COVID-19 has introduced unique stressors to the health care community over the past year. The overall impact of COVID-19 on the health care workforce will likely have lasting effects in the years ahead. While the pandemic has opened up new avenues for innovation, it has also introduced great strain on many of our caregivers. Join us for a panel where we’ll discuss the evolving data on clinician burnout and well-being and provide insights into innovative strategies to combat clinician burnout for the long-term.
What does health care look like in 20 years if we are successful in centering the well-being of the health care workforce and reducing burnout? What does it feel like to be a physician in that future state?
Are there any specific resources you've found particularly helpful in gauging the effects of burnout on your organization and strategies on how to address it?
The AMA offers various toolkits on burnout and wellbeing that I'll link to here! edhub.ama-assn.org/steps-forwa...
Our organization has approached the mitigation of burnout in a variety of ways. One particularly helpful intervention has been our Peer Processing Groups which emerged during COVID. This intervention involved a mental health professional and a leader working together to co-facilitate a small group discussion. Initially, the leader demonstrated vulnerability by sharing their story. When other members of the team heard their story there was a clear recognition of a shared narrative. From here, people's stories, responses and feelings were validated. The co-facilitators then discussed what coping strategies people had find helpful and which ones not helpful. There was dialogue around sense making and what we could take from this experience. Ultimately the goal was to move toward post traumatic growth and away from PTSD. This intervention helped to build connectivity, a shared story and helped bring teams closer. This intervention is still ongoing and the conversations have morphed to include other traumatic experiences including thoughts and feelings around vaccination, politics, race, etc....Peer Processing Groups is just one of many interventions but this one has had particular impact in helping people cope with the impact of COVID.
We strive to provide ongoing team opportunities to review the scientific research and recommendations from experts, including models, strategy, and tactics. Then together we can tailor solutions or interventions to meet our unique needs and priorities. In addition to the AMA Steps Forward Modules, below are a few resources we have used:
*Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org)
*Shanafelt et al. A Blueprint for Organizational Strategies To Promote the Well-being of Health Care Professionals. NEJM Catalyst. Vol. 1 No. 6 | November — December 2020
*DeChant et al. Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review. Mayo Clin Proc Inn Qual Out 2019;3(4):384-408
*Shanafelt et al. Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Academic Medicine, Vol. 96, No. 5 / May 2021
*Shanafelt et al. Healing the Professional Culture of Medicine. Mayo Clin Proc. 2019;94(8):1556-1566
For a deeper dive:
*Swensen & Shanafelt. Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace. Mayo Clinic Scientific Press/Oxford Press 2020. [Great book consolidating evidence, strategy, and specific tactics. We are using this in a year long program, meeting monthly to review a portion and create action plans for specific areas and for systemic work].
*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. doi.org/10.17226/25521.
National meetings such as the American Conference on Physician Health (ACPH)
AMA offer no-cost assessment services in which we work with health systems to deploy the validated Mini-Z burnout assessment, analyze results, and identify interventions for improvement. Interested sites can reach out to me directly at Kyra.Cappelucci@ama-assn.org or can learn more here: ama-assn.org/system/files/2020...
Throughout COVID, we have begun to work with many organizations that are thinking about burnout/well-being for the very first time. What advice would you share with leaders who may just be entering this space and don’t know where to start?
Approaching wellness work and knowing where to start can be overwhelming. In my opinion, the first place to start is through asking and listening. All systems and organizations are unique. It's important that you understand the culture of your organization including the unique pebbles, rocks and boulders that impact your clinicians and employees. After asking and listening, you need to pick a measurement tool so that you know where you are at in terms of your overall well-being, distress, or burnout. From all of the data you have collected through asking, listening and measuring you need to develop your overall strategy. Within the strategy will be your tactics. Your plan should contain multiple prongs and include a focus on working with system leadership on issues that impact your culture including your policies and processes. The focus on the system will be the bulk of your work with some secondary focus on developing tactics to address provider well-being. We all know people in health care are very resilient so be careful to not just focus on the individual when you create your strategy. Once you know your strategy, start developing tactics, implementing them and measure their efficacy using your chosen measurement tool.
