Secondary Logo

Journal Logo

Perspectives

The Health Care Chief Wellness Officer: What the Role Is and Is Not

Ripp, Jonathan MD, MPH; Shanafelt, Tait MD

Author Information
doi: 10.1097/ACM.0000000000003433
  • Free

Abstract

A new leadership position has been added to the C-suite of many large health care organizations and institutions—the chief wellness officer (CWO). The health care CWO’s role is distinct from CWOs or other wellness leadership positions at organizations outside of medicine. Those in such positions outside of health care typically are responsible for the well-being of all employees within their organization. Because the employees they oversee have such diverse work environments and distinct work experiences, these CWOs typically focus on employees’ development of personal resilience strategies, good health habits, and self-care. Organizations created these positions to improve health behaviors among their employees and to reduce health insurance expenditures—which was often used as a measure of program effectiveness.1

The health care CWO serves a very different function. This position was established to reduce the rate of burnout and occupational distress among clinicians, not simply to promote good health behaviors and reduce health insurance costs. Instead, the health care CWO focuses on protecting clinicians from occupational distress to enable these clinicians to provide high-quality, patient-centered care. There is a developing understanding and recognition that the well-being of clinicians is central to an optimally functioning health care system. Professional burnout is a World Health Organization (WHO)-designated occupational syndrome2 that is characterized by exhaustion, cynicism, moral injury, and loss of meaning and purpose in one’s work. It is caused by characteristics of the work environment rather than individual vulnerability or lack of personal resilience, and it is one of the most common occupational injuries among physicians, nurses, social workers, and other health care providers.3,4

Burnout in medicine has profound implications for patients, with numerous studies showing that it affects health care quality, patient satisfaction, and access to care.5,6 As burnout is not caused by personal shortcomings, organizations must offer solutions that go beyond personal resilience training and include interventions aimed at improving organizational culture, optimizing the efficiency of workflows and processes, addressing staffing issues, and improving support in the practice environment.

In 2017, Stanford Medicine was the first large health care organization to create a health care CWO position. Since then, more than 20 organizations have created similar positions. Although CWO is the most common title for these leaders, some organizations have used other titles such as Dean for Wellness or Vice President of Vitality instead. As the National Academy of Medicine and leaders from influential health care accrediting bodies have recommended that all academic medical centers establish a health care CWO position, we anticipate that many other organizations will follow suit in the coming years.7,8

The impetus for this movement to tackle the issue of burnout head on developed in part in response to the growing data on occupational distress among clinicians and evidence of its effects on quality of care.3–6 This distress is multifaceted and can take many forms, including burnout, fatigue, struggles with work–life integration, and moral distress/injury. The “Charter on Physician Well-Being,”9 which was created by the Collaborative for Healing and Renewal in Medicine and first appeared in the Journal of the American Medical Association in 2018, provides organizations with a framework of guiding principles and commitments, and a website dedicated to the Charter provides individuals and organizations with an opportunity to formally pledge their willingness to take action.10 The National Academy of Medicine’s report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being also highlights a number of guidelines focused on improving the practice environment to promote clinician well-being.8

Occupational burnout is the best-studied dimension of well-being among clinicians, as well as the domain most strongly linked to quality of care, patient satisfaction, turnover, and medical errors.6 Although some dislike the term “burnout,” it is a formal and well-defined occupational syndrome, recognized by the WHO. It has been studied for more than 40 years, and criterion and standard instruments have been created to assess it.11,12 Resistance to the term burnout has primarily developed as a reaction to the inaccurate use of the term by some, and the erroneous suggestion that burnout syndrome is due to an individual’s lack of personal resilience. Resentment toward this use of the term is exacerbated by the well-intentioned but misguided efforts of some organizations to offer personal resilience training to their employees as their primary strategy to address the problem. As with historical misunderstandings of major depression (e.g., suggesting to those who are affected, “You need to cheer up.”), the appropriate way to address misconceptions about occupational burnout is to provide education. It would accomplish little to change the term or label, and doing so would disconnect the importance of clinician well-being from the very evidence that has, at long last, motivated organizations to act. It would also separate efforts to make progress from decades of organizational science that has the potential to accelerate positive change.

