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Identifies methods to create the organizational structures that can result in more satisfied and productive physicians and other health professionals
Provides tools to guide the executive leadership team in creating a joyful practice environment and thriving workforce
A more engaged, satisfied workforce will provide better, safer, more compassionate care to patients, which will, in turn, reduce the total costs of care. The Triple Aim of better care for individuals, better health for populations and at lower costs has been updated to the Quadruple Aim, with the fourth aim of clinician well-being.1
Despite attempts to raise awareness of the costs of burnout in recent years, they remain widely under-recognized. Health professional burnout poses a significant threat to the clinical, financial, and reputational success of an institution. But burnout can be prevented with intentional organizational initiatives. The return on investment for organizations that address burnout can be substantial.
The aim is to go beyond reducing burnout to increasing professional fulfillment—to create the organization environment that allows clinicians to thrive.
What, then, are the organizational foundations that can foster joy, purpose and meaning in work and reduce the risk of burnout for clinicians?
How many physicians experience burnout?
Nearly half of US physicians experience some sign of burnout, a condition that impacts all specialties and all practice settings.3
Is burnout limited to physicians?
Burnout can impact all health care workers, but may be especially prevalent among physicians.
What drives burnout?
The predominant drivers of burnout are systems-level factors rather than individual physician-level factors. Burnout is driven by:
Workflow inefficiencies, especially those related to the design and implementation of electronic health records (EHRs)
Increased time spent in documentation
High volumes of inbox messages
Loss of meaning in work
Social isolation at work
Loss of control over the work environment
A cultural shift from health values to corporate values2
Why should an organization care about burnout?
Quality reasons: Burnout negatively impacts quality of care, patient safety, patient satisfaction, and productivity. For example, each 1-point increase on a scale that evaluated 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) correlates with a 3% to 10% increase in the likelihood of physicians reporting major medical errors.4
Humanitarian reasons: Burnout impacts the personal lives of individual health care professionals, and has been associated with greater rates of dissatisfaction, divorce, drug and alcohol abuse, depression, and death by suicide among surgeons and medical students.5,6
Financial reasons: Burnout results in higher levels of physician turnover and reductions in professional work effort.7 For example, physicians who are burned out are more likely to leave their current practice or reduce to part-time as those who are not burned out.7- 9 Replacement costs attributable to burnout are significant for organizations (see the Organizational Cost of Physician Burnout tool). For example, consider an organization of 500 physicians with an annual turnover rate of 7% and typical replacement costs of $500,000 per physician. This organization would be expected to incur costs of over $5 million annually related to burnout-associated physician turnover.8
Watch a discussion recorded during the Health Evolution 2017 Summit about how organizations are aligning values to compensation and other factors essential to helping physicians achieve Joy in Medicine
The 9 steps to creating the organizational foundation for Joy in Medicine are presented within the 3 domains of the Stanford WellMD Model: Culture of Wellness, Efficiency of Practice, and Personal Resilience.
Defined as the creation of a work environment with a set of values, attitudes and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients, and self.
STEP 1: Engage Senior Leadership
STEP 2: Track the Business Case for Well-Being
STEP 3: Resource a Wellness Infrastructure
STEP 4: Measure Wellness and the Predictors of Burnout Longitudinally
STEP 5: Strengthen Local Leadership
STEP 6: Develop and Evaluate Interventions
Defined as the value-added clinical work accomplished divided by time and energy spent. Factors that contribute to physicians' efficiency of practice include workplace systems, processes, and practices that help physicians and their teams provide compassionate, evidence-based care for their patients.
STEP 7: Improve Workflow Efficiency and Maximize the Power of Team-Based Care
STEP 8: Reduce Clerical Burden and Tame the EHR
Defined as the set of individual skills, behaviors, and attitudes that contribute to personal physical, emotional, and social well-being, including the prevention of burnout.