First of all, don’t forget the basics - what is already known about clinician burnout, which is well summarized in the AMA StepsForward program and the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience. Second, be aware of how the global pandemic has added new factors such as shortage of personal protective equipment, threats to health of the clinician and his or her family, and how Covid modifies the previously known factors that contribute to burn out. The previously identified issues are still there, they have been magnified and modified by Covid. Good examples are shortage of conditions, and increased workload.
Getting out and making rounds, listening and learning from your colleagues is a valuable first step. As others suggested above, it is important to understand our colleagues’ everyday experience, and to get to know the micro cultures within the larger organization. It is also meaningful to form these relationships with colleagues and to make it known that foundational work is taking place.This can take a considerable amount of time, several months, but is a worthy first step.
It is important early on that you measure burnout within your organization and report that to leadership. Choose a framework model for your work to ground you in the various areas that should be addressed and start small, choosing the area of biggest impact based on your conversations and survey results. You will need to develop a strategy specific to your organization, based on what you learned from your conversations and survey.
(Another great resource is the Joy in Medicine program through the AMA. It provides a great outline and framework as to all of the different areas that really should be addressed and gives ideas as to the work that can be done in each area to tangibly improve our professional experience.)
Start identifying and building relationships with other leaders who will help make your work come to life. Collaborating with executive leaders, systems directors, and other leaders is vital in moving the work forward.
I completely agree with all of the above, the importance of NOT reinventing the wheel as there are so many fantastic resources out there from AMA, NAM, IHI, etc. It's also critical, as Dr. Reily mentions, to have conversations and really get a pulse on what is happening on the ground with various stakeholder groups across your institution. While of course, it's important to weed out issues and understand the problems, it's also important to hear about STRENGTHS and what the institution/ service/ floor is already doing well so that we have places to go, aim for, and capitalize on. The language we use REALLY matters in shaping these conversations and the perception of the work - if we focus exclusively on problems, we will surely find a ton of them, but that may not leave us in a position to generate tangible low-hanging solutions. Some questions to ask clinicians might be:
1) What are the conditions (both internal and external) when you feel the most alive, energized, and engaged in your work here?
2) What are some of the barriers your face (both internal and external barriers) to 'thriving' at work?
3) In what parts of your workday (time of day, tasks, responsibilities) do you "lose yourself" most in the work i.e., find a flow state, experience time moving more quickly or slowing down, etc.?
4) What do you enjoy most about your job?
5) What do you wish you could change about your job to better support your well-being?
6) Tell us about your relationships with your colleagues and supervisors at work? what are some of the strongest relationships? What relationships could use improvement?
7) Tell us about the best leaders you work with -- what do they do that makes them great?
8) If the sky was the limit, what sorts of supports or resources would you want at work to support your well-being?
Stigma around burnout and mental health is rampant in the field of medicine. Are there strategies that you have employed to address stigma around this issue?
Stigma is a huge barrier for folks to seek help with mental health challenges, and likely a barrier to addressing burnout. In my experiences, stigma is especially potent for things that we cannot SEE in medicine - e.g. conditions of the mind, rather than the body. This all dates back to the mid-seventeenth century, when Rene Descartes unleashed ‘Mind-Body Dualism’ on Europe and the world, postulating that the mind and body were distinct and separate entities, and henceforth, the human body could be dissected without consequence for the human soul. This was fantastic for progress in many ways, making way for understanding visible morphology - however, this paradigm also set in motion the basis of our modern health care system, one that relies heavily on lab tests, biomarkers, histology, and pathology to validate disease. According to this model, “real” medical problems are those observable phenomena, diagnosed and legitimized by visible evidence of disease... I think this remains true today and unless we make conditions of the mind like burnout KNOWN, many of us proceed through our practices suffering silently.
