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Success Story: Reduce Burnout with Local and Organization-Wide Initiatives

Learn how Carilion Clinic developed organization-wide programming and tailored local initiatives to address burnout.

What Was the Problem?

Carilion Clinic leadership recognized that the integration of technology and the rapid change happening in the health care system at large would likely take an emotional toll on clinicians. They recognized that there was uncertainty about how best to create a foundation for clinician well-being while focusing on the Clinic's mission of patient-centric care during this time of rapid change. Over the years, Carilion tried numerous approaches to address and prevent burnout. These programs evolved with the changing practice environment and in response to physician feedback.

Developing the Intervention

Early organization-wide initiatives included:

  • A series of programs overseen by the Office of Continuing Professional Development (OCPD), including a physician leadership academy, a faculty development fellowship, and a service excellence initiative for physicians (Physicians Leading Service Excellence, or PleaSE)

  • A 4-month “virtual book study” for physicians to discuss the teachings in the book “The Resilient Physician” to help them navigate changes in the health care system1

  • A Professional Wellness Committee whose goal was to provide structure for organizational work focused on professional well-being. This committee brought together interested thought leaders from different sectors of the organization, including undergraduate and graduate medical education, OCPD, nursing, the Jefferson College of Health Sciences (JCHS), the employee assistance program, human resources, and the chaplain service. At first, this group served as a repository for initiatives throughout the system, and eventually became a catalyst for integrated action. The committee chair met with the clinical chairs and Vice President dyad partners to provide education about national burnout data and to raise organizational awareness of the committee's work in furthering wellness.

  • Adoption of the “Quadruple Aim,” which gradually became part of the organizational vernacular at the direction of the chief medical officer, sparking ideas for other initiatives dedicated to improving professional satisfaction2

At the local level, departments independently launched tailored initiatives to address clinician well-being and burnout in their practice environment. For example:

  • “Schwartz Rounds™,” a program that offers health care teams a regularly scheduled time to openly and honestly discuss the social and emotional issues they face caring for patients and families3

  • A “Second Victim” program, titled the “TRUST Team,” which was created to provide resources and support to struggling clinicians involved in unanticipated adverse patient events4

  • A focus in other areas of the organization on mindfulness and introducing support groups to improve well-being

Despite these efforts and a high level of understanding of stress within the medical community, the Professional Wellness Committee leadership team believed they needed a more formalized process to further identify specific local challenges. A research project started in the spring of 2016 sought to measure the level of burnout at Carilion and use this data to raise awareness of how important professional well-being is to advance the organizational mission. A survey that included the Maslach Burnout Inventory (MBI), the Physician Well-Being Self-Assessment Tool (PWSAT) and a few Carilion-generated questions focused on items measuring employee engagement was distributed to all physicians, residents/fellows, advanced care practitioners, and medical students in the system.4 The results indicated that 59% of Carilion physicians were experiencing high burnout; this was slightly higher than the national average based on studies available at the time.

From this latest information came a heightened awareness of the extent of clinician burnout and a renewed focus from organizational leadership to rectify it. Leadership brainstormed innovative ways to address this concern and fast-tracked initiatives already being developed. Some examples include:

  • Aggregating resources for students and clinicians. The medical school created a web portal to provide additional education and resources to support the well-being of medical students. The health system is currently developing its own web portal to consolidate information about a variety of support services and well-being initiatives in a single location.

  • Forming individualized wellness committees that meet the needs of practitioners in a specific department. Several departments started their own small wellness committees to tease out the most pressing challenges faced by their teams that lead to burnout. These committees are tasked with implementing local changes. For instance, the Department of Family and Community Medicine started a “4th Aim Better Life Team” that found inefficiencies with the electronic health record (EHR). The 4th Aim Better Life Team learned that to correct inefficiencies, they needed to create a culture of clinical consistency while also decreasing clinical variation in a way that allowed for appropriate autonomy. Some of these inefficiencies included:

    • Extensive time spent after hours on the EHR: The department began tracking time and noting the specific clinicians who were impacted. Physicians are contacted to learn more about their charting patterns. Physician champions selected for their EHR skills form teams to work one-on-one with their colleagues to increase proficiency with EHR systems so they spend less time in them.

    • Inefficient keyboarding/data-entry skills: The department actively promotes the use of either speech recognition software or scribes to assist clinicians. Those who use the voice recognition software (particularly with the most recent upgraded version) have been pleased with how it has impacted their charting efficiency.

    • Ineffective EHR templates leading to a breakdown in charting workflows: These challenges are found with the collection of regular feedback. The committee keeps a running list and systematically addresses them with the information technology (IT) team.

    • Overuse of EHR “Best Practice Advisories,” or BPAs: The phenomenon of “BPA fatigue” was once cited regularly by the group, and the committee was tasked with prioritizing the BPAs based on departmental and organizational priorities.

