How Will This Module Help Me?
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?
Nine STEPS to Creating the Organizational Foundation for 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.
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 1 Engage Senior Leadership
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.
STEP 2 Track the Business Case for Well-Being
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.
STEP 3 Resource a Wellness Infrastructure
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.
STEP 4 Measure Burnout and the Predictors of Burnout Longitudinally
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:
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 practice.transformation@ama-assn.org with “Mini-Z Request” in the subject line.
STEP 5 Strengthen Local Leadership
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
Physician Opinion of the Leadership Quality of Their Immediate Physician Supervisor Survey (34 KB)Use this survey to regularly assess physician self-care.
STEP 6 Develop and Evaluate Interventions
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.
Physical space
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.
STEP 7 Improve Workflow Efficiency and Maximize the Power of Team-Based Care
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.
STEP 8 Reduce Clerical Burden and Tame the EHR
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.
In late 2021 to 2022, three in five physicians reported at least one manifestation of burnout, a problem consistent across nearly all specialties. 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.
Table 1. Key Measures of EHR Inefficiencies
| Measure | Abbreviation | Definition |
|---|
| Total EHR time | EHR-Time8 | 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.
|
| Work outside of work | WOW8 | 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.
|
| Time on encounter note documentation | Doc-Time8 | 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.
|
| Time on prescriptions | Script-Time8 | |
| Time on inbox | IB-Time8 | |
| Teamwork for orders | TWORD | 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%.
|
| Undivided attention | ATTN | 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.
|
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:
STEP 9 Support the Physical and Psychosocial Health of the Workforce
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.
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.