I think that sharing stories can be a very powerful antidote to stigma, in the form of informal conversations, process and support groups, panels, and/or story-sharing events. For learners and trainees, hearing stories of vulnerability from senior faculty and leadership who can share their own narratives of burnout may be hugely impactful. At my medical school, we have an annual monologue performance called The Story Project where students write and anonymously submit stories that are performed by other students on stage. This project highlights universal and unique challenges, instills hope, and ultimately shows medical students that they are not alone. Check out the recording of the 2021 The Story Project production:
I agree with Dr. Feingold that leaders and faculty sharing their stories of vulnerability when they reached out for help can be very powerful for others. It says, "I was struggling and I got help. It's not only okay to get help but it's the right thing to do". In addition to the sharing of stories, we have also tried to reduce stigma by making getting help just part of "what we do" in medicine. One way we are trying to do this at Henry Ford is through our TRUST Peer Support Program. This peer support program was developed in order to provide support after an unanticipated patient event. It's peers supporting peers. It is our goal to normalize having supportive conversations. We should say, "Of course you'd get support when you have an unexpected outcome." Hardwiring that into your culture takes time but many organizations refer to their peer support programs automatically vs. waiting for people to reach out. Moving toward "this is just what we do" has been slow and COVID has certainly impacted the spread of this idea. Changing the culture for our organization and for any organization is going to be a slow process but hopefully we can break down this important barrier to care.
Dr. Jo Shapiro and others have highlighted the importance of peer support to mitigating burnout. This may be more effective than other methods of assistance since your peers have quite literally “walked in your shoes.” joshapiromd.com/peer-support
I agree with the comments made by the other participants as this is a very delicate area for most practitioners and there is a sense of shame in admitting difficulty and setting limits. One thing we have all learned however through the strength and courage of people like Simone Biles and Naomi Osaka, is that no one is immune. By acknowledging our limitations and setting boundaries, we become stronger and more adept at our work. In my book, A Woman’s Guide to Healthy Aging, I discuss how we need to learn to say NO to some things. We should not say “I’ll try” or “Let me think about it” or “I’ll get back to you” when we clearly know the request is creating a situation of overload. For when we learn to say no to that something, in reality we are saying YES to something else….family time, down time, personal time. And if we don’t learn this important lesson and always say yes, to please someone or gain something, we actually lose in the end, be less proficient, more resentful and move towards burning out. I encourage patients and colleagues to be positive, make it a clear yes when you accept a responsibility. But also make it a clear no, when the work becomes a burden.
Research shows us that administrative burdens are a leading cause of burnout in health care. What are ways that health care leaders can think about reducing administrative burdens? Are there practice efficiency interventions that you have successfully implemented in your organization?
Using a multiprong approach to wellness work is important for any organization but I would argue practice efficiency is one of the most important focuses of this important work. There is good research that demonstrates a focus on this area can have lasting impact on those who provide care. Documentation support, fixed order sets, inbox management support and a focus on all team members working at the top of their license have all been shown to be effective strategies. It's important to recognize that every system has their own culture and within in that greater culture, smaller areas of work. When approaching wellness work, connecting with those who do the work to understand their burnout drivers (i.e. the pebbles, rocks and boulders) needs to be a critical step in helping to work with local leadership to co-create interventions for change. Wellness work should be approached with a quality improvement mindset which includes asking, telling, measuring, developing, implementing and measuring again (just like a PDSA cycle). Some interventions we have developed at Henry Ford include increased MA support/training, wider computer screens, M-modal support for all and scribes for some, inbox management support, as well as many others. The important thing is to work closely with leadership to understand the work area and customize the intervention to that particular team, clinic, division, department or hospital.
I agree with all of the great points that Dr. Maclean made above regarding efficiency of practice. It is important to meet at a local level with individual clinics and teams to identify the administrative tasks and inefficiencies that specifically burden them in their unique environments. Decreasing administrative burden can seem like a daunting and overwhelming task, but getting in to the local culture within a team and picking just 1-2 issues to improve upon makes the results achievable. Ways we've worked on this in my organization include:
1. We've used the AMA Steps Forward Modules to create pilot projects that have been very successful and have shared these outcomes with other clinics. This is an excellent resource and I highly recommend spending some time exploring these modules.
Examples of pilot studies my team has taken on have included team based documentation, pre-visit planning, pre-visit labs, bundling of prescriptions, re-working of patient messaging routing.
We also utilize standardized order sets. I have shared these projects in other clinics as a way to encourage change. These projects have been very successful and have sparked enthusiasm for change among other providers.
