Many leaders of health care organizations are navigating tricky waters these days. Most now recognize that clinician burnout is a problem but are unsure what to do about it. Some avoid surveying clinicians because they don’t want to unearth problems that seem impossible to fix. Others schedule a resiliency retreat or mindfulness training. Individual solutions like these are a great start but if leaders go no further in addressing the systemic problems, they may face backlash from physicians who are angry at the implication that the problems they face are of their own doing.
Given how difficult it can be for organizations that have acknowledged burnout among their clinicians to determine how to address it, I was intrigued to hear how one physician leader, Chief Physician Experience Officer and Executive Medical Director for Patient Experience at UCSF Medical Center, Diane Sliwka, MD, has steered this largely uncharted path.
Did leaders adapt best practices from other academic health systems and institute them at UCSF? Did they pick a handful of specific interventions to try? Did they offer the standard individual-based solutions? Did they attempt to identify and address the systemic causes of burnout? And, of course I wanted to know what kind of results they’ve seen.
Sliwka told me that four years ago, it became clear that the organization would not be able to make significant inroads into improving the patient experience without addressing clinician burnout. “We heard, ‘We can’t do any more than we’re already doing.’” Sliwka’s job title was subsequently expanded to create an executive-level leadership position accountable for improving clinician wellbeing. It would require a book to describe all the steps Sliwka and her organization have taken to reduce burnout and improve the clinician experience. Here I’ll highlight three elements of their general philosophy and one specific intervention.
1. Digging for Underlying Causes
The organization began a yearly survey of physicians (other clinicians and staff were already surveyed on an annual basis). A pivotal question on the survey was, “How likely are you to recommend UCSF’s heath clinical enterprise as a place to work?” I love the simplicity of this question, and the fact that it provides an overall litmus test of the clinician’s experience at work, which might be missed with a series of very specific questions about satisfaction. The use of the question also points to a specific definition of success: a positive work environment in which clinicians can thrive and provide superior care.
According to Sliwka, the responses to the open-ended questions on the survey were invaluable for identifying underlying drivers of burnout. “The survey takes the focus from burnout prevalence to the workplace and why. That’s where we found the key information on what is working and what to improve.”
2. Sharing Accountability and Goals
Many organizations identify or convene a single entity to address clinician burnout. Instead, UCSF focused on distributed responsibility. Leaders spread the message that staff well-being and resilience are priorities from the top down and to every unit. “Wherever performance metrics are listed, clinician work experience is now included as a key part of the organization’s priorities,” Sliwka said. She told me these metrics are included in discussions at every level—from system-wide organizational goals in the executive dashboard, to annual “state of the department” reports, to daily management huddles and leader rounds within clinical units.
3. Implementing a Wide Array of Interventions
An important aspect of the UCSF approach is that it is comprehensive. “It’s not just one size fits all,” Sliwka explained. “We plan for interventions in eight domains. If you just work in one you won’t solve everyone’s problems. A scribe might help one person but not another.”
The eight domains they have identified include:
- Feeling valued and appreciated (including recognition, salary, working at top of one’s license, and having workflows and structures that work well)
- Personal well-being
- Open communication and trust
- Ongoing professional development
- Having influence
- Meaning and purpose
- Balance of academic and clinical missions
To identify interventions in each domain, the organization gathers input from frontline clinicians via surveys, open forums, feedback from the provider experience champions in each department, and discussions in faculty meetings. When choosing which interventions to prioritize, leaders have focused first on the “low-hanging fruit”—interventions that are simple and inexpensive—and those that incur a cost but are likely to help many clinicians. Since beginning to measure and understand the problem, more than 50 system improvements have been put in place to support the eight domains. According to Sliwka, problems are continuously identified and addressed at the local department, division, or practice level, fostering improvement across the whole organization.
A Specific Intervention: EHR Support
It became clear from the clinician surveys that the electronic health record (EHR) had a significant impact on patient and clinician experience. For this reason, leaders directed resources toward developing the Practice Efficiency and APeX Knowledge (PEAK) program to provide EHR support to clinicians. In the first wave, a dedicated team, led by PEAK Program Manager, Lona Sharma-Laughhunn, and Medical Director for Ambulatory Informatics, Maria Byron, MD, provided outreach to each ambulatory clinical group to understand the challenges faced by clinicians and to provide EHR optimization and coaching. The organization offered RVU-based compensation for time spent with the EHR coaches. A subject matter expert (also one of the clinicians) helps to liaison with the EHR team to represent the needs of the group and to communicate improvement opportunities to colleagues.
According to Sliwka, the 2.0 version of the program combines the EHR team with Lean methodology to streamline the EHR work across the entire clinical care team, helping to improve workflows for the whole practice. She cites data from an in-basket management project with a group of primary care practices showing a 74 percent improvement in satisfaction with the in-basket process in their practice. The same physicians reported a 15 percent improvement in satisfaction with EHR overall after the initiative.
The organization also initiated a scribe program, led by Chief Faculty Practice Officer Susan Smith, MD, to reduce the documentation burden for the busiest ambulatory clinicians. Before scribes, one in four physicians spent more than three hours on documentation after hours while none reported doing so after the scribe program was implemented. The cost of the scribes is offset using a system that clinicians in the pilot study for the program deemed acceptable. If a clinician is at or above the 50th percentile for productivity, then a scribe is assigned with no expectation for increased patient volume. If a clinician is below the 50th percentile, a scribe is offered, but with the expectation of a modest increase in productivity.
Continued expansion of the program is planned based on the positive impact seen in the early phases. As one physician said, “Scribes have made such a profound difference in my work day. I can’t imagine going back to the way it was before. [The scribe program] is great for my patients. Now I focus on them and not on computer.”
“After three years we are finally seeing the needle move in the right direction,” Sliwka told me. For the first 2 years, Sliwka primarily received comments about problems. About a year ago, the tide started to shift. “Some clinicians began reporting that they could feel real change. Although there is so much remaining need, seeing ongoing attention and investment has increased trust that things can improve.” Supporting these anecdotal responses, the organization’s third annual clinician survey showed an improvement of 18 points from the prior year.
Year of Survey and Net Promoter Score*
FY 15: -11
FY 16: -22
FY 17: -4
*The Net Promotor Score reflects responses to the question, “How likely to recommend UCSF’s heath clinical enterprise as a place to work?” Scores range from -100 (unlikely to recommend) to +100 (likely to recommend), and high performing organizations score in the +50 range.
As Sliwka told me, “There is no magic bullet for addressing burnout. In the short term, it is difficult to see improvement. We all need to be committing to this in a longer term way.”
A comprehensive strategy based on the actual needs of the frontline clinicians, prioritization among other organizational goals, and longer-term investments—Is your organization game?
Photo credit: Richard Frankel, PhD