The Case for Addressing Well-Being

Here, we discuss 4 considerations that support the need to address and improve clinician well-being: the moral case, the business case, the regulatory case, and the tragic case.13 The moral case relates to the desire of organizations to care for their people and the strong correlation between burnout and the adverse personal consequences for those experiencing it. Such consequences include problematic alcohol use, broken relationships, increased risk of depression, suicide, and leaving the health care profession.5,6 There is strong evidence that large numbers of physicians are dissatisfied with their jobs.3,14 They are also working more hours than ever—sometimes well past the confines of the standard workday—and in some cases, beyond the level at which they can provide highly effective patient care.15

The second consideration, the business case, is based on the evidence that burnout erodes quality of care, patient satisfaction, and access to care.6 One of the most critical factors distinguishing clinician burnout from burnout in people in other occupations is that clinician well-being affects both the clinicians and the patients under their care. Evidence indicates that burnout increases the risk of medical errors and unprofessional behavior.6 Multiple studies have also found that clinicians are reducing their professional work effort and/or leaving the profession in response to burnout14,16 and that physicians who experience burnout are at twice the risk for leaving their organization than those who do not experience burnout.17 These and other consequences related to burnout have substantive financial implications that provide a compelling reason for organizations to act.13,18 It is therefore in the interest of the public as well as organizations to address this issue.

The third consideration, the regulatory case, is driven by a call to action to improve the learning environment in medical school and residency.19 Accrediting organizations, such as the Accreditation Council for Graduate Medical Education (ACGME),20 have prioritized the well-being of physicians in training by requiring that all institutions that train physicians cultivate learner well-being. Both the ACGME and the Association of American Medical Colleges have made mitigating trainee burnout a priority through their partnership with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.21 The ACGME has also begun to review institutions’ efforts to cultivate physician well-being and their approaches to assessment as part of the accreditation process.

Finally, in some instances, there are potentially tragic consequences resulting from clinician distress that prompt organizations to act. Suicide is more common in physicians and trainees than in the general population.22,23 While mental health concerns and burnout are related concepts with one possibly contributing to the other, they are also distinct.12,24 When designed correctly, resources created to support individuals experiencing occupational distress (which can later lead to depression in some individuals) may also allow for early intervention that reduces the proportion of individuals who experience depression. The CWO should ensure the adequacy of mental health support for those in need as well as direct efforts to promote system-level drivers likely to enhance the well-being of the entire physician community, most of whom will not receive a depression or other mental health diagnosis.

Why Is a CWO Needed?

Organizational efforts to address clinician burnout must include a wide array of potential drivers. These include optimizing workloads, improving practice efficiency, addressing challenges with work–life integration, optimizing implementation of the electronic health record and other technologies, reducing clerical/administrative burden, fostering collegiality and community, attending to organizational values and aligning them with the altruistic values of the profession, cultivating leader behaviors that promote well-being in team members, and helping clinicians find meaning in their work.4 In addition, organizations must regularly measure dimensions of clinician well-being, such as satisfaction, professional fulfillment, burnout, and other measures of distress, while also tracking operational metrics related to well-being, such as time spent on documentation outside of clinical hours. It is not possible to accomplish these goals through wellness committees, which are unable to affect large-scale improvement. Developing and overseeing the execution of a strategy to address these challenges and working with other operational leaders to drive organizational change require a correctly placed senior leader with appropriate authority and resources.25 The health care CWO position was created for this purpose. This leader oversees these large institutional commitments and is empowered to implement changes that are designed to drive system-level progress.