2. We (physician wellness officers) have strongly encouraged providers to take a lead role in identifying "pebbles" and making changes that are meaningful to them and their teams. (i.e. taking ownership of their own improvement projects)
3. We have a "Practice Effectiveness" committee made up of clinicians (physicians, APCs, nurses), informatics specialists, operational specialists, and clinic leads. They are working on things like standardized order sets, pre-visit planning models, prescription bundling and refills through a centralized service.
This work is very challenging, but when broken in to small, doable projects, it can be done, and is vitally important to our well-being. It is certainly time well spent.
Really great points and very helpful specific examples of how to affect change in this vital area. We follow some similar processes. We use our engagement and well-being surveys to identify areas of high opportunity (scores below national benchmarks for specialty and/or significantly lower than other areas locally) then work closely with that local team, similar to the “targeted work unit interventions “. Really listening and Engaging the front lines to identify and prioritize their specific drivers and empowering them to design and implement small pilot projects (using rapid reiterative process). Also agree, the AMA Steps Forward modules are a great resource, particularly for local champions wanting to focus on practice efficiency with evidence based tactics. Some of our examples: team-based care/documentation, expanding scope of MAs, GROSS - getting rid of the stupid stuff, better leveraging technology/platforms for more effective communication (between team members and with patients), simplifying and better communicating processes to obtain needed resources
In general, most now use an electronic medical record that leads to a great deal of stress and burnout as we "click the boxes" and "fill in" those parts we need for billing and coding. Most EMRs are designed for billing / coding and not to help the clinicians care for patients. It is typical for a clinician to document from home or in the hospital / clinic / ED well after they have finished their shifts. Being able to leverage the power of the EMR and making it a "friend" is so helpful. As an example, we have developed numerous "Pathways" in our EPIC EMR that allow us to fill in a lot of the boxes automatically and to ensure we are treating the patient at the latest standard of care. We have developed several of these pathways across our healthcare system for numerous disease processes and they have made a great difference. An example is our COVID pathway, that walks you down the evaluation and treatment algorithm from the most complicated to the easy patient and fills in so many of your orders and documentation requirements. These pathways are made through a consensus of stakeholders rather than having one person dictate what is in them. This has been a positive leverage of the EMR.... finally.
It is not uncommon for organizations to superimpose their own interpretations on those from regulatory and accrediting bodies. It would be good to periodically review local interpretations of external regulations to see if they are really needed. pubmed.ncbi.nlm.nih.gov/304039...
Have these drivers changed over time?
The biggest burnout drivers for our organization fall under the ease of practice tactic. We continue to struggle with having enough staff to do the work, working at the top of one's license and complicated documentation/billing processes. Our MA turnover has been another struggle even though our health system raised the amount MA's made a way to retain and attract good MA's. With COVID, we have also struggled with the continuation of asking people to do more and more and then asking again. We need to continue to think of strategies that by taking something off someone's plate, things improve vs. always looking to add one more thing. Using the IHI Joy in Work method to work collaboratively has a been a great way to drill drown with our providers to try to understand the pebbles and rocks that get in the way BUT to also to work with them on creating strategies for change that can be tested over time.
In addition to the well-known drivers of burnout which can be summarized as an imbalance between job demands and resources, we need to superimpose the special challenges of health care workers during the COVID-19 pandemic. pubmed.ncbi.nlm.nih.gov/322591...
As I have just begun my residency training this July, I have been very tuned in to how the drivers of burnout shift from medical school to residency for colleagues and myself, and how these drivers may be unique to the trainee experience. In medical school, it seems like burnout stems from two distinct paths -- workload and work-life integration, and physician identity formation. Workload and work-life integration was really about navigating studying for board exams and other tests while also engaging in long hours on clinical rotations, bearing witness to illness, death, and dying, and finding spaces to process it all (the stuff we 'signed up for') while confronting the limitations and sparsity of these opportunities in the midst of all of our other responsibilities. Additionally, figuring out how to 'turn off' and just be a human being can be a tension for many (and was for me). This relates to the second bucket of drivers which I call "identity formation" all about what it means for us to be doctors, healers, and live up to all of the narratives we hear (a la health care heroes). So often, students feel like just an extra person without the technical skills or experience to meaningfully further patient care, and it can be challenging and exhausting for such educated, highly-motivated students to feel this way.
The most effective medical students are those who are tapped into the needs of the team, don't necessarily wait to be asked to help with something but can be proactive--this can be VERY draining, especially for more introverted students, and lead to that 'low sense of personal accomplishment' feature of burnout.
I do think these drivers change quite a bit once in residency ('learning the system,' navigating the EHR, the responsibility of driving patient are)--- a common feature is the 'IMPOSTER syndrome' that I think is really pervasive among trainees (and likely practicing physicians as well....)
Leadership buy-in is crucial for this work. What strategies have you used to gain (and maintain) leadership buy-in and allocation of resources?
Even before the COVID pandemic, my health system has supported and allocated resources to build tactics with the goal of improving provider vitality. That said, especially during the peak of the pandemic, we recognized that we needed to invest in our leaders as well as our providers. Some key strategies we have developed specifically for leadership support are: Training in psychological first aid, a leader support group we named Conversations with Leaders, tools for leadership rounding, and an ACT based resilience workshop just for leaders. This support has been received with openness and engagement and helped our leaders to continue to support our work with our providers within our organization.
Some additional tactics leadership have supported include: our TRUST peer support program, physician affinity small groups with food reimbursement, a buddy program which links providers with other providers to help to promote acculturation, and an "in the trenches" care cart which gives away free health snacks and support resources. It's now very common to see leaders rounding on their areas with the care cart where they can connect with and support their teams. Another key strategy has been our peer processing groups where a leader and a therapist meet with small groups to process the impact of COVID or any stressor, validate feelings and emotions, review health coping and promote post traumatic growth. Our leadership has also stepped up to improve our vacation policy which gets at the bottom line but also says, "we care" about your well-being.
I agree, executive leadership buy in and support are key! Dr Maclean, I am very inspired by the many supports you have put in place for leaders as well, this seems an often overlooked area. It is also great to hear how engaged they are in the offerings!
As obvious as it might sound, coming back to some fundamentals, like investing time/energy in building trusting and collaborative relationships with those leaders and linking well-being efforts directly to our ultimate purpose of caring for patients. Also, really understanding as fully as possible the top priorities/challenges of the organization and the executive leaders, tailoring the ask and/or presentation to your audience, and starting with the “why”.
The good news is that improving the well-being of caregivers will positively impact almost every area and well-being efforts can easily be framed around supporting the organizational priorities. When talking to a more general audience, we typically use the Quadruple Aim and highlight the well-established link between well-being and the other key priorities of safe quality care/patient experience, population health, and organizational sustainability (turn-over/related costs can be huge here). We strive to build our programs and metrics around this framework as well. For example, if there is a big initiative for improving access, we can support those efforts by introducing models of care/staffing designed to bring more resources and increase "top-of-license" work, improve the experience of the entire care team, and ultimately take better care of more patients, ie improving access, quality, and revenue.
Agree that executive leadership support is critical! Addressing clinician well-being has been and remains a priority of our institution. We have a well-being committee that reports directly to executive leadership. With their support, we've been able to establish a peer support program, re-vamp our lactation spaces, and identify key areas to focus on for ongoing systemic improvements to enhance clinician well-being.
I agree wholeheartedly with the critical importance of leadership support at the highest levels of an institution, and I happen to be at a place where this is so central to our mission and well-being permeates literally every aspect of our medical campus. That being said, for institutions where this may not be the case, I think one approach to catalyzing a shift is to bring the c-suite and leadership FEASIBLE SOLUTIONS rather than problems - this might look like intimate knowledge of what other programs are out there at other places and might be feasible to implement, ready-made workshops or speakers to bring in to start addressing the issue, ideas of how to measure well-being/ burnout at your institution if this is not already being done, etc... This work can be daunting, and coming with solutions rather than just an awareness of the problem can help move a contemplative or pre-contemplative c-suite into being ready to implement necessary change.
Wellness committees differ across the country. Some may focus specifically on physicians or trainees while others may be wide-ranging in their focus across role types. Some are physician-led while others are led by the administrative teams. Similarly, some committees include only physician membership while others include leaders from across the organization (human resources, compliance, IT, etc.).