  • Enhancing visibility and sharing between groups. Ongoing support groups for both residents and faculty physicians have become more visible. There is a more active and successful sharing of structure and process between the various groups and across clinical departments.

  • Considering every member of the care team. An organizational well-being/burnout survey for all nurses was recently completed. The results will be used to help advance the culture of well-being for all Carilion clinic nurses. The division of Graduate Medical Education has also renewed its work addressing resident well-being and burnout.

  • Celebrating successes and sharing updates on wellness initiatives in email newsletters. The Department of Family and Community Medicine included a regular column on the “4th Aim” in their weekly clinical e-newsletter, which is sent to all clinicians and staff in the department (and throughout the country), called “Take 3 – Practical Practice Pointers.” A more system-wide e-newsletter is also being developed.

  • Demonstrating administrative and managerial support. The original Professional Wellness Committee re-launched to focus more specifically on physician well-being, in collaboration with other committees focusing on specific constituent groups. The OCPD also hired a full-time administrative manager to help advance the ongoing work pertaining to leadership development and clinician well-being.

  • Acknowledging the contribution of adverse events to burnout and collaborating with the appropriate departments. Process improvements are underway to more closely align the work of both the Professional Wellness/Physician Well-Being committees and the Second Victim team with the work of Carilion Clinical Advancement and Patient Safety, which oversees all quality, safety, compliance, and risk management work.

  • Following through, revising and refining based on feedback. Initial plans are in place for repeat surveys of the clinicians. Some individual clinical departments intend to repeat the burnout/well-being survey one year from the original survey to determine the impact of the initial interventions. As anecdotal evidence of successes or challenges comes in, education and development programs for physician and administrative leaders have expanded to include understanding the impact leadership has on clinician well-being and burnout. For example, Family and Community Medicine received positive feedback on improvements to EHR efficiency made at the behest of their department's wellness committee. Clinicians regularly comment on how much they appreciate being part of a department that is placing this improvement as a priority.

Tips for creating an organizational foundation that furthers wellness:

  • Form a centralized, diverse well-being committee with the necessary resources to drive this work and increase visibility across the organization.

  • Embed Quadruple Aim language in the organizational mission.

  • Establish a baseline of local data on clinician burnout/well-being using a validated instrument with national comparative data. Widely and openly share the results of local data and use it as a consistent measure of burnout within the organization.

  • Make an explicit connection between addressing clinician well-being/burnout and organizational quality, safety and risk management initiatives.

  • Create both a global organizational plan as well as department-specific plans to address pressure points that interfere with achieving the 4th Aim: improving “the experience of caring.”

Results

Carilion Clinic is committed to helping other organizations identify and address physician burnout by sharing their story. The Professional Wellness Committee created and circulated an internal white paper that laid out an organizational roadmap for addressing burnout. Carilion has also presented their data and efforts in this area at the local, regional, and national level and continue to publish on this topic. In October 2016, Mark Greenawald, MD, shared his own powerful story of burnout in a U.S. News and World Report special report, “Diagnosis Burnout.”6

About the Organization

Carilion Clinic is the largest not-for-profit, multi-specialty integrated health system in Western Virginia. Nearly 1 million people are served by the system's 7 hospitals and more than 220 physician practice locations. Seven hundred physicians and over 200 residents and fellows work at Carilion.

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Article Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

References
1.
Sotile  MO, Sotile  WM.  The Resilient Physician: Effective Emotional Management for Doctors and Their Medical Organizations. 1st ed. American Medical Association; 2002. https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1170019&navAction=push.
2.
Bodenheimer  T, Sinsky  C.  From Triple to Quadruple Aim: care of the patient requires care of the provider.  Ann Fam Med. 2014;12(6):573–576. doi: 10.1370/afm.1713Google ScholarCrossref
3.
Mudge  B, Stanzler  M.  Schwartz Center Rounds® and Magnet®: Enhancing patient- and family-centered care.  American Nurse. January 12 , 2012. Accessed March 11, 2020. https://www.myamericannurse.com/schwartz-center-rounds-and-magnet-enhancing-patient-and-family-centered-care/Google Scholar
4.
 Second victim experience. Center for Patient Safety. Accessed March 11, 2020. http://www.centerforpatientsafety.org/second-victims/
5.
 Hospitals are getting physician burnout and engagement all wrong – here's why.  Becker's Hospital Review. March 27 , 2017. Accessed March 11, 2020. http://www.beckershospitalreview.com/hospital-physician-relationships/hospitals-are-getting-burnout-and-physician-engagement-all-wrong-here-s-why.htmlGoogle Scholar
6.
Steinberg  S.  Diagnosis: burnout.  U.S. News & World Report. September 8 , 2016. Accessed March 11, 2020. https://www.usnews.com/news/articles/2016-09-08/doctors-battle-burnout-to-save-themselves-and-their-patientsGoogle Scholar

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