CWOs are first and foremost officers of the organization who typically report directly to the chief executive officer or dean. They are executive leaders who have deep expertise in organizational science, the variables that contribute to professional fulfillment for clinicians, and the factors that contribute to burnout. They should have leadership expertise, experience leading improvement work, and the ability to lead by influence. They must also be able to collaborate with other officers of the organization, including the chief medical officer, chief quality officer, chief operating officer, chief human resources officer, chief financial officer, chief medical information officer, and chief nursing officer, to drive progress. CWOs should be supported by a team commensurate with the size of the organization, the scope of their work, and the number of clinicians they serve.25

What the Health Care CWO Role Is Not

When considering what the role of the health care CWO is, it is helpful to consider what it is not. The CWO should not focus primarily on developing individual-level interventions, such as personal resilience, mindfulness, exercise, and self-care offerings. Although such offerings can be important components of an organization’s well-being portfolio, the CWO should focus on larger interventions—like improving the organization’s work environment and culture. The goal is to address what is wrong with the system, not simply teach individuals how to better tolerate a system that is broken. Second, the CWO is not the chief human resources officer and his or her focus is not primarily on compensation, benefits, health plans, performance evaluations, or organizational structures. Similarly, the CWO should not be responsible for the disciplinary process or addressing unprofessional behavior, as doing so undermines his or her effectiveness to carry out other responsibilities (such as providing support to clinicians experiencing burnout who subsequently have higher rates of unprofessional behavior). Although the CWO frequently collaborates with the officers of diversity and inclusion, health care quality, and patient experience, he or she is not primarily responsible for the organization’s progress in these domains. Similarly, there is a high likelihood that no meaningful progress will occur if organizational efforts to promote well-being are simply added to the duties of other leaders who already have expansive responsibilities and whose focus inherently lies elsewhere. The CWO also should not personally provide mental health services to faculty, staff, or trainees that involve a clinical relationship with individual employees. Finally, while the CWO of some organizations will pursue substantial scholarship and contribute to the evidence base of best practices to address clinician well-being, this is not the primary function of the CWO, and conducting research should not be an expectation of this role.

Evaluating the Efficacy of the CWO and Well-Being Programs

When developing metrics to evaluate the efficacy of the health care CWO and his or her team, it is important to distinguish between metrics of organizational progress and measures of program effectiveness. The CWO and his or her team are responsible for guiding the organization’s wellness effort, but they are not accountable for the well-being and professional satisfaction of the clinicians in the organization,25 just as chief financial officers are not accountable for the net operating income or overall financial health of the organization. The chief financial officer helps set the organizational strategy and financial plan, measures progress toward its achievement, keeps other leaders informed of that progress and whether the organization is on track, identifies areas where performance is suboptimal, and makes suggestions regarding how deviations from plans could be addressed (e.g., delaying capital or other investments, cost cutting, growing activity in certain areas). Similarly, the chief quality officer is not accountable for the quality of care in every work unit. Rather, he or she develops the strategy for the organization to improve quality of care; engages clinicians and leaders across the organization to help drive progress toward optimal function; and provides expertise, tactics, coaching, and support as local leaders and clinicians identify opportunities to improve quality and carry out that work.

Similarly, optimizing the efficiency of the practice environment,26 improving levels of professional fulfillment, and decreasing clinician burnout are the responsibility of all leaders in an organization. Measures of progress in these domains are indicators of organizational success and are the collective responsibility of the entire leadership team (as is financial performance). In contrast, measures of the CWO’s effectiveness include how well he or she:

  • accurately measures and tracks burnout and professional fulfillment among clinicians in the organization;
  • provides relevant and actionable data to other leaders;
  • develops an organization-wide action plan;
  • advocates to secure resources for improvement;
  • identifies hot spots (i.e., departments, divisions, work units that are struggling);
  • provides guidance, recommendations, tactics, and support to the leaders of those hot spots;
  • develops system-wide resources to support individuals in distress;
  • develops system-wide resources to help leaders cultivate behaviors that promote well-being in team members and develop leadership skills;
  • advocates for the well-being of clinicians in organizational decision making;
  • influences the thinking of other leaders in the organization and creates a sense of shared ownership of clinician well-being; and
  • partners with these leaders to help create the optimal practice environment.25

For more detailed information on the responsibilities of the CWO and measures of organizational progress toward well-being goals, see Table 1.

