Why it’s so hard to work at top of license
Doctors and nurses want to be with patients. They want to be caregivers. The problem is that they are tasked with too many other things that make it difficult for them to work at top of license.
Top of license work has long been an aspiration of our clinical workforce. We want all of our clinicians’ education, training, and expertise to be put to use. We want to steer their work and workflows away from things where all of that training and expertise doesn’t add any value.
Advisory Board’s research on top-of-license work for nurses and care teams across the past decade has consistently said the same thing: there are competing and consistently escalating demands on clinicians that make it hard to practice at top of license. The reality is that we need clinicians practicing at top of license because care complexity continues to increase in terms of the number of conditions, comorbidities, medications, and providers a patient has.
"Fatigue rarely comes from the specific thing people are supposed to be or want to be doing, like patient care. It comes from all of the additional [things] we ask them to do, typically administrative, not top-of-license stuff."
- Health system executive
At the same time, the administrative burden on clinicians is enormous. “Too many bureaucratic tasks” is the top contributor to clinician burnout: nearly three out of five physicians say it is the biggest contributor to their feelings of burnout. That’s not a surprise: between one-third and one-half of physicians’ time is spent reviewing medical records and writing notes.
Unfortunately, most health care organizations see hiring more staff as the only way to address the complexity of care and to relieve the administrative burden. The reality of provider finances and labor markets is that they can’t add staff—they can’t afford it, or qualified candidates aren’t available, respectively. Nine out of every 10 nurses say that they have considered leaving the nursing workforce, mostly because of staffing constraints.
Advisory Board has literally written the book on care-team redesign, and that undertaking is an important step in understanding and advancing top-of-license practice. But given the increasing complexity of the issue, it’s not unreasonable to think that health care has reached a point where clinicians simply can’t practice at top of license without a new approach to the problem.