STEP 9: Support the Physical and Psychosocial Health of the Workforce
Leadership should define professional wellness as a core organizational priority and dedicate appropriate resources toward it. Establish workforce wellness as a key leadership responsibility, with shared accountability across all domains of leadership. Include the efforts made toward improving professional well-being in the organization's annual strategic plan.
How can our organization manifest professional satisfaction as a core priority?
Commitment to professional well-being can be realized in a variety of ways:
Develop a mission and vision statement that includes professional wellness.
Educate the governing board about the positive impact that improving clinician joy, purpose, and meaning in work can have on the mission of the organization, including quality of care, patient experience, physician retention, and a healthy financial bottom line. Use the calculator below to calculate the costs of burnout (See STEP 2).
Share accountability for workforce wellness.
How can we share accountability for workforce wellness?
Linking a leadership performance review to improvement in clinician well-being is a powerful tool to drive change. This way, sub-optimization around a narrow domain of responsibility is prevented because one division is not optimizing the organization around its particular goals (eg, data security or compliance) at the cost to other organizational goals (eg, patient satisfaction, productivity, or workforce well-being).
For example, evaluate the chief executive officer (CEO), chief medical Information officer (CMIO), chief compliance officer, chief wellness officer (CWO) and others on the executive leadership team on improvement in the well-being for the entire institution as part of their annual performance review.
Once structures for shared accountability are in place, create and encourage opportunities for administrators and department and division leaders to collaborate with each other to develop plans for improving workforce wellness.
Shared accountability for wellness across multiple domains of leadership also helps establish trust among the workforce.
How can leadership facilitate effective change?
At the highest level, it can be helpful to identify trust, courage, and empowering frontline workers as keys to success.
When creative, committed physicians and others feel powerless or subjected to excessive top-down controls or decisions based on fear, they resist change and add drag to the system. In contrast, when physicians and their teams are trusted and empowered to solve problems locally, have strong change management support and a light regulatory touch, then the innate professionalism of the workforce is allowed to flourish and everyone gains.
Physician burnout is expensive to an organization. It contributes to direct costs of recruitment and replacement when physicians leave or reduce their clinical work effort to part-time.9 Costs can range from $500,000 to over a million dollars per physician. This estimate includes the costs of recruitment, sign-on bonuses, lost billings, and ramp-up costs for replacement physicians.
Leadership should regularly estimate and report the organizational costs of burnout. Calculate the costs of burnout using the Organizational Cost of Physician Burnout calculator below.
The costs of burnout also include the indirect costs of medical errors, higher malpractice risk, reduced patient satisfaction, and damage to the organization's reputation and patient loyalty. These are not factored into the calculator in this module.
How does physician burnout impact work effort?
Physicians who are burned out are more likely to reduce their work effort to part-time as a primary coping strategy. Studies have shown that for every 1-point increase in burnout (on a 7-point emotional exhaustion scale) is associated with a 30% to 40% increase in the likelihood that physicians will reduce their professional work effort in the next 2 years.9
Medical errors are expensive to our organization, both through malpractice claims and through our global payment contracts. How does physician burnout impact cost and medical errors?
Burned out physicians may make more medical errors. A 1-point increase in 1 domain of burnout has been shown to increase the risk of medical errors by 11%.4,10,11 Burned out physicians order more referrals, tests, and prescriptions. For an emotionally exhausted physician, this may be a socially acceptable way to end a patient visit.
Our organization is increasingly financially rewarded or penalized for our patient satisfaction scores. How does physician burnout impact patient satisfaction?
Patients are more satisfied with their care and more adherent to their physician's treatment recommendations when their physicians have higher rates of satisfaction.12- 14
How does physician satisfaction impact patient health-related behaviors?
Physicians who are happier in their careers are more effective at working with patients on behaviors that improve health, which has the potential to lower the overall costs of care. For example, patients of satisfied physicians are more likely to adhere to their physician's medication, diet, and exercise recommendations.14
We are entering into more capitated contracts. How does physician satisfaction impact our potential to be financially successful in this model?
