In order to systematically improve well-being among physicians and other health care professionals, leading organizations are creating a new C-level executive position called the Chief Wellness Officer (CWO). Once the position is established and a chief wellness officer is chosen, it is important that he or she implement specific and effective strategies for change. For individuals wanting to learn how to lay the groundwork for such a position at your organization, visit our related module, Establishing a Chief Wellness Officer Position. For new CWOs, this module is built for you, outlining a step-by-step approach to executing your new role as Chief Wellness Officer.
Clearly Define Your Scope and Charge
Study and Understand Your Organization
Build Your Team
Identify Existing Organizational Programs, Gaps, and Resources
Define and Develop Your Team's Mission and Strategy
Establish Partnerships, Distributed Leadership, and Thematic Task Forces
Develop a Bidirectional Communication Strategy
Set Performance Metrics for the Organization and the Team
Avoid Common Pitfalls and Mistakes
An important first step, when assuming your CWO leadership position, is to be clear about your scope and charge. Chief wellness officer roles in health care organizations are created to fill a gap in organizational efforts to create a practice environment that cultivates engagement, well-being, and esprit de corps. In organizations outside of health care, the CWO role is typically housed in the human resources department, their primary purpose to reduce the organization's health care expenditures by encouraging healthy living and individual approaches to foster stress reduction and personal resilience. CWOs in these organizations typically oversee all employees, including any number of what could be vastly different job descriptions, each with their own obstacles to reduced stress. The original focus of CWO roles in organizations like these, coupled with the need to reach all workers in dramatically different job types, typically results in such efforts devolving to an individual-focused approach (eg, personal resilience, mindfulness, exercise, self-care). This is not the CWO in health care organizations.
The health care CWO has a dramatically different role and function. This role focuses on addressing the unique needs of health care professionals by improving the efficiency of the practice environment, such as by reducing EHR documentation times, improving operating and turnaround times, or optimizing schedules and cross-coverage, and improving elements of organizational culture, such as by creating collegiality and community between health care professionals, advancing leadership behaviors among clinical and section leaders, or creating peer support and other support resources for those in distress.
Your organization should have already decided whether the CWO position is responsible for physician well-being only or if it is responsible for the well-being of other members of the health care team, as well. Whatever your organization decides, it is important keep your focus on this target group. Much of the CWO's work intersects with efforts of other functions within the health care organization; it is also important to coordinate efforts with these areas.
As CWO, you and your team will set the strategic vision of why and how the organization will improve the work environment to advance the well-being of health care professionals. This project will involve making the needs of physicians and other clinicians an important consideration in all organizational decisions. Thus, in your role as CWO, you perform an important function as a physician advocate and organizational influencer that may be analogous to that of the chief quality officer, chief medical officer, or chief patient experience officer. The goal of these efforts is to serve as a catalyst to spur evolution of the organizational culture toward more affirmational qualities, including participatory leadership, professionalism, equity and fairness, mutual respect, service, continuous learning, and an attitude of caring for self and others.
Your role, however, goes far beyond advocacy. CWOs must oversee the development and execution of the organization-wide strategy to advance professional well-being, as well as lead the implementation of a number of specific initiatives and tactics.1 There are numerous potential improvement opportunities and no CWO or organization—no matter how authentic their commitment—can take them all on at once. It is critical to identify and ensure the success of those strategies that are most important for organizational progress. This requires saying “no” to a number of worthy endeavors to effectively drive forward those that are most critical.
CWOs are also typically directly responsible for assessing professional fulfillment and distress, benchmarking the organizational experience relative to other medical centers, and tracking these measures over time.2 This data must be granular at the work-unit level (department, division, section, clinic) and used to engage the leadership of those work areas, provide support and guidance on how to deploy tactics for improvement, and support their local efforts to make progress. In addition to systematically engaging all units, you should also use this data to identify hot spots that require greater time, attention, and support from leaders outside the work unit to make progress.
Additional considerations regarding the CWO role and job description are provided in the STEPS Forward™ module, Establishing a Chief Wellness Officer Position.
Should a health care CWO focus first on personal resilience?
