Driven by the Triple Aim framework of improving the individual experience of care, improving population health, and reducing the per capita cost of healthcare, healthcare systems are shifting to a value-based model of care. The intent is that the Triple Aim will guide the redesign of healthcare systems and improve population health while simultaneously lowering healthcare costs. However, the Triple Aim neglects to address the provider’s critical role in this transformation and takes on the additional responsibility to manage patient satisfaction, meet budget expectations, and hit established outcome matrices. These increased demands potentially lead to providers experiencing higher burnout rates.1 According to 2019 data, on a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.2
It is well established in the literature that healthcare provider burnout leads to low work satisfaction, which has significant downstream effects in the healthcare setting.3 When physicians and other advanced practice providers cannot provide quality care to patients, measures such as the patient experience, patient compliance with a medical plan, and physician suicide are a direct result.4 The advice given nationally to affect physician burnout has been variable, often focused on the individual health care provider and not on systemic change.5 Traditional individual interventions have included yoga, cognitive therapy, and mindfulness training.6,7
Recognizing the provider’s critical role in transforming healthcare, Berwick, Nolan, and Whittington8 introduced the Quadruple Aim, which expands the Triple Aim to underline the importance of provider wellness through improved work-life balance and joy in work.9 Lincoln10 proposes strategies for physician wellness needs that focus on a layered approach for change to include the individual, work unit teams, organizations, and national healthcare mandates. A novel strategy for pivoting physician work demands is starting from a favorable position and working backward.
Research finds that when healthcare providers can return to the reasons they are trained in medicine, practical solutions for their wellness can be extrapolated. By making work engaging and restoring joy, healthcare leadership can reframe barriers to reduce burnout. This paper presents the results of an organizational system-wide intervention designed to rethink the approach to lowering burnout by improving joy in work to address provider well-being.
Instead of addressing the causes of individual provider burnout to improve wellness, we pivoted to concentrate on systemic organizational change focusing on creating a “joyful, engaged workforce.” We followed the Institute for Healthcare Improvement (IHI) white paper, IHI Framework for Improving Joy in Work, to accomplish this goal. The IHI contends when healthcare providers can return to the reasons they trained in medicine, practical solutions for their wellness can be extrapolated.11 We also drew on Deming’s scientific approach to improvement, which provides that joy is a crucial component of the “psychology of change” and a fundamental right that leadership must ensure in its workforce. According to Deming, “Management’s overall aim should be to create a system in which everybody may take joy in his work.” By creating a framework of making work engaging, a healthcare provider can reframe daily barriers into the context of healthcare.
The board of directors at Guthrie Health System established an overall system strategic goal of increasing physician and Advanced Practice Provider (APP) engagement. During that time, the organization’s clinician burnout rate mirrored the national average. A physician process owner was selected to lead a dedicated engagement team of stakeholder representatives from each health system entity. Four strategies were defined and supporting tactics created by the engagement team with feedback and final approval from the healthcare system’s senior leadership. The four strategies were: (1) increase Physician Press Ganey Employee Engagement surveys response rates; (2) implement a formal process of engagement focusing on leader development; (3) increase entity and senior leader presence and visibility, and (4) define and create joy in the workplace. Under each of these strategies, eighteen tactics were developed to implement change, and each tactic was described as a system-wide initiative or specific target-area of focus. A single point accountability partner was assigned to each tactic, and a timetable created based on workflow.
Before implementing engagement-building interventions, baseline data measuring the current level of engagement by location and board-certified specialty and each unit’s readiness for change was obtained from the organization’s November 2018 Press Ganey Provider Engagement Survey results. Upon consultation with a statistician from Press Ganey and the baseline data, the organization selected seven areas (three surgical specialties and four medical specialties) to target for intervention. The target chosen areas had low baseline engagement scores, high readiness to change, and a volume of staff in the department to make a statistical difference in the analysis.
The engagement team chose to improve scores for five organizational provider engagement questions and four key drivers of engagement questions. Press Ganey has established validity as being the most telling for these constructs (Power Items). The Press Ganey organizational provider engagement items are:
I am proud to tell people I am affiliated with this organization. (PG Q41)
I would stay with this organization if offered a similar job elsewhere. (PG Q42)
I would recommend this organization to other physicians and medical staff as a good place to practice medicine. (PG Q43)
If I am practicing medicine three years from now, I am confident that I will be working at this organization. (PG Q44)
I would recommend this organization to family and friends who need care. (PG Q45)
The four Press Ganey key drivers of engagement questions are:
I rarely lose sleep over work issues (PG Q49)
I have confidence that this clinic/group will be successful in the coming years. (PG Q14)
I am satisfied with the recognition I receive. (PG Q34)
The organization conducts business in an ethical manner. (PG Q31)
(Survey items sourced from Press Ganey Employee Engagement surveys are copyright 2020 Press Ganey Associates LLC and used herein with permission.)
