Successful Organizational Strategies for Clinician Burnout

Successful Organizational Strategies for Clinician Burnout

Roberta E. Funck, MHS, PA-C Northern Arizona Healthcare, Cottonwood, AZ

ABSTRACT

Objective: Clinician burnout is a public health crisis that demands immediate attention and intervention. This article reviews the organizational strategies of two established well-being programs shown to reduce clinician burnout and increase professional engagement. Method: A search of PubMed and the Cochrane Review databases revealed two articles on active clinician well-being programs (Mayo Clinic and Stanford Medicine). Fifteen documents supplied background information and supporting evidence. Results: Little research has been done on active evidence-based well-being programs or cost analyses for starting and supporting a viable clinician well-being program. Conclusion: Despite increasing awareness of the devastating consequences of clinician burnout, most health care systems lack a robust well-being program. Further research is necessary to estimate startup and maintenance costs, and the unique applications of burnout interventions in various health care settings. Keywords: Physician, burnout, well-being, organizational interventions, administration

INTRODUCTION

Clinician burnout is a public health crisis with devastating consequences.1,2 It is driven by rapid changes in health care and the work environment, and is widespread among clinicians.1 Health care organizations typically seen burnout as the practitioner’s problem; however, evidence shows that it is primarily a system issue.3 The purpose of this paper is to review two premier health care systems with highly developed, evidence-based wellness programs (Mayo Clinic4 and Stanford Medical Center5) and to highlight their successful strategies.

METHOD

PubMed and Cochrane Reviews databases were searched to capture articles on established organizational well-being programs. The inclusion requirements included articles published in the United States within the last five years, institution-based interventions, active well-being programs, and practicing clinicians. Articles excluded were those on a specific specialty only, medical students and residents, and individual-based interventions. The terms “physician assistant,” “nurse practitioner,” or “advanced practice provider” were not used because their

inclusion narrowed the search to exclude important physician-based studies. The literature search produced 354 articles. Of the 354 articles, 118 were reviewed and six articles chosen. A review of the references of the six sources produced another nine articles. Two references were from a textbook on organizational behavior (Borkowski et al).

RESULTS

There are few research studies on health care systems with established clinician well-being programs. An extensive search of the literature captured two publications on the Mayo Clinic Physician Well-Being4 and the Stanford Medicine WellMD Center5 programs. Fifteen other articles detailed the costs and consequences of burnout. Overall, most burnout studies have been on physicians with very few investigating the impact of burnout on physician assistants and nurse practitioners.

DISCUSSION

First described in 1974 by American psychologist, Herbert Freudenberger,6 clinician burnout is now so prevalent that at least 50% of physicians experience it.7 Burnout can negatively impact job satisfaction, patient outcomes, and health care costs.4,7,8 It is a moral-ethical imperative to acknowledge that health care delivery is dependent on talented, dedicated, and committed professionals and address burnout.8 Most organizations erroneously see burnout as a clinician’s problem and have focused on less effective individual-based interventions (mindfulness, stress management, etc.).4 However, systematic reviews and meta-analyses have found organization-based interventions to be more effective in reducing burnout.9,10

There is a lack of awareness of the economic costs of clinician burnout.8 Atrius Health cited the cost to replace a physician at $500,000 to $1,000,000 in their 2017 report.2,8 Most health care organizations assume that burnout interventions are cost-prohibitive; they are not aware that many strategies are relatively inexpensive or cost-neutral, and small investments make a big impact.4

Both Mayo Clinic and Stanford Medicine have evidence-based, comprehensive clinician programs shown to improve well-being. Mayo’ s “Nine Strategies to Promote Physician Well-being” (see Table 1) arose from annual physician surveys and research on clinical work units.4 Stanford’ s WellMD program is based on three domains (see Table 1): Culture of Wellness, Workplace Efficiency, and Personal Resilience.5 Both programs arose from research, implementation, and reassessment of applied interventions in their respective institutions.