Highly satisfied physicians are able to contribute more to their organizations in a myriad of ways: going the extra mile for patients, engaging in quality improvement projects, and simply providing safer, higher quality, and more personalized care.
In addition, a more engaged, satisfied workforce whose workflow has been optimized is more effective at controlling population health costs. One study estimated that if all practices adopted the workflows and professional attitudes of those in high-performing practices, health care costs would be reduced by 12.5%.15
Our physicians report that they are under-staffed and thus doing work that doesn't require their training, and yet staffing costs are one of our largest expenses. How can we afford additional staff?
Most industries recognize the importance of maximally leveraging the skills of their highest trained workers. Health care has been an exception. Yet, by reassessing current assumptions about having minimal staff support, and factoring in the costs of burnout and of replacing physicians who cut back or leave, organizations have an opportunity for a triple win: a win for the patient, a win for the care team, and a win for the organization.
Consider a hypothetical population of 6000 patients:
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Create an executive-level champion position, such as a chief wellness officer (CWO), who reports directly to the CEO and is on par with other leaders such as the chief operating officer (COO) and chief medical officer (CMO) and is resourced accordingly. This leader should ensure all leadership decisions consider the potential effect on workforce wellness.
Establish a sufficiently resourced Well-Being/Clinical Transformation Center that is responsible for improving clinician well-being, improving clinical workflows and EHR performance, and enhancing a sense of community among physicians and other health professionals in the organization.
How much should we invest in our wellness infrastructure?
Leaders are often unaware of the costs their organizations incur as a result of physician burnout. You can estimate the costs related to burnout using the calculator in this module.
Establish physician wellness or burnout as a critical quality metric on the organization's data dashboard. Assess burnout, its drivers, and the costs to the organization at least annually and report the results regularly to the organization's governing board.
Survey instruments to assess physician well-being include the:
Maslach Burnout Inventory
Oldenburg Burnout Inventory16
a©MedEd Web Solution. Dr Shanafelt is a co-developer of the Well-Being Index and may receive royalties from the licensing of this tool.
bNote: The AMA can survey your organization and provide customized, detailed feedback. Please contact us at firstname.lastname@example.org with “Mini-Z Request” in the subject line.
The leadership skills of a physician's direct supervisor can have a powerful impact on physician burnout. For example, one study of several thousand physicians found that every 1-point increase in leadership score (based on a total possible score of 60 from 12 questions each scored on a 5-point Likert scale) for a physician's immediate supervisor was associated with a 3.5% decrease in the likelihood of burnout and a 9.1% increase in physician satisfaction.17
For this reason, it is important to regularly assess the leadership performance of division chiefs, department heads and other direct supervisors of physicians. This can be done directly, by surveying the individuals they lead, and indirectly, by evaluating the well-being scores of those under their leadership.
Leaders can also combat physician burnout by ensuring that physicians have some control over their work environment and the nature of their work. For example, having control over the start and stop times of clinic, appointment length, and task delegation among the physician's team can improve career satisfaction and retention.
In addition, it is important to allow time for physicians to pursue their passions. Research has shown that if work is structured so that physicians have 20% of their time dedicated to the professional activities they find most meaningful, such as quality improvement work, community outreach, mentorship, teaching, meeting needs of underserved, etc., then burnout is reduced.2
Use this survey to regularly assess physician self-care.
What are the important attributes of leaders who support the professional satisfaction of others?
In the words of physicians, a leader who promotes professional satisfaction17:
Holds career development conversations with me
Inspires me to do my best
Empowers me to do my job
Is interested in my opinion
Encourages employees to suggest ideas for improvement
Treats me with respect and dignity
Provides helpful feedback and coaching on my performance
Recognizes me for a job well done
Keeps me informed about changes taking place at my organization
Encourages me to develop my talents and skills
Are there other ways leadership can improve communication and relationships with physicians?