Do you have a wellness committee within your organization? If so, how is it organized? How did you define its scope? How have you effectively engaged important stakeholders?
I am incredibly fortunate to be part of an organization where we have an institutional Office of Well-Being and Resilience led by a Chief Wellness Officer, with Senior Associate Deans who oversee the well-being of faculty, residents/fellows, medical students, and graduate students/ post-doctoral fellows, respectively.
The Office of Well-Being and Resilience at Mount Sinai is a pretty amazing model — in my opinion — for wellness infrastructure at academic medical centers - see more @ icahn.mssm.edu/about/well-bein.... We also have a year-old center called the Center for Stress, Resilience, and Personal growth that runs resiliency trainings and has developed a mobile app to help constituents track their own well-being/
Within each of the stakeholder groups, there are also faculty “well-being champions” throughout the departments who are responsible for and empowered to bring well-being-related initiatives to their constituents. We also have medical student and resident well-being infrastructure. Overall I think it's critical that well-being initiatives be DISTINCT from mental health offerings (e.g. counseling, crisis lines). Well-being is about health promotion and prevention and has a distinct mission from helping folks manage and treat mental illness. Both are incredibly important, and I think when these fall within the same umbrella, this can lead to confusion and loss of specificity.
We developed a wellness committee in our residency and after a few years it led to the development of an additional wellness committee that includes the whole ED including residents, faculty, nurses, and ancillary staff. The residency committee started with the development of goals and a budget and included members from each residency class. The Chair position rotates annually and is one of the senior residents who has been on the committee. From the outset, it has been resident driven with the support of the residency leadership. The role and impact from the Residency Wellness Committee has grown each year. To be honest, it started with the idea of one resident in 2014 and grew from there. Every journey begins with the first step.
The ED committee is chaired by a motivated faculty member who has buy-in from physician and nursing leadership to help make things happen. It includes residents, faculty, nurses, tech, social workers, clerks and even a chaplain. It is a great group of people to allow for a better perspective of the whole setting.
This sounds like an amazingly supportive organization. Thanks for sharing.
Another great question. Those of us who are passionate about well-being work know that we cannot do it alone. Indeed, it takes many people passionate about wellness work within your organization to make change. A wellness committee is one way to broadly include many diverse members of the medical team. In our health system, we have a faculty physician wellness committee with broad representation from departments across the organization. This model is also utilized for our GME programming. Not only are the members of our committees wellness champions who can help to promote our initiatives, they are key to developing tactics to address the well-being of our providers. They are literally on the front and in the weeds and can help to drive change, bring truth to leadership and work collaboratively to improve the well-being of all our team members. These committees also work in collaboration with our Thrive Program which works to address the well-being of every person within our organization.
Wow, it is very inspiring to hear how others are approaching this, thank you for sharing your experiences. We have had a clinician wellness committee 4-5 years now, with a mix of leaders and front-line physicians and APPs. We also recently started a system-wide THRIVE Team charged with promoting systemic interventions for enhancing well-being for all staff/caregivers. That team has representation from multiple areas including clinical, admin, education, patient exp, safety/quality, HR, org development, spiritual services, EAP, and behavioral health. Both teams use the Stanford model, attempt to measure “Quadruple Aim” metrics to show the broad impact of interventions, and primarily target ways to improve the work environment and culture. We are also developing an infrastructure to allow protected time for a clinician well-being champion in each service line. The goal is to allow a local/front-line clinician to be the voice and ears of their colleagues, synthesize the feedback and then work with their colleagues to develop pilot interventions. These projects in essence will be developed and implemented by the team, for the team, based on their own top priorities and solutions (with the support of the committee and other leaders).
Wow, this is amazing and sounds like an incredible place to be. Thank you for sharing.
