Contributors: Wren Keber, Lisa Soroka, and Z. Colette Edwards, WG'84, MD'85
To learn more about Wren, Lisa, and Colette, click here.
Many years before the pandemic, there was long-standing dissatisfaction evident among healthcare workers, particularly among physicians and other clinical providers. Dissatisfaction was due to a variety of factors such as the increasing burden of administrative tasks [e.g., documentation and charting requirements in templated electronic health records (“EHRs”), patient portals], long, pressure-filled work hours, not enough resources and programming to address issues, insufficient support staff levels coupled with high turnover, and the inability to practice at the top of one's license.
All these factors, combined with rising stress and cost of care delivery, has led to a widespread feeling of burnout among providers. In response, introduction of the "4th aim" – improving provider work life – was intended to draw focus to the criticality of addressing these challenges and to improve overall satisfaction of the healthcare workforce. (The “quadruple aim” of the Institute for Healthcare Improvement is composed of four goals – enhancing patient experience, improving population health, reducing costs, and improving the work life of healthcare providers (restoring “joy in work”).
Physician, nursing, and allied health shortages, an aging population with an increasing chronic disease burden, medical school debt averaging more than $250,000, a shortage of residency positions, changing care delivery and reimbursement models, and medical knowledge that doubles every 73 days all contribute to stress, which, if left unmanaged, leads to burnout. Pre-pandemic, a 2019 article in the Annals of Internal Medicine estimated the cost of physician burnout at $4.9 billion annually, largely attributable to costs related to turnover.
This alarming state of affairs was further exacerbated by the COVID-19 pandemic. Forty-three percent of physicians in the U.S. are 55 or older, and many individuals chose to retire or leave the workforce and pursue other careers that did not involve direct patient care. Morning Consult reported in 2021 that 18% of healthcare workers had quit their jobs, and a study by Definitive Healthcare estimated that 117,000 physicians had left their work as clinicians in 2021. Those departures have led to an even greater shortage.
In 2020, the Association of American Medical Colleges (AAMC) estimated that by 2030, the U.S. will suffer a shortage of up to 121,300 physicians. A 2019 study projected a nursing shortage of approximately 918,232 nurses by 2030. A survey of 36,000 physicians published in JAMA Network in 2022 indicated 20% planned to leave practice.
The long duration and devastating nature of the pandemic (>1.1M deaths in the U.S. and 500 patients still dying from COVID every day) contributed to moral injury, while practice buyouts by hospital systems and private equity firms dramatically changed the business and workplace dynamics of practicing medicine, in both positive and negative ways. In addition to the physical and emotional toll of caring for patients who were among the sickest staff had ever treated, reduced reimbursement levels, supply chain issues, and provider consolidation further decreased autonomy and increased the administrative burden on providers. Cybersecurity threats and issues with electronic health record (EHR) systems and portals only added to the already overwhelming workload (including uncompensated expectations to increase communication with patients enabled by enhanced technology.)
Despite efforts by Management Service Organizations (MSOs) and other operators to reduce administrative burden, increase patient satisfaction, and improve provider experience, these efforts are widely considered to be not at all sufficient and/or effective. There continues to be an increasing shortage of certain types of staffing, such as social workers and behavioral health professionals. Additionally, the healthcare workforce continues to be subjected to discrimination and bias based on race/ethnicity, sex and gender identity, including pay inequity. And increasingly workplace violence towards them by patients and family members threatens their safety and has even resulted in catastrophe.
All of these factors contribute to provider dissatisfaction and burnout, which in turn can ultimately lead to career changes (including early retirement and leaving healthcare practice/employment entirely.) Underscoring all these factors is a shift in expectations among younger generations of healthcare workers with regard to work/life balance, shift scheduling, compensation, and scope of practice, to name a few. The lack of sufficient attention and focus on prioritizing these issues and taking concrete and effective action further frustrate the workforce because needs continue to go unmet, and burnout continues to rise.
A study published in AJMC found burnout can lead to poorer patient outcomes and lower patient satisfaction. That’s just the patient side of things.
What can healthcare leaders do?
Health is personal, and healthcare is viewed just as personally by patients. Healthcare is different than most industries because, if delivered badly, lives are at risk. But the truism that “if you take care of the employees, they’ll take of the customers” applies in healthcare as it does in most other arenas. Just as most people would not want the plane they’re on piloted by a team that’s overworked, underpaid, and burned out, having patient care delivered by clinicians and nonclinical staff who are over-burdened, under-resourced, and physically and mentally exhausted doesn’t seem like a plan for safety, optimal clinical outcomes, or a good patient experience.
Because of the sacred responsibility those in healthcare carry, it is even more incumbent upon leaders to provide the resources and support necessary to avoid jeopardizing the health and well-being of the workforce, to ensure workplace safety, and to create a culture and environment in which those from all walks of life are respected and given the opportunity to thrive. And the added benefits of having a healthy workforce which feels appreciated are many – lower rates of turnover and absenteeism, lower costs related to temporary/contract staff and recruitment, fewer adverse events, better clinical outcomes, and higher NPS scores.
A study published in BMC Psychiatry in December 2022 found during the pandemic there were certain factors that helped protect against psychological distress (burnout, depression, anxiety, and PTSD) in healthcare workers – perceived organizational support, social support, and resilience.
Healthcare organizations need a strategy and action plan to address current challenges, including burnout and the fallout resulting from the trauma of the pandemic and taking care of legions of patients who fell victim to COVID-19, both directly and indirectly (e.g., delayed care). The effort must be sustained and ongoing in order to be effective. As is most often the case, there is no silver bullet or panacea. Time, financial investment, holding leaders accountable, establishing and tracking KPIs, and putting people first are key to getting the job done.
Tactics to Address Burnout
Although it often may not feel like it, healthcare leaders have the power to make changