Article In Brief
As part of a wellness initiative at Geisinger Health System, administrators surveyed its faculty about the issues causing burnout, and with them, developed some program changes and metrics to track their progress.
Neil R. Holland, MD, FAAN, chair of neurology at Geisinger Health System, kicked off the department's first anti-burnout initiative—a survey, group discussion, project implementation—earlier this year, and it seems to be progressing well. His colleagues say the work is only possible because of what came before it.
In departments where burnout is systemic, providers become emotionally exhausted and unable to provide meaningful feedback on a burnout survey because bitterness makes everything seems like a problem, said Kelly Baldwin, MD, a neurologist in the 40-provider department and neurology residency program director.
“The culture of the department, and the well-being of the providers, has to be fixed before someone can do what Dr. Holland is doing here at Geisinger,” she said.
A Two-Team Approach
When Dr. Holland became chairman four years ago, the department's high turnover rate made working life miserable for the neurologists that remained, and recruiting new colleagues was difficult.
He introduced a two-team approach to patient care: neurohospitalists working predictable shifts provide care for inpatients and emergency department patients while outpatient neurologists see patients in their offices and have no hospital call. Beyond that, Dr. Baldwin said, neurologists' schedule templates allow more time to handle their paperwork and faculty members have protected time so they no longer have to prepare lectures and mentor residents on their own time.
“I think we are all in such a good state now that we can take his survey and say ‘OK, these are the things we want to work on for the next year,’” Dr. Baldwin said.
In a healthy department, acknowledging in an open discussion that day-to-day working conditions can be improved and simply getting started provides its own reward, said Scott M. Friedenberg, MD, vice chair of the neurology department.
“I think another term for burnout is simply frustration because of a lack of control—when we feel like we're in a bad situation and there's no way to fix it,” he said. “So when everybody sees that we are all working towards making things better, it creates a nice environment.”
The experience offers two, perhaps counterintuitive, takeaways: If physicians are angry about their working conditions, any attempt to measure and address burnout is likely to be seen as one more burden. And when physicians feel their department or practice is well-managed, that's the time to focus on burnout.
“Once we were able to recruit people, then we wanted to make sure that we kept them,” Dr. Holland said. “So I started looking: ‘What else can we do?’”
Assessing and Addressing Burnout
As part of the 2018 cohort of the AAN's Live Well, Lead Well cohort, Dr. Holland devised a three-step initiative, involving a survey, a discussion on findings, and the development of metrics to track progress toward addressing the problems causing burnout.
A survey fielded earlier this year revealed that 90 percent of respondents did not consider themselves to be burned out, but 70 percent felt they had little or moderate control over their workload.
“It was helpful just to see that because you can't fix a problem unless you understand it,” he said.
The questionnaire included two open-ended questions: (1) What does burnout mean to you? and (2) What's one thing that the department could do to address this?
The first question elicited a range of responses that could be grouped into five categories: lack of enjoyment/satisfaction from the job, lack of empathy towards patients, lack of control over work, workload, and feeling underappreciated by patients.
Responses to the second question—what's one thing that could be done?—also coalesced into four distinct categories: add support staff, fix scheduling problems, provide time for unfulfilling tasks, and increase control over an individual's own schedule.
Geisinger neurologists work in several different locations, but they came together to discuss the survey findings and decide how to proceed.
“When you're working for a big organization, there are some things you don't have control over and some things that you do,” Dr. Holland said. “It is important to focus on the things that you really can change.”
With that in mind, staff members agreed to focus on two specific issues: time to room patients and support staff structure.
The group came to consensus on a small number of metrics—for example, percent of providers who feel they have sufficient support and percent of times a provider sees a patient on time—that correspond to their priority issues.
The operations team, with input from providers, has come up with various ideas to address the priority areas and they are currently being implemented. Having a metric tied to an issue, rather than a possible solution, decreases the chances that an idea won't work out and the whole effort will be dropped as a failure, Dr. Holland said.
“These things we are trying may or may not work—we may have to change them,” Dr. Holland said. “But just tracking a metric and following it over time is really helpful.”
Lessons Learned to Date
Many survey instruments are available to measure burnout, and Dr. Holland had previously tried to use a fairly long questionnaire to survey his department members. The response rate was too low to make a valid analysis of the findings, and he suspected the time needed to respond to all the questions was the reason.
So he adapted the Mini Z Burnout Survey (available online for free from the American Medical Association) and used Survey Monkey to field the survey in his department earlier this year. That questionnaire can be completed in less than five minutes; the initial response rate was much better and, after a few reminder emails, the response rate reached 80 percent.
“I think it was cutting down the number of questions that made the difference,” he said.
The Mini Z survey will be repeated at some point, Dr. Holland said. The more important metrics at the moment are those that track progress—for example, “percent of times in which the first patient of the day is in the room ready to be seen by the provider at their appointment time”—on the process-improvement projects.
“Thinking about burnout is important, but before you can improve the burnout, you have to make a change to improve something,” he said.
Results of the burnout survey and the discussion about how to proceed were discussed at an annual staff retreat. The seemingly simple act of getting together to talk about big-picture issues is not simple when busy neurologists are scattered over several practice sites, Dr. Friedenberg said.
Routine department meetings typically focus on business-related issues, rather than the “people issues” that are most likely to resonate with physicians.
“Most of the time when we get together, we are not talking about vision and esprit de corps and the personality of our practice,” he said. “We are applying this wellness issue really as a fulcrum for improving our entire practice.”
Finally, Dr. Holland said, it is important to recognize that because everyone is working on the same improvement strategies, everyone is responsible for helping them succeed.
“There are designated people to go to with questions or concerns and there's not a veil of confusion between what the administrators are doing and what the physicians are doing,” Dr. Friedenberg said. “The communication piece helps people realize that they are working together to make things better.”
The metrics chosen to evaluate progress on the improvement projects will be reviewed at regular department meetings, so they don't become a source of failure and disillusionment, Dr. Holland said.
“If the metrics get better, that's great; if they get worse, we really have to increase our efforts,” he said. “Just tracking the metrics may help with engagement because people can see that they have some control and are involved in the process.”
For Geisinger, There's a Bigger Picture
Anti-burnout strategies are often unique to a specific department or work unit. The patient-rooming protocols designed to improve job satisfaction for Geisinger neurologists, for example, are unlikely to be relevant to another department.
But clinician wellness must be a priority for an entire organization if it's going to truly address the burnout crisis in medicine, according to neurologist Kelly Baldwin, MD, who is also Geisinger's director of well-being for graduate medical education.
Dr. Baldwin was appointed to that newly created position this year after four years as chair of a committee working to measure resident wellbeing to fulfill requirements of the Accreditation Council for Graduate Medical Education and develop programming to improve resident wellbeing.
“I came to realize that, without involving the attending level and the department level in this effort, we will not gain any traction because our residents in the end will model behaviors that the attendings are showing them,” said Dr. Baldwin, who also directs the neurology residency program.
Geisinger currently has a Center for Professionalism and Provider Support that works with individuals who are experiencing a burnout crisis. In her new position, Dr. Baldwin is working with leaders at that center and the wellness director at Geisinger Commonwealth Medical School to propose an alignment of wellness standards that will be presented to executive leadership.
“Across the system, then, we will all be on the same page with our expectations for wellness and burnout prevention for our providers at any level,” she said.
Meanwhile, she hopes that research projects initiated by the graduate medical education wellness committee may lead to Geisinger-wide wellness programs and policies. In one of those projects, Geisinger Health Plan is making high-intensity interval training and nutrition counseling available—free and on campus—for residents and fellows.
Researchers will track several physical and mental-health indicators, including burnout, depression and fatigue measures, to determine if the intervention improves participants' wellness. If it does, the health plan intends to extend the benefit to all Geisinger employees.
In another project, Geisinger's neurology and internal medicine departments piloted a simple intervention for their residents: Having a primary care visit and a dental visit is a goal on each resident's action plan for his or her six-month evaluation. That assures that residents are getting preventive-health screenings and making their own health a priority.
“Just having that well-being piece on our evaluations has increased their access to health care in a meaningful way,” Dr. Baldwin said. She intends to publish results of that pilot program, which has been completed.