Health care CWOs are not "personal resilience" officers. Although providing resources to assist health care professionals with self-care is a component of their work, CWOs spend the majority of their time focused on creating a more efficient and supportive practice environment through workflow redesign and strengthening dimensions in organizational culture such as leadership, teamwork, professionalism, collegiality, and community.
Before the CWO can get started on implementing and tracking new initiatives, it is important that he or she have a strong foundation of knowledge regarding the gaps and needs of the organization. The following areas of focus are fundamental:
Organizational structure in terms of size, geographic distribution, number of sites, and leadership hierarchy3
Relationship of the organization to its physician workforce—whether via direct employment, an open staff model, an affiliated network, or some combination of these—and the reporting structure of who oversees these individuals
Key priorities as outlined by the executive leadership team, typically articulated in the organization's strategic plan; priorities may include expanding access, improving quality, market expansion, evolving toward new payment models, pursuing contracts with local employers, or preparing for value-based payments
Current financial health of the organization
Current reputational strengths and risks
External landscape and competitiveness of the practice environment in which the organization functions
It is also crucial to obtain quantitative data once these broad organizational factors are understood. Such assessment typically involves an institution-wide survey of physicians and other professionals within the CWO's scope. Such surveys should include standardized and validated instruments for which there are national benchmarks and that holistically evaluate dimensions of professional fulfillment and occupational distress. Examples include the Well-Being Index by Mayo Clinic, the Stanford Professional Fulfillment Index, the Maslach Burnout Inventory, and the AMA Professional Burnout and Satisfaction Survey (the Mini-Z).
Quantitative data can be used to catalyze qualitative conversations throughout the organization. Employ a “listening tour” to further understand the data and your organization. A listening tour can involve sharing the results of the survey with different work units, obtaining feedback as to whether the results accurately reflect people's experiences, and soliciting input on the greatest system-wide and local opportunities for improvement.
At this juncture, it is important to emphasize that the organization is at the data-gathering stage and will use this input to inform prioritization of the issues to be addressed. Avoid setting the expectation that the CWO and institutional leaders will fix every problem articulated in these sessions. These conversations can also include discussion of positive elements using the framework of appreciative inquiry. Such a framework may include asking those participating in the sessions to articulate (or write on cards for collection) 2 or 3 aspects of their work that are going well in addition to the 2 or 3 things that are most frustrating.
Our organization already measures professional engagement. Is this enough?
Although it is tempting to focus on and measure only positive elements such as engagement, numerous studies have demonstrated the strong relationship between elements of occupational distress and critical organizational objectives (eg, quality of care, patient satisfaction, and turnover). Accordingly, these elements of distress should be evaluated along with positive dimensions to obtain a holistic picture.
Should we measure employment statistics, such as trends in turnover and part-time status?
Yes. Institutional information on turnover, part-time status, the length and cost associated with open positions, and trends in these metrics should also be collected from the human resources department. This information can be used to estimate the costs of burnout for the organization in multiple dimensions (eg, economic, quality, reputational, recruitment/retention, malpractice risk).4
Are there non-financial costs associated with burnout that we should also consider?
In addition to the core dimensions of burnout, work effort and turnover, it is also important to recognize the non-financial costs to the organization resulting from the impact on professionalism, quality of care, teamwork, continuity of care, and patient experience.5- 11
For CWOs who are creating a center or program, building the team is an important early step. The optimal timing of your effort in the sequence of other activities can be somewhat flexible. After determining the scope, role, and structure of your position, many of the specific functions and skills required for your center will become apparent. Your team should include:
Administrative or operational leaders
Statistics and methodology experts
Communications professionals (to assist with both external and internal communication)
While all centers will need to attend to some of these roles, such as communications, other roles are best contracted (eg, survey administration and statistical analysis) for many centers.
Quiz Ref IDBefore devising the organizational strategy, you and your team must first identify what programs, resources, and activities to advance your efforts are already in place. Most organizations have existing training and activities to advance personal resilience. Others have programs and initiatives to advance professionalism, leadership development, teamwork, and diversity and inclusion. The goal for your team is not to take over all of these activities or topic areas, but to (1) integrate support and increase utilization of programs and resources that already exist, and (2) identify important gaps where new efforts are needed. It can also be informative for you and the team to understand what previous initiatives have been tried and discontinued due to lack of interest, low efficacy, unsustainable costs, or other factors.