An executive steering committee was formed. This committee consisted of physician medical department leadership, senior nursing leadership, and senior executive leadership from the respective service line. The inclusion of target area leadership helped remove barriers to implementing engagement tactics, ensuring timely survey completion, and maintaining the department’s engagement project momentum. Each target area received the intervention and personal conversations with a physician facilitator based on “What Matters to You?” as advocated by the IHI. The Engagement Team provided a script to each facilitator to ensure a consistent message was delivered, and the methodology followed (see Appendix A). The interviews were conducted in all target areas with 1:1 or very small group meetings. The responses were categorized for each target area based on the questions, “What Barriers Prevent a Good Day in Your Department?” and “What Barriers Prevent a Good Day at Our Health System?”. The script was used for the assigned facilitator and the provider(s) for whom the intervention was ongoing. The interviewer wrote down comments during and after the interviewer and presented the information to the Engagement Team. The interviews were not recorded. Commentary and feedback were grouped into themes, such as scheduling, communication, and staffing.
Provider feedback from each target area was categorized by emerging themes and the themes used to create a Pareto chart (see Figure 1 for example) that identified issues with the most considerable potential for impact. A unique Go Forward Plan was created for each target area based upon this information. A meeting was held with each target area’s executive steering committee to review the results. Each target area was asked to choose one or two projects listed within the document to improve in the next three months. At the three-month mark, each target area leadership team attended a meeting with the Engagement Team to report out their action plan progress. To measure the impact of the methodology used in the target areas, the Press Ganey Provider Engagement Survey will be repeated, and the difference in scores examined for statistical significance.
While each target area had its unique barriers, scheduling and recognition emerged as system-wide barriers. The engagement team provided recommendations to address the most prominent individual target area barriers and investigate improvement opportunities with the central scheduling process implementing a formal employee recognition process. Each target area was charged with building upon the good identified through the interviews, prioritizing work to remove barriers, determining the metrics to tracking progress, developing a communication plan for ongoing work, and implementing a rounding schedule.
The Press Ganey survey was repeated in March 2020. Engagement question scores were analyzed to reflect the impact of the methodology used in the target areas. Overall engagement increased from 3.82 (23rd percentile vs. national clinical physician average) in 2018 to 3.97 (35th percentile) in 2020. Eight Power Item questions had a positive change from 2018 to 2020, with five questions showing a statistically significant improvement (Table 1).
As reported in Table 1, creating engagement team goals and tactics and stakeholder collaboration has been a critical component of improving engagement scores, allowing the engagement team to understand better how the work affects physicians and APPs. For example, meetings with key personnel from Central Scheduling opened communication lines between the providers and the off-site team that makes patient appointments.
Engagement is how a person feels joy in work; that is when the work has meaning and purpose. To address healthcare provider burnout, we must shift our focus from individual provider wellness to addressing systemic organizational change to bring about joy in work. “What Matters to You?” conversations provided specific recommendations that included improving processes for recognition of peers, review of current policy on orientation, and workflow in shared spaces, such as the operating room. When a conversation can spark organizational change through strategy and tactic, healthcare provider engagement fundamentally changes.
The project’s foundation is from IHI’s white paper IHI Framework for Improving Joy in Work and focuses on the “What Matters to You” conversations. Choosing any other foundational document could lead the Engagement Team down a different path of strategies and tactics. Other measures of engagement may result in alternative outcomes. It is too early to determine if this initiative has any direct effect on reducing provider burnout.
Within the healthcare system, there are many opportunities for further research. Previous attempts at improving midlevel management at Guthrie created coaching opportunities. This series was designed as a one-year program and sunset in FY20. This program could be rolled out to physicians and APPs if a need were determined. Many executives have professional coaches, and research has not yet been established on the benefits of coaching medical professionals from a return-on-investment standpoint. Coaching for physicians and APPs could be explored as an additional tool to support professional retention within the healthcare system.
Additionally, hardwiring change in culture must have dedicated champions. The Engagement Team will dissolve at the FY20 conclusion. The project management team has attempted to create long-standing change, but this work may return to baseline as time goes forward without surveillance.
This article was reformatted after publication as part of The Guthrie Journal’s move to a new platform so that all of our articles would have a consistent look. The article was published March 15, 2021, and reformatted in March 2022. In addition to small formatting changes, Figure 1 was given a title and moved to appear near its mention in the text. The in-text citations and reference list were changed to AMA style. In one place, the word “fours” was corrected to “four.”