Acknowledge and Assess the Problem

Mayo’s first intervention is for leadership to “acknowledge” that clinician burnout is a problem that demands immediate attention and “assessment.”4 This is a “necessary first step” in setting up a well-being program.4 Once an organization recognizes the pervasive and destructive effects of burnout, it can intervene and act. A successful program develops through the shared responsibility of clinicians and health administration.4

Leadership Development

Mayo’s second step is to “harness the power of leadership.4” Committed leadership is key to implementing interventions and monitoring burnout.4 Mayo selects leaders who can listen, engage, and lead clinicians.4 Behaviors of physician supervisors play a critical role in the well-being of the practitioners they lead.4 At Mayo, physicians evaluate their supervisors annually; those leaders with consistently poor ratings are removed.4

Stanford has a similar strategy –

“leadership development” – although it focuses more on physician leadership,5 whereas Mayo focuses on the collaboration of physicians with leaders.4 Stanford’s leader selection is an egalitarian process that supports a combination of transformational and servant leadership.11 Transformative leaders primarily focus on organizational success;5 servant leaders focus on the growth of others and building of community.12 Together, this leadership fusion model seeks to learn their constituents’ aspirations, engage their perspectives, and develop their abilities.5

Mayo and Stanford both support participatory decision-making of clinicians with leadership.4,5 Stanford also advocates for an executive level burnout champion, a Chief Wellness Officer (CWO).5,7,13 The CWO is solely accountable for the clinician well-being of an organization.5,7,13 Their role should be clearly defined,5 with the CWO on par with other executive leaders and reporting directly to the Chief Executive Officer (CEO).13

Cultivate Community and Collegiality

A culture of wellness creates a work environment that encourages clinicians to collaborate, communicate, and coordinate patient care.5 Peer support is critical for helping practitioners maneuver clinical challenges.5 Organizations should encourage clinician gatherings and create dedicated spaces with amenities (healthy food and beverages, computer workstations, etc.).4,5 They should also provide clinicians protected time to gather together during the workday.4,5 Strong social connections can improve engagement, fulfillment, and productivity.14 Open, frank, and collaborative dialogue between clinicians and organizational leaders is another important aspect of a healthy, dynamic community.4

Develop and Implement Targeted Interventions

To counter burnout and improve engagement, promising interventions need to be developed at the local level (departments, work units, etc.)4,5 Each work unit is unique with its own burnout and engagement factors.4,5 Mayo’s approach is to first identify local influences that can be quickly changed.4 Then Mayo focuses on “high-opportunity work units” – those units with the highest burnout rates.4 These high-opportunity units are prioritized based on external benchmarks: burnout rates higher than the national average and clinician satisfaction scores below the 50th percentile relative to other US health organizations.4 All work units are annually reassessed for burnout and engagement using the same external benchmarks.4

Mayo’s goal is to have at least 50% of high-opportunity work units improve so they are no longer high-opportunity with twelve months.4 This goal is now part of the CEO’s annual performance

Workplace Efficiency

Stanford specifically addresses the electronic health record (EHR) as a driver for burnout and professional dissatisfaction,5 and other research supports the EHR as a burnout source.13,15 Measures should be taken to improve EHR usability and interoperability.5 A study of physicians in a three-day EHR intensive training program showed improvement in job satisfaction, proficiency, and work-life balance.15

Careful evaluation of any new EHR task needs to be done with the goal of eliminating waste and redundancy.5 Stanford advised the simplification, automation, and sharing of EHR tasks, in addition to allotting adequate time to document.5

Clinicians should be involved in the clinical structure and process design for workplace efficiency and improved quality of care.5 Team-based models should allow every team member to function at the top of their license, and support positive team attributes (clear goals and roles, mutual support, etc.).5 Input for solutions should be explored at all levels: work units, departments, organization, policy, and law.5 Stanford encourages physician involvement in the design of effective team-based models.5

Appreciation, Rewards, and Incentives

Appreciating each other and celebrating achievements are effective ways for clinicians to connect while improving satisfaction and motivation.5 Appreciation and celebration can counteract the negative effects of burnout and promote community.5