To facilitate these efforts, it is important for you as CWO to meet with other relevant organizational leaders, including the chief quality officer (CQO), the chief medical officer (CMO), the chief experience officer (CXO), the chief medical information officer (CMIO), the chief diversity officer (CDO) or other leaders of diversity and inclusion, the chief human resources officer (CHRO), the chief operations officer (COO), and other key members of the operational leadership team. These meetings can provide understanding of what activities and efforts these leaders have in their respective portfolios and allow you as CWO to ensure that new initiatives are complementary and integrated with other efforts. As part of these meetings with the other executive leaders, you may also begin to discern which are natural allies, as well as which may be more resistant to some wellness programs, plans, or initiatives.
Once your team is in place, it is important to define and develop your team's mission and a strategy to achieve it. The mission often takes the form of an aspirational mission statement that envisions an ideal future state or articulates the purpose behind the program's creation. The strategy is a specific plan that selects a few critical thematic focus areas through which you, your team, and the organization as a whole will accomplish that mission.
The strategy must be adapted for each organization based on the unique opportunities, priorities, gaps, and resources of that organization. While the mission for your center or program can typically be developed in a single session or over a few days, developing a cogent strategy typically takes several months and requires extensive input and review from stakeholders both inside and outside the center.
The strategy should specify a limited number (3-5) of long-term focus areas. A well-developed strategy will undergo minimal change year to year, even as the tactics to advance that dimension of the strategy change. Many physicians have limited experience with strategic thinking and strategic planning. They often mistake a collection of tactics or a conceptual framework for a strategy. This is a critical error. Deploying a collection of tactics without having considered the core dimensions of a plan typically results in a fragmented and ineffective effort to make organizational progress, even if the tactics themselves are proven to be effective approaches.
The strategy of one organization cannot simply be wholesale adopted to another organization. Again, conceptual frameworks are not the same thing as a strategy.12,13 Such frameworks are, by design, holistic overviews intended to provide a comprehensive view of the variables contributing to the challenge and/or the opportunities. No program, however, no matter how robustly staffed or resourced, can effectively advance all components of such models at once. One of the most critical elements of a strategic plan is therefore not only to help determine what the team will do, but also what it will not do. The process of developing a strategy is best done as a team followed by vetting and input from multiple leaders and advisors. Full-length manuscripts that provide design considerations for strategic plans for organizational programs to advance well-being have been published and executive-level training courses for CWOs designed to assist with the strategic planning process have also been created.14,15
To be effective as Chief Wellness Officer, you will need to develop partnerships with multiple other leaders to be effective, such as the chief medical officer (CMO), chief clinical officer (CQO), chief experience officer (CXO), chief human resources officer (CHRO), chief medical information officer (CMIO), and the chief operating officer (COO). If you work in an academic medical center, you will also need to work in close collaboration with the deans of undergraduate and graduate medical education, the dean of faculty development, and the ombudsman.
In addition to these enterprise-level partnerships, an effective CWO must regularly interact with department chairs and hospital executives. It can also be helpful to build a network of local wellness leaders within each department. Once these individuals are identified and appointed (typically by the department or work-unit-level leader), they should receive basic leadership training prior to helping implement local-level tactics and acting as a conduit for bi-directional communication with the local units.
As CWO, you may periodically commission thematic, time-limited task forces to help the organization make progress on specific issues that span multiple organizational silos or departments. In these circumstances, you and your team may help craft the task force mission, charge, and timeline before appointing other institutional leaders to lead the task force.
Such task forces may focus on the needs of physicians at different career stages, the needs of physician parents (particularly breastfeeding mothers), or other topics. Even though these task forces will be led by others, you should not underestimate the logistical support and time demands such task forces require. Quiz Ref IDIn general, a CWO should not be overseeing or commissioning more than 1 task force per year. Accordingly, potential focus areas for task forces must be identified, prioritized, and commissioned in sequence.