T1
Table 1:
Responsibilities of the Chief Wellness Officer (CWO) and Measures of Organizational Progress Toward Well-Being Goals

Conclusion

In 2000 and 2001, respectively, the National Academy of Medicine released its influential consensus reports, To Err is Human: Building A Safer Health System27 and Crossing the Quality Chasm: A New Health System for the 21st Century,28 which shed light on the dramatic and devastating impact of medical errors on patients and outlined a system approach to make progress. What followed was a quality movement—a dramatic shift in attention on and efforts to improve quality of care. In 2019, the National Academy of Medicine released another watershed consensus report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,8 recognizing the epidemic of clinician distress and its implications for quality of care. In keeping with the recommendations from this report, vanguard health care organizations have begun to put into place the leaders, infrastructure, and improvement teams necessary to address clinician burnout.25 The health care CWO plays a key role in the oversight of these organizational efforts and is critical to their success.

References

1. Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes: A randomized clinical trial. JAMA. 2019;321:1491–1501.
2. World Health Organization. ICD-11 for Mortality and Morbidity Statistics. QD85 Burn-out. https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f129180281. Published April 2019. Accessed February 14, 2020.
3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94:1681–1694.
4. Dyrbye LN, West CP, Johnson PO, et al. Burnout and satisfaction with work-life integration among nurses. J Occup Environ Med. 2019;61:689–698.
5. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129–146.
6. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med. 2018;178:1317–1330.
7. Kishore S, Ripp J, Shanafelt T, et al. Making the case for the chief wellness officer in America’s health systems: A call to action. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20181025.308059/full. Published October 26,2018. Accessed February 14, 2020.
8. National Academy of Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2019.Washington, DC: National Academies Press;
9. Thomas LR, Ripp JA, West CP. Charter on physician well-being. JAMA. 2018;319:1541–1542.
10. American Medical Association. Charter on physician well-being. https://www.ama-assn.org/amaone/charter-physician-well-being. Accessed February 14, 2020.
11. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422.
12. Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016;15:103–111.
13. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826–1832.
14. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91:422–431.
15. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med. 2016;165:753–760.
16. Sinsky CA, Dyrbye LN, West CP, Satele D, Tutty M, Shanafelt TD. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc. 2017;92:1625–1635.
17. Hamidi MS, Bohman B, Sandborg C, et al. Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: A case study. BMC Health Serv Res. 2018;18:851.
18. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170:784–790.
19. Ripp JA, Privitera MR, West CP, et al. Well-being in graduate medical education: A call for action. Acad Med. 2017;92:914–917.
20. Accreditation Council for Graduate Medical Education. ACGME common program requirements. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Published 2017. Accessed February 14, 2020.
21. National Academy of Medicine. Action collaborative on clinical well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being. Accessed March 24, 2020.
22. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003;289:3161–3166.
23. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016;316:2214–2236.
24. Koutsimani P, Montgomery A, Georganta K. The relationship between burnout, depression, and anxiety: A systematic review and meta-analysis. Front Psychol. 2019;10:284.
25. Shanafelt T, Trockel M, Ripp J, Murphy ML, Sandborg C, Bohman B. Building a program on well-being: Key design considerations to meet the unique needs of each organization. Acad Med. 2019;94:156–161.
26. DiAngi YT, Lee TC, Sinsky CA, Bohman BD, Sharp CD. Novel metrics for improving professional fulfillment. Ann Intern Med. 2017;167:740–741.
27. National Academy of Sciences. To Err is Human: Building A Safer Health System. 2000.Washington, DC: National Academies Press;
28. National Academy of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.Washington, DC: National Academies Press;
Copyright © 2020 by the Association of American Medical Colleges