Several methods can help physicians build strong, enduring bridges with administration.
Establish “co-creation” as the standard approach for organizational initiatives, including in the development of institutional policies and regulations. With a co-creation approach, policies are created with input from both organizational leaders and those who will be impacted by the policies.18
Choose to “empower and encourage” rather than “design and deploy” or “command and control” when rolling out new initiatives. This method requires local customization within standard workflows. For example, rather than developing a standard template for daily huddles that is mandated for all practices, invite each practice to develop a template and create the time, location, and content of daily huddles that fits best within their workflow. The template users know what is most helpful to them.
Develop a communication platform for physicians to address daily work challenges and rapidly disseminate key issues from the front lines to top-level leadership who are capable of addressing these issues.
STEPS Forward™ offers several modules on improving leadership.
We suggest creating a toolkit of interventions and the associated staff to assist with their implementation, and then inviting individual units to choose where to start. If your organization has a Wellness Center, the Center's staff could track and report annually on how the interventions impact well-being and other metrics, such as productivity and retention.
Workflow improvements are among the most powerful interventions to reduce burnout. In addition, combating professional isolation and increasing opportunities to build community within the workforce can improve satisfaction. In the Healthy Work Place trial, 3 types of interventions were successful: workflow redesign, communication improvements between provider groups, and quality improvement initiatives in chronic disease management in areas of concern to clinicians.19 Social isolation has become more prevalent, especially for physicians in ambulatory practice. Organizations can intentionally support collegiality and create community by re-examining how the physical space is designed, activities are scheduled, and channels of communication are employed.
Optimizing space in a way that is conducive to communication and collaboration can take many forms.
The University of Minnesota created collaboration hallways in its ambulatory clinics building. These corridors of communal workspaces cut crossways through patient care hallways. An endocrinologist can walk down the collaboration hallway to easily consult with a dermatologist. A surgeon can walk over to talk with a general internist about their mutual patient.
At Beth Israel Deaconess Medical Center and Atrius Health, both in Boston, space is assigned to encourage people of different roles to cross paths with each other in the course of the day, increasing the opportunities for communication. For example, Atrius Health co-locates physicians with MAs and nurse practitioners in a common office that is on a shared corridor with other teams.
Other organizations have found that a provider lunchroom, physicians' lounge, or other meeting space helps to combat isolation and build stronger working relationships.
Schwartz Rounds/Empathy forums
Supportive forums for health professionals to explicitly address the emotional and spiritual needs of patients and caregivers can build a sense of community within an organization.20
Physician engagement groups
Mayo Clinic offers all of their physicians the opportunity to meet in small groups for dinner at a restaurant in town to discuss topics related to physicianhood every 2 to 4 weeks. A discussion question is provided to start the conversation. Mayo Clinic pays for the cost of these meals. Burnout was shown to decrease in those who participated.21
Writing and literature groups
Other organizations have supported writing and literature groups for their workforce as a means of strengthening social connections. For example, The Stanford Literature & Medicine Dinner and Discussion series is an opportunity for physicians to come together and share a meal while discussing works of literature. This program is supported by the WellMD office at Stanford.
Physicians spend nearly 2 hours on EHR and deskwork for every hour of direct clinical face time with patients.22 This is often not satisfying to patients or to physicians. Many practices can save several hours of physician and support staff time per day by strategically re-engineering the way the work is done, the way technology is used, and the way care is shared according to ability within the team.
For example, some work, such as prescription renewal or results reporting, can be re-engineered to be moved out of the physician's workflow. Other work, such as visit note documentation and order entry, can be delegated to other members of the team.
Where can I learn more about improving workflow efficiency?
