As we have seen across the past few months, the ramifications of the Dobbs v. Jackson decision are far-reaching. Not only do leaders have to navigate consequences for patients themselves, but they must also balance the needs of the clinical workforce. Here are a few ways that leaders of provider organizations should address the most pressing impacts of the ruling on their workforce right now.
1. Continue revisiting care delivery protocols as legislation changes.
The legal landscape around abortion in the United States has and will continue to change rapidly, making it difficult for clinicians to keep track of changes in real time. Since the ruling, we've seen a wave of new abortion bans enacted in states, followed by almost immediate challenges to the law in each state—many of which are still being worked out by the courts.
The ruling has also sparked many states to consider new abortion restrictions, such as Indiana's near-total abortion ban, which took effect in September, and Kansas's proposed abortion amendment, which was not passed by voters.
At the same time, the federal government has extended the Federal Emergency Medical Treatment and Labor Act (EMTALA) to override state abortion restrictions when the mother's life is at risk. Some states, including Texas and Idaho, have already seen this guidance challenged in courts.
All that to say that the current legal landscape has created a "can I/can't I" environment in many states, making it impossible for clinicians to keep up with current regulations and complicating care for pregnant people. Because of this, lawyers now need to be more involved in clinical decisions than ever before, especially in states that are seeing rapidly evolving laws and responses. Without this legal guidance, providers can easily fall into clinical paralysis.
As operational complexity increases, so will confusion among your staff. And confusion isn't just limited to abortion procedures themselves—the Dobbs v. Jackson decision will impact other aspects of care as well, down to collecting medical histories and performing routine pregnancy tests during exams. Now is a time to be consistently revisiting your clinical workflow and communication strategies.
As you change care delivery protocols, ask yourself the following self-assessment questions:
- Have we reviewed and updated all relevant care processes (at a minimum OB/GYN, ED, primary care)?
- Have we established clear triggers to revise clinical protocols when laws change in the future? Who is responsible for triggering those changes?
- Are we following consistent criteria and cadence for communicating legal changes to staff?
- Have we established a protocol for clinical decisions that our frontline staff have identified as newly complex or uncertain, such as determining whether a mother's life is at risk?
- Do we have a procedure for collecting and distributing guidance to staff as new types of clinical decisions arise?
- If we operate across state lines, have we taken into account different local variation in our protocols and how they are communicated to local staff? How are we making it easy for staff who work across state lines to access the relevant protocols?
2. Include all front-line staff in training on protocol changes.
Clinical uncertainty isn't limited to providers. While it's true that physicians and nurses are bearing the brunt of liability, the same feeling of paralysis is being felt by anyone talking to patients and documenting medical histories moving forward. In fact, that paralysis may be even more intense for non-providers as it adds a new set of protocols and ramifications to ordinarily routine tasks. As such, provider organizations need to redefine who's considered "frontline staff."
At minimum, we suggest training front desk staff, medical assistants, and ultrasound technicians, as these staff will often be interfacing with patients before they reach the clinician. Their roles also often require them to ask questions (e.g., date of last period) or performing exams (e.g., sonogram) that could have legal ramifications.
Leaders must work with staff to decide what to both ask and document during scheduling, medical history gathering, procedures and follow-up—and then expand training, education, and legal protections to cover the majority (if not all) of the workforce.
To revamp your communication protocols, ask yourself the following self-assessment questions:
- Are there communication protocols or committees we assembled to quickly respond to Covid-19 that we can repurpose to scale communication around abortion to all staff?
- Have we conducted training for physicians, APPs, and nurses to react to potential changes in the laws, and taken into account feedback on gaps in that initial training?
- Have we developed and distributed communication guidelines to all staff who communicate with patients in any way (e.g., schedulers, front desk staff, MAs)?
- Have we audited for new roles who require this training since the Dobbs ruling?
- Have we reviewed clinical documentation practices and removed questions we should no longer ask patients or document?
- Have we trained all staff on new protocols?
3. Ramp up your burnout strategy to address the additive impacts this will have on the current workforce crisis.
Especially in the wake of Covid-19, more clinicians are experiencing burnout than ever. And while the Dobbs v. Jackson ruling will impact people all over the country in different ways, we expect that this ruling is exacerbating health care worker anxiety and exhaustion. Providers—ranging from the ED to OB/GYN to oncology—are experiencing moral distress associated with not being able to perform a procedure they believe is medically necessary. The potential legal ramifications discussed above put even more stress on provider decisions, as they must take into account not only patient care but also potential consequences for themselves or their employer.
Regardless of what side of the abortion debate they are on, many providers object to the government's intrusion into medicine and the patient-physician relationship. We know that the top thing physician value in their roles is autonomy, especially autonomy to make the decisions that are best for their patients. In an industry that is increasingly limiting the autonomy of physician decisions in favor of standardization, this ruling will be an additional burnout driver for many. In addition, the uncertainty and confusion in states where the landscape is rapidly evolving that we have discussed is adding to the complexity of care decisions, even further exacerbating burnout.
Finally, we know that this decision will be trigging for staff on both sides—especially female staff. After all, health care employees are humans who have feelings, opinions, and beliefs that don't disappear when they walk into work. Since women make up over three quarters of the health care workforce, it's safe to assume that a majority of your staff is processing and having reactions to this decision. This is yet one more reason to double down on your burnout strategy amidst an ongoing workforce crisis.
To refine your burnout strategy, ask yourself the following self-assessment questions:
- Do we have a good enough sense of our staff's views on this issue to understand variation among our employees and where policies conflict with personal beliefs? Do we need to take additional steps in surveys, listening sessions, focus groups, etc. to better understand our employees' views?
- Have we instituted sustainable support systems for staff to discuss these issues (e.g., peer groups, chaplains, mental health practitioners)?
- Are there segments of our workforce who have experienced disproportionate impacts of both Covid and this ruling (e.g., ED staff, ICU team)? Have we identified steps to support them specifically?
- Have we assessed how this ruling impacts our employee value proposition? Do we need to add any additional initiatives to balance out any loss of the employee value proposition (e.g., autonomy) deriving from this ruling to help retain our workforce?
Address near-term pressures, and prepare for further changes in the future.
As laws change and will continue to change, so should your organization's strategy and communication approach. Above are the short-term challenges we need to consider, but leaders should also be thinking about longer term implications for the workforce, which we'll discuss in a forthcoming post.