You must also take care not to commission task forces on topics that are squarely in the leadership purview of other executives—particularly the CQO, the CHRO, CMIO, or COO—unless coordinated and commissioned together. Task forces that fall under this category of “coordinate and commission jointly, if at all” include those focused on teamwork, benefits or specific HR policies, EHR-related factors, and staffing issues. Other broad task force topics, such as specific dimensions of organizational culture, should typically be launched by the Dean or CEO rather than the CWO. In these cases, your role as CWO may be to chair, rather than commission, the task force. Still other topics, such as efforts focused on efficiency of practice, are typically best addressed at the work-unit level, and not by an enterprise-level task force. CWOs must, accordingly, take great care when considering which topics are appropriate for a task force they will commission and which are not.
Physicians need to know what their organizational leaders are doing for professional well-being as well as have a voice in these efforts. Developing an infrastructure to disseminate updates on your efforts as CWO is important and should be an initial focus area for your team. Such communication can take the form of newsletters, emails, brief video report-outs, or guest presentations at department meetings.
It is also important to build in channels for physicians across the enterprise to share feedback with you and other organizational leaders. Possible channels include listening sessions, focus groups, electronic suggestion boxes (see the Getting Rid of Stupid Stuff module), and periodic surveys. Opportunities for physicians to volunteer to work on department-wide or organization-wide thematic initiatives are another possible channel. A multi-faceted communication strategy is typically needed to reach physicians across the organization.
CWOs should review and decide upon performance metrics for both their organization and their team.1,3 These metrics are discussed in detail in the STEPS Forward™ module, Establishing a Chief Wellness Officer Position. It is important to remember the critical distinction between organizational metrics (Table 1) and metrics for you and your team (Table 2). CWOs cannot be held responsible for the burnout scores of their organization, but can and should be responsible for providing education, advocacy, and leadership, as well as developing a strategy to guide the organization.
Many other factors that are dominant determinants of wellness are not under a CWO's control. These factors can include variables such as productivity expectations, the adequacy of staffing, compensation models, organizational leadership, teamwork characteristics, transition to new facilities, and EHR characteristics, among others. You and your team cannot fix many of the local department-specific or work-unit-specific issues that frustrate care team members within the organization. Although you and your team can help identify these issues and support work-unit-level efforts, addressing these issues is the responsibility of the local work unit leaders. Accordingly, the high-level outcome metrics of the well-being and professional satisfaction of the organization's physicians and other clinicians is a shared responsibility of all organizational leaders. Such a framework is consistent with the shared responsibility of organizational leaders for quality outcomes, financial performance, and other measures.
Common pitfalls and mistakes for a new CWO include:
Conflating metrics of organizational progress with the metrics of CWO efficacy
As discussed, you and your team do not have direct authority over many of the organizational decisions and factors that impact professional fulfillment (eg, productivity expectations, leadership, staffing, workflows, the EHR, the efficiency of the practice environment). It is therefore critical to distinguish organizational metrics and goals from the measures by which the efficacy of you and your team will be assessed.
Failing to develop a strategy
Failing to invest the appropriate amount of time in developing an organizational strategy is another common pitfall. Deploying a collection of tactics, even if they are tactics that are proven to be effective, is unlikely to lead to organization-level improvement. A well-thought-out organizational strategy is necessary in order for the team to identify both the critical focus areas that will be prioritized first as well as the worthy alternative opportunities that will not be pursued immediately.
Rushing to build your team
Selecting the right team members, hiring and onboarding these individuals, and deploying them in alignment with the strategy all take time. Even in the most optimal circumstances, this process takes 6-12 months. Although some of the elements discussed in this module can be advanced in parallel with team-building, many of the initiatives and actions of your center will not be able to advance until this process is complete.
Trying to directly oversee too many initiatives
Although you and your team will need to directly develop and implement a number of initiatives, there are other efforts where you will need to work in partnership with other leaders and groups in a support or advisory role, instead. Trying to directly oversee and execute too many initiatives puts the well-being of your own team at risk and is a recipe for failure.
Trying to take on too much too fast
The natural tendency for a new CWO is to “hit the ground running.” However, CWOs must take care not to launch too many initiatives too quickly. Doing so often results in decreasing the effectiveness of all initiatives. It is more important to start with a limited number of initiatives and activities and get traction before expanding the portfolio. Given the extent of the need and the breadth of the opportunities to be pursued, adhering to this principle requires substantial discipline, even with a well-devised strategy.