The STEPS Forward portfolio of toolkits can provide guidance and practical tools and actionable downloads, including sample policies, checklists, and metrics for each intervention. A practice team or pilot group can use the STEPS Forward Practice Assessment to assess their organization's current state and guide their choice as to where to start. Many organizations have also found that including patients and families in the change process results in better outcomes.
Where can I learn more about leading change?
Change management techniques, such as Lean, PDSA cycles, and Listen-Sort-Empower can be helpful for empowering frontline workers to choose the problems they want to solve and to create and assess solutions themselves with support and guidance of organizational leaders. It is important that those doing the work have some control over how their work is done, both on a day-to-day basis and during times of significant process redesign.
The EHR is a significant source of stress and burnout for physicians. Some of this relates to the design and regulation of EHRs, but much of the stress is due to organizational decisions made during implementation. Many of these decisions have pushed more work to the physician—work that may not require a medical education—and thus contributes to time pressure and demoralization.
Your organization may want to track additional metrics of EHR use.23 Some of these can be measured behind the scenes with programs supplied by the EHR vendor, while others may require direct observation through time-motion studies or diaries.
Total time on EHR (during and outside of clinic sessions) per 8 h of patient scheduled time.
Example: A physician with 32 patient-scheduled hours per week, 20 h of EHR time during scheduled hours, 10 h of WOW each week would have EHR-Time8 of 30/32 × 8 = 7.5.
Time on EHR outside of scheduled patient hours per 8 h of patient scheduled time.a
Example: A physician with 32 scheduled patient hours per week and a total of 10 h of EHR time outside of these scheduled hours would have WOW8 = 10/32 × 8 = 2.5.
Hours on documentation (note writing) per 8 h of scheduled patient time
Example: A physician with 32 scheduled patient hours per week and a total of 20 h of documentation time (both in the room with the patient and outside of the room) per week would have DocTime8 of 20/32 × 8 = 5.0.
Total time on prescriptions per 8 h of patient scheduled time
Example: A physician spends 3 h per week on prescription work and has 24 h of patient scheduled time per week. Script8 = 3/24 × 8 = 1
Total time on inbox per 8 h of patient scheduled time
Example: A physician spends 10 h per week on Inbox work and has 20 h per week of patient scheduled time. IB8 = 10/20 × 8 = 4
The percentage of orders with team contribution
Example: A physician working with a team that is empowered to pend, send orders by protocol, or operationalize verbal orders, may compose 25% of the orders from start to finish on their own, while the rest are pended or completed by team members for the physician's co-signature. In this case, TWORD = 75%.
The amount of undivided attention patients receive from their physician. It is approximated by [(total time per session) minus (EHR time per session)]/total time per session.
Example: A physician who is actively on the EHR 3 h of a 4-h clinic session would have a lower ATTN score (4-3)/4 = 0.25 than would a physician who was actively on the EHR 1 h of a 4-h clinic session. (4-1)/4 = 0.75.
aFor consistency, and to avoid distortion owing to different session lengths, the study authors define work outside of work precisely as that time outside of scheduled patient hours and do not include any “shoulder time” before or after clinic.
Organizations have taken different approaches to reduce the burden of the EHR. For example, Atrius Health has created a “Joy in Practice IT bundle” to improve physician efficiency and reduce stress. This bundle includes:
Wide screen monitors replaced smaller screens in exam rooms so that physicians had continuity between their desktop view and the view in the exam room
Efficiency assessment through the EHR vendor's use tool to generate data on inefficient actions and then target interventions to improve efficiency
Workflow assessment involving a comparison of a given unit's workflow to Atrius Health's ideal practice model, with change management assistance to transform toward the ideal model if desired
Electronic prescribing of controlled substances (EPCS) using a smartphone application (for more information, visit the Drug Enforcement Administration's Diversion Control Division website)
Clinical leadership and operations leadership engagement that encourages clinical and IT leadership to team up to solve challenges
Other organizations have implemented the following to reduce the clerical burden of EHRs:
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Voice recognition software with natural language processing
The EHR is a major source of stress for our health professionals. What tools are available to assess EHR inefficiencies?