We started our first "resiliency" committee in 2016. It was made up of physicians and APCs. This was in the relatively early days of wellness work across the nation. Papers were coming out at that time and for a few years prior highlighting growing concerns about burnout in clinicians. It was exciting to be part of these early conversations in my organization. As a committee, we were able to identify the problem of burnout in our organization by personally interviewing more than 50% of our physicians and later applying the AMA burnout survey for the first time in 2016. We were able to bring this issue to our hospital board and start the conversation around burnout, which was very important. However, as time went on, we realized that we needed more than a committee in order to move toward real change. The group dismantled after a couple of years. However, one of my colleagues and I continued holding large gatherings outside of work for peer support and collegiality. In 2019, we went on to propose our current position which is System Directors for Provider Wellness. In these positions, we really have been able to form the right relationships with other leaders and start working more specifically on the various domains of wellbeing, which expands much past resiliency, which was the focus of our committee. Now, we really can work more effectively on the culture of wellbeing and the efficiency of practice.
Recently, a new Resiliency Committee has formed out of Covid, led by non-physician employees and they are doing great work to address all employee health and resiliency during covid and beyond. We are collaborating with them as well as with other committees who are doing work that benefits wellbeing.
I'm so encouraged by the great work noted by many of the institutions above! We have an institutional well-being committee that helps to identify institutional priorities to address, but what I've found to be the most impactful for change are the more grass roots committees we've seen pop up. Having committees at a departmental, divisional, and trainee level has helped us best identify issues and tailor change initiatives at a more local level. Having representation from those directly impacted by the systems we're aiming to change is key!
Are there data sources that health systems are not currently using that you see as opportunities for the field to consider? (e.g. EHR data, quality measures, patient satisfaction, etc.?)
That's a great question, Kyra. I think the most important thing is to have an identified metric and to watch it over time. There are many potential metrics an organization could follow that can be specific to your overall strategy. If we consider a three prong approach like Stanford's WellMD Model: Culture of caring, ease of practice and personal resilience. Some metrics you could consider include:
1. Culture of caring: Burnout rate, distress level, vacation time utilized, satisfaction with leader, provider turnover
2. Ease of practice: Number of clicks, pajama time, quality indicators
3. Personal resilience: patient satisfaction, physician engagement
Again, regardless of the metrics you choose, measuring and reporting your findings is key to knowing where you stand and where you need to focus your energy.
Clinician turnover is a useful metric to follow in health care organizations. It is relatively easy to understand and measure and is related to clinician burnout.
Since 2016, we have been using the AMA burnout survey which incorporates the Mini-Z questionnaire. Working with the AMA, we are provided with a robust analysis of results, which helps with communication with our other leaders around well-being as it pertains to our organization. The information also helps us to identify areas to work on.
As we continue to develop our work and move forward, we have begun to approach this in a way similar to what Dr. Maclean mentions above, structuring it around various domains in which we desire to see improvements. For example, when looking at culture, specific to my colleagues' feedback regarding culture, I would like to start surveying leaders and the teams who report to them, with specific questions and evaluation of performance. In addition, in regards to my colleagues' responses regarding EHR stress, I have begun with pilot projects looking at work outside of work, inbox management, and team-based order entry. The robust data provided in our EHR dashboards can serve as a useful tool by which we can measure reduction in our inbox, decrease in work outside of work, improvements in team-based documentation and ordering, all of which will improve well-being. We do need to be cautious with this data, however, as reporting of such can sometimes be misinterpreted as demeaning or blaming toward providers when we point out how much time they spend doing particular tasks. Also, depending on how the time is calculated in the EHR and dashboard, there can be errors in the data.
I can't agree more about the need to collect data and track it over time. We've used the AMA survey platform as well to identify key areas for systems change. From there, we have been able to identify more specific metrics that can be used at a more local level (e.g. using EMR data to track hours on EMR outside of working hours in an effort to decrease "work outside of work" time).
You can’t change what you don’t measure. How do you leverage data to respond to burnout within your organization? Are there measurement tools that you have found the most helpful? If you have measured burnout, do you share these results in a transparent manner across your organization?
Great question, as assessment is such a vital part of any strategy to address burnout! Systematically and repeatedly measuring, with validated instruments can identify rates of burnout, related drivers, areas of strengths and opportunities for targeted interventions, and help track the impact of those interventions. Sharing these results openly along with engaging clinicians in plans for addressing key areas helps build trust and shows this as a priority. This also opens up conversations and helps break the cycle of "suffering in silence".
