Previously published on June 11, 2020. Updated based on an American Medical Association news article published September 17, 2020 by Mark Zarefsky.
Learn how hospitalists at University of Colorado created an improvement program with 4 domains to restore joy in medicine.
Think about your health care workplace for a minute. How would you describe your work culture? Are there signs of physician burnout? How excited are your colleagues about the work you all do?
Hospital medicine is the country's fastest growing medical specialty, yet more than half of hospitalists report that they experience burnout symptoms. With COVID-19, these hospitalists face even more stress because of the sheer number of patients who are testing positive for SARS-CoV-2 and require hospital care.
Recent investigation identified a sense of clinician workforce crisis in the United States, described as an epidemic of burnout. Increasingly, correlation is being drawn between clinician burnout and the quality of care delivered. Unfortunately, hospital medicine remains among the specialties most impacted by high burnout rates and related turnover.
In 2014, the Hospital Medicine Group leadership team at the University of Colorado set an explicit vision: to become the best academic hospitalist group in the nation by being an outstanding place to work. The team asked the question: If everyone in our group were thriving in their profession, what would that look like? The team committed to regularly measuring the experience of the group every 12-18 months within several important domains using standardized survey instruments. Importantly, measurement was not an end, but rather a springboard for group dialogue that explored insights, surfaced shared core values, and identified intervention priorities.
Developing the Intervention
Based on the dialogue that emerged from the measurement tool, interventions focused on 4 domains (Figure 1).
Figure 1. Areas to Intervene to Alleviate Hospitalist Strain
Organizational leaders often exclusively focus on the fourth domain—redesigning structures and processes. While this is no doubt important, it is insufficient for the purposes of promoting joy in practice and overall well-being. Smaller interventions at the level of the hospitalist team members and team leaders in all 4 domains were the focus of these quality improvement (QI) projects. Examples included:
Improve the emotional experience of work with “Something Awesome”
In this domain, an agenda item called Something Awesome was added to the monthly hospitalist group meetings. For this item, a hospitalist shared a 3-minute story of a recent “awesome” encounter he or she had while providing care for patients.
Translate empathy to action with “Flash Mobs”
In this domain, the group developed their own spin on flash mobs. Here, Flash Mobs were group conversations—facilitated by a group leader and convened in the hospital in real-time—in order to hear from people and discuss topics of concern. Topics ranged from strategies to manage patient volume surges, to how holidays should be scheduled, to disagreements between specialties. These conversations often have led to direct and timely interventions.
Provide professional development with Launch-Pad
In this domain, the group created a novel, year-long Launch-Pad seminar series for new faculty. The series included practical training related to clinical and academic success in four areas: Clinical Skills, Quality and Safety, Leadership, and Education and Scholarship. Continuing Medical Education (CME) funding rules were also changed to allow a broader range of activities of interest. Whereas traditional CME funding was limited to clinically focused professional conference attendance, the expanded rules supported a range of activities, from purchasing board review materials to attending a leadership development course.
Redesign of structures and processes
In the domain of redesign of processes and structures, one clear target for improvement was the clinical schedule. To better understand the goals for change, a working group conducted multiple structured individual interviews with more than 20 hospitalists to understand and mutually define the core values of the group related to the clinical schedule (eg, fairness, flexibility, timeliness, alignment with other hospital responsibilities). The group then used QI tools such as value-stream mapping to analyze and improve the clinical shift schedule. This enhanced the ability for clinicians to place PTO requests more fairly and predictably, and to have the clinical schedule in place with more lead time.
Additional examples included a collaborative case review for tough clinical cases, “Above and Beyond” awards, a leadership development series, leader rounding, annual review revamp, leadership role expansion by placing more practice members in new “associate” leadership roles in key strategic domains such as quality and safety, faculty coaching, a parental leave task force, and an excellence in communication course.
To support these efforts, it was essential to create venues to tap into the fundamental knowledge and creativity of hospitalists to build novel solutions for themselves. A select group of “incubators” received a small amount of funding to apply design-thinking processes to key questions. In this way, solutions were not “rolled-out” from the top-down, but rather co-created by the group itself. This allowed for quicker timelines for changes to be made, which is often not possible for top-down policy changes.
From 2014-2019, the hospitalist group developed over a dozen tangible and sustainable interventions as a result of these individual QI projects. Quantitative improvements in well-being measurements were significant. In 2014, 30% felt that “our culture makes it easy to learn from the mistakes of others,” 24% had become more callous toward people in their current job, and 45% were experiencing burnout. By contrast, by 2017, 59% felt that “our culture makes it easy to learn from the mistakes of others,”(”69% increase), there was a 38% decrease in workers who were more callous towards others, and 33% were experiencing burnout (27% decrease from previous years). Average annual turnover in the 5 years before the first survey was 13.2%; turnover declined during the intervention period to 6.6% (adjusted for increased number of positions). Based on the Organizational Cost of Physician Burnout Calculator, the cost of burnout plus turnover in 2013 was $464,385 per year. In contrast, all of these interventions were delivered for a fraction of that cost (an average of $86,000 annually).
The University of Colorado Hospital Medicine Group sits within the Division of Hospital Medicine, and consists of over 50 practicing internal medicine hospitalist physicians and advanced practice providers. These clinicians provide care primarily in a 600-bed academic quaternary care hospital and each typically care for 12-20 medically complex patients per day.