Becoming the complaint department
The extent of distress and frustration among physicians is widespread and substantial. Once a CWO is appointed and a center created, these individuals finally have a leader to whom they can express their frustrations, concerns, and ideas. This often results in complaints of all types being directed to CWOs and their teams. This influx of complaints can include a dizzying array of challenges, including many which are far beyond the scope and responsibility of a CWO. We have seen CWOs receive complaints or requests regarding changing policies to allow physicians to bring their pets to work, the length of commute, parking, providing on-site childcare, cost of living in the community, the cleanliness of the call rooms, firing certain physicians, terminating all the administrators, and invalidating efforts to uphold professional standards. Although you and your team can connect these individuals to leaders responsible for some of these dimensions, you should avoid becoming the clearing house for all complaints about the organization as this will distract you from pursuing the actions and initiatives prioritized in your strategy to make initial progress.
Trying to please everyone
Related to the previous example, once the CWO's team has been established, everyone believes their pet project or activity should be and will be prioritized and implemented by this team. This is not feasible given the limited time, attention, and resources available; it is not an effective path to organizational change, either. As would any CWO, you will inevitably face criticism as a result of this, and it is important to have “thick skin” in this regard.
Becoming a personal resilience officer rather than the CWO
Your primary function as CWO is not to create a portfolio of personal resilience and self-care offerings. However, because such individual offerings are relatively easy to create and give the illusion of progress, many CWOs initially focus their attention on such activities. Although systematic efforts focused on improving efficiency of practice, optimizing workflows, evolving leadership behavior, and addressing problems with the organizational culture take more time, they are the initiatives that will ultimately result in greater impact. It is thus important to invest the energy necessary to launch such efforts rather than focusing exclusively on personal resilience offerings or devoting the majority of your energy to individual-focused initiatives.
Failing to develop a robust communication arm
A final pitfall is failing to build the infrastructure to facilitate bidirectional communication between the program and the physicians in the organization. Even when a CWO and team are effectively executing their strategic plan and making progress on multiple fronts, it is challenging to keep physicians across the organization informed of these efforts. Developing an infrastructure to disseminate updates on these efforts is important and should be one initial focus area for your team. It is also important to build in channels for physicians across the enterprise to share feedback with you and other organizational leaders. A multi-faceted communication strategy is typically needed to reach physicians across the organization.
A CWO is a unique and vital leadership position within a health care organization. Using an established “road map” to success can help new CWOs navigate this new territory.
Focus efforts on improving the practice environment rather than on improving the personal resilience of the workforce.
Establish a strong internal team as well as liaisons within the organization.
The CWO cannot be held responsible for the burnout scores of the organization, but should be responsible for providing education, advocacy, and leadership, and for developing a strategy to guide the organization.
Journal Articles and Other Publications
Annals of Internal Medicine: “Estimating the Attributable Cost of Physician Burnout in the United States”
Health Affairs Blog: “Making the Case for the Chief Wellness Officer in America’s Health Systems: A Call to Action”
JAMA Internal Medicine: “Creating a 'Manageable Cockpit' for Clinicians: A Shared Responsibility”
Journal of Healthcare Management: “Physician and Nurse Well-Being: Seven Things Hospital Boards Should Know”
NEJM Catalyst: “A Blueprint for Organizational Strategies to Promote the Well-Being of Health Care Professionals”
Enjoy complimentary access to the full text of this article and learn more about this newest publication from NEJM Group.
Joy in Medicine Recognition Program—More than an award, the criteria for the recognition program laid out in this pamphlet doubles as a road map for organizations invested in improving physician well-being and restoring joy in the practice of medicine
Creating the Organizational Foundation for Joy in Medicine™—the AMA STEPS Forward™ toolkit behind the Joy in Medicine Recognition Program
Debunking Regulatory Myths—Regulatory clarification from the AMA for physicians and their care teams to improve day-to-day practice while avoiding unnecessary burden created by overinterpreting regulations and regulatory myths
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