We have chosen to primarily use the Mini-Z. We have found great benefit of having it owned/housed within the AMA database; bringing some sense for those being surveyed of extra confidentiality protection and reputability for the survey. The AMA team support and data lab is tremendous, making it so easy to put together reports and drill down where desired to make working with the data very user friendly and visually appealing. We have also appreciated the statistical support for deeper data dives, for example examining the strength of correlations between feeling valued and intention to leave; burnout level with intention to leave-very useful in making the case for interventions.
A few other helpful tools or metrics to consider: Mayo Leadership Index to examine evidence-based domains that impact clinician well-being and engagement; turn-over rates and related cost of turnover to help make the business case; work outside of work data from EHRs.
In general, we aim for our projects to have a “Quadruple Aim” focus, with metrics in each of the four domains to help make the connection between clinician well-being/fulfillment and patient experience, population health, and sustainability of the organization.
It's important to measure the well-being of the people who provide care within your organization. Some would argue you should measure the well-being of every employee. By measuring, you demonstrate that you care enough to ask and secondly, it gives the wellness leader important data that they can use to advocate for wellness resources within the organization. Sharing the results can be very powerful and I would attest should be part of what every organization does.
Leadership needs to know that addressing distress and burnout will not only help to improve patient satisfaction, reduce medical error and improve quality, it will help to reduce provider turnover and distress. Ignoring the wellbeing of your providers literally touches on the bottom line of your organization. There are many great tools out there that measure burnout, distress, provider fulfillment, or well-being, etc....
Our organization chose the Well-Being Index for multiple reasons. First, it has multiple versions - Employees, APP's, Medical Students, Residents/Fellows, Nurses, and Physicians. The tool is confidential, anonymous and short! It also has national comparative data so an organization can see how they compare to other organizations. The best feature of the tool is that after completing it, the provider gets a dashboard that tells them how they are doing and then links to support resources within your organization. SO - people don't just find out they are struggling but they also find out where to go within your organization to get help.
When you think about wellness work within your organization, I would recommend the following approach: ask, listen, measure, tell, develop, implement, ask again, measure again, etc.....Measuring is critical to knowing where you are at.
In my work studying burnout through the Office of Well-Being and Resilience at Mount Sinai, measures of burnout are done regularly to hold the institution accountable and understand trends in these measures over time. We rely on the Maslach Burnout Inventory (MBI) and the AMA Mini-Z item as two excellent measurement tools.
What's great about the MBI is that it is really a gold standard in the field, and captures burnout over the last YEAR. It has multiple versions for different populations and has an abbreviated, validated 2-item format which can help for populations that are surveyed frequently to mitigate survey fatigue. It is proprietary, which means there is a cost associated with its use, so for organizations without a ton of support or resources, the cost may be prohibitive.
The Mini-Z l is also excellent to, and an instrument that I hope will really take off in the literature. This is excellent for measuring burnout NOW, as well as other dimensions of work satisfaction. The single burnout item includes the question:
1. Using your own definition of “burnout,” please circle one of the answers below:
a. I enjoy my work. I have no symptoms of burnout.
b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.
c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.
d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.
e. I feel completely burned out. I am at the point where I may need to seek help.
I’ve used this instrument with a cutoff at item c or above - dichotomizing -burnout as items A or B and +burnout as items C, D, or E.
I’m curious what others think about this tool, and whether something like this could become a new gold standard?
We've also used the Mini-Z survey (through the AMA partnership) to assess clinician wellness. It's been very helpful to collect baseline data for our institution and we plan to use it annually to track change over time. We disseminate data and recommendations for improvement to leaders and clinical managers.
No matter how hard we work, we will never eradicate all the stressors which drive burnout and distress. However, a future state could be where people feel heard, processes for improvement are ongoing and providers feel content and connected to their meaning and purpose of work. There is always going to be stress - the work we do is difficult but I think we can learn to do it in a way that there is less waste, people work at the top of their license, and we are all doing the work that matters the most in environments that care about and support us. There needs to be ongoing recognition that we cannot just keep asking people to do more and more. Sometimes the solution is in taking something away or creating a new way to do it. Hopefully, a future physician would say, "I love what I do. Isn't it amazing that I get to help people heal everyday?"