Many EHR vendors have the capacity to generate EHR-use data. This data can provide insight into practice inefficiencies to target for improvement. For example, an organization can assess the time their providers spend on inbox work, and then reduce that time by instituting in-basket management changes. Pre-intervention and post-intervention measurements can demonstrate the impact such changes have made and help spread change throughout the organization.
EHR-use data can identify efficient physicians from whom others can learn best practices. Such data can also identify physicians at high risk for burnout (eg, those who spend 2 hours of their personal time each night doing EHR documentation), as well as physicians who would benefit from new workflows or improved task delegation among their team. For example, a physician who spends considerably more time on orders than their peers will benefit from help re-engineering their process to delegate some of this work to team members.
Our doctors report they spend too much time on data entry. What does it cost for physicians to perform data entry that others could do?
Asante Physicians Partners in Grants Pass, OR, calculated that it costs $8 per patient for the MA to record elements of the patient's history into the record compared with $32 per patient if this same work is done by the physician.
Consider the costs of data entry performed by an MA versus a physician for visit note documentation, billing, and order entry.
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In addition, there are the indirect costs of reduced professional satisfaction and retention when highly trained professionals perform repeated tasks that do not require their training.
Physicians are highly resilient individuals. In fact, a study in 2020 found that physicians have higher levels of resilience than the general population.24 And yet, even among the most resilient physicians, nearly 1 in 3 experienced burnout.24 While the majority of physician well-being is driven by systems factors within the institution or the health care system at large, it is also important to support self-care efforts at the individual level.
To support wellness, some organizations provide assistance for physicians in accomplishing basic life tasks. For example, one organization has arranged for onsite dry cleaning drop off, another arranges for home delivery of healthy meals as a thank you for service on institutional committees, and another has an office that provides resources and referrals for physicians as they manage childcare or care for aging parents.
An organization may also choose to regularly assess physician self-care as part of an annual survey.
What are some additional measures that an organization can take to support personal wellness and resilience?
Provide access to healthy food and beverages
Offer training in mindful eating and set aside the time to practice the technique
Install on-site exercise facilities
Offer on-site showers (so that workers can bike or run to work or exercise during a work break)
Present convenient opportunities for yoga, tai chi, mindfulness, or other resiliency-oriented classes
Establish a quiet “refresh and recharge” room for physicians to go to after a stressful event
Develop a peer support program so that physicians are trained to listen to their peers undergoing trauma from lawsuit, medical error, career misgivings, etc.
Extend counseling with a financial professional via an annual review of financial health
Include self-care in the institution's code of ethics
Establish after-hours, off-site, and confidential psychological counseling services
Integrate presentations on personal resilience and well-being into the calendar of scheduled grand rounds or other organizational presentations
Teach compassion and self-compassion22
At a time of dynamic change in medicine it is essential to improve the experience of the caregivers, which depends on recognizing the costs of burnout and the value of a fulfilled professional workforce. Recognizing and quantifying the problem of burnout is the first step toward meaningful systematic change. Creating the organizational foundation for Joy in Medicine can be achieved by addressing issues within the 3 domains of physician well-being: efficiency of practice, culture of wellness, and personal resiliency.
Executive leadership teams have an opportunity to improve the health and well-being of patients, and their organization's financial bottom line, by improving the health and well-being of physicians and their practices.
Journal Articles and Other Publications
Shanafelt T, Stolz S, Springer J, Murphy D, Bohman B, Trockel M. A blueprint for organizational strategies to promote the well-being of health care professionals. NEJM Catal. 2020;1(6). doi: 10.1056/CAT.20.0266
Enjoy complimentary access to the full text of this article and learn more about this newest publication from NEJM Group.
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AMA STEPS Forward™ presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
AMA CME Accreditation Information
Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
Renewal Date: October 19, 2020
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