Compensation should facilitate individual and organizational long-term health.4 Productivitybased pay sometimes forces clinicians to shorten in-person patient time, order more tests and procedures, and work long hours.4 To counter these behaviors, Mayo promotes the incorporation of self-care and well-being dimensions into the productivity-based equation.4 Another option is to switch to salaried compensation.4 Job satisfaction improves when clinicians can spend 80% of their time attending to organizational objectives and the remaining 20% in pursuing professional interests.4

Strengthen Culture/Community and Align Values

Inequality, discrimination, and exclusion erodes well-being, and affects medical decisionmaking and patient outcomes.5 It is an organizational imperative to promote a culture of wellness that supports equity, diversity, and inclusion.5 Equity provides fair treatment, opportunity, and advancement for all.16 Inclusion creates environments where anyone feels welcomed, respected, and supported.16 A diverse community is rich with varying people and viewpoints.16 When equity, diversity, and inclusion are supported, all employees can fully participate within the organization.16

are vulnerable to implicit bias.5 Normalizing diversity can reduce subconscious bias.5 Leaders can support an inclusive community by celebrating and recognizing the contributions of women and under-represented minorities.5 Clinicians should feel comfortable about work regardless of their age, gender, race, ethnicity, language, or other characteristics.5

Health care organizations should support a healthy work culture.4,5 Every year, all Mayo staff complete a survey, rating how well Mayo Clinic is living out its values.4 In 2011, the staff perceived an erosion in Mayo’s commitment to them.4 A task force of physicians and leaders collaborated to determine the problems and develop the solutions.4 The task force produced a document of eleven key components that outlined their shared commitment to Mayo’s mission and values.4 This document was reviewed and approved by the staff.4

Promote Flexibility and Work-Life Integration

Stanford’s program supports “job-crafting,” which allows individuals to shape their jobs based on their needs, abilities, and preferences.17 Job-crafting can improve well-being and increase overall performance.17 Organizations benefit from policies that allow clinicians occupational flexibility and work-life integration.4 Flexibility in work schedules allows practitioners to meet their personal obligations.4 Decisions for any schedule adjustments should take place within the work unit.4

Promote Resources for Resilience and Self-Care

Although health care organizations and systems are the major drivers of burnout and disengagement,3 individual resources are a part of a healthy work environment.4,5 Organizations should provide interventions to improve self-care and resilience.4 These resources can address work-life integration, exercise/fitness, diet, relationships, hobbies, etc.4 Senior clinicians and leaders can inspire others by exhibiting healthy habits.4 Providing accessible, healthy food and beverages, on-site exercise facilities, stand-up desks, and mindfulness training can reduce the impact of burnout and improve engagement.4

Expectations of long work hours should be discouraged; improving clerical burden should be the reality.4,5 Clinicians need to prioritize self-care to preserve and improve cognitive and physical performance.5 Easily accessible counseling resources allow clinicians to manage distress and promote well-being.4 Confidential peer support groups and mental health services should be readily available.5

LIMITATIONS

Limitations to this review included the scantness of literature on established clinician well-being programs. Also, most burnout studies focus on physicians with only a few on physician assistants and nurse practitioners. There is little data studying the implementation of burnout inventions by different health care organizations. This author did not find any research on the upfront costs or cost analyses to aid organizations in starting a well-being program. Mayo is already furthering research through its ninth strategy: “facilitate and fund

organizational science.”4 New research studies can gather more information specific to the implementation and maintenance of clinician well-being and engagement programs.

CONCLUSION

Clinician burnout is a public health crisis with far-reaching, destructive consequences. It demands attention and requires the shared responsibility of all health care organizations and key stakeholders. Vanguard institutions like Mayo Clinic and Stanford Medicine have created wellbeing programs based on evidence-supported strategies that improve burnout and professional engagement. Other health care systems can adapt these strategies to meet their own local and individual needs.

REFERENCES

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5. Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Probl Pediatr Adolesc Health Care. 2019;49 (12):100664. doi:10.1016/j.cppeds.2019.100664

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Behavior in Health Care. 4th ed. Jones & Bartlett Learning; 2021:213-214

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Nurs Manag. 2018;26(3):321-331. doi:10.1111/jonm.12551

Stanford Domains1

Culture of Wellness*

Efficiency of Practice**

Stanford Strategies1

Leadership Development

Control and Autonomy

Collegiality and Community

Teamwork

Appreciation

Equity, Diversity, and Inclusion

Electronic Health Record (EHR)

Workplace Efficiency Stanford WellMD and Mayo’s Nine Strategies

Stanford Interventions1 Mayo Nine Strategies2 Mayo Interventions2

-Select, assess, develop leaders -Egalitarian leadership selection -Physician leaders -Alignment of mission and values -Participatory decision-making -Clinicians “job-craft” for needs, preferences ~20% of clinician worktime allotted for meaningful pursuits

-Protected clinician time to gather, reflect -Clinician lounges

-Teammates function at licensure -Team shares clerical workload -Clear goals/roles, mutual support, etc. -Give/receive appreciation -Celebrate “above and beyond”

-Align climate (beliefs, attitudes) with culture (policies) -Goals/procedures to reduce implicit bias -Normalize diversity -Support parent clinicians (onsite childcare, lactation facilities) -Improve usability, interoperability -Simplify, automate, share tasks -Share EHR work w/non-clinician teammates -Adequate time for documentation -Refrain, evaluate, review, reduce, eliminate when adding new tasks

-Engage clinicians in clinical structure, design, improvements -Seek solutions at all levels: work units, departments, policy, law -design effective team-based models

1-Acknowledge/assess the problem 2-Harness power of leadership

-Select the right leaders -Physicians and leaders work together -Equip leaders with core competencies -Assess leaders’ performance -Remove those with poor ratings

4-Cultivate community at work -Clinicians, leaders collaborate -Dedicated clinician meeting spaces -Formal and informal clinician meetings

5-Use rewards/incentives wisely

6-Align values, strengthen culture

-Counteract negative effects of productivitybased pay -Add self-care/well-being into productivity equation -Allow meaningful pursuits -Salaried compensation models -All staff rates organization through annual survey -Work units, divisions, etc., are optimized into healthy environments

3-Develop/implement targeted interventions

-Determine burnout/engagement of each work unit/division -Target high-opportunity work units -Tailor interventions to specific work unit/ division -Use external benchmarks to monitor burnout, report progress

Personal Resilience*** Support Healthy Lifestyle Behaviors

Peer Support

-Leaders, clinicians are role models for resilient health habits -Healthy choices available: food, beverages, exercise facilities, etc. -Reduce/eliminate expectations for after-hours work

-Confidential, proactive peer support programs -Secure confidential mental health services

7-Promote flexibility, work-life integration

8-Provide resources for resilience/self-care

9-Facilitate/fund organizational science

-Flexibility/work-life integration policies -Flexible schedule for personal responsibilities -Team/work units decide schedules -Burnout drivers periodically assessed -Well-being is a performance metric with other key organizational metrics

-Easy access to individual resources -Clinicians/leaders model healthy habits -Healthy options available: food, beverages, exercise facilities, etc.

-Vanguard institutions develop evidencebased strategies for use

1. Olson K, Marchalik D, Farley H, et al. Organizational strategies to reduce physician burnout and improve professional fulfillment. Curr Probl Pediatr Adolesc Health Care. 2019;49(12):100664. doi:10.1016/ j.cppeds.2019.100664 2. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/ j.mayocp.2016.10.004

*CULTURE OF WELLNESS: the relationships physicians need to effectively collaborate, communicate, and coordinate patient care. **EFFICIENCY OF PRACTICE: sufficient resources for the clinician and administrative workload to maintain quality, productivity, and work life balance. To promote workplace efficiency. ***PERSONAL RESILIENCE: organizational support for work-life integration and personal resilience allows for self-care and rejuvenation required for peak performance and the ability to manage and bounce back from adversity.