and demonstrate accurate patient care documentation.


Often, there is a disconnect between the people who know best practice standards, those who create the documents that guide practice, the teams that provide education and training, and the frontline caregivers. This results in fragmented communication of organisational expectations and variations in practice, leading to an increase in unintentional medical harm and burnout. Although a total transformation for healthcare to become highly reliable organisations is necessary to solve problems through a systems-based approach, you can begin to reduce burnout just by making it easier for frontline caregivers to know what to do and where to find those expectations.

Conflict of Interest



Kohn LT, Corrigan J, Donaldson MS (2000) To err is human: Building a safer health system. Washington (DC): National Academy Press.

National Academies of Sciences, Engineering, and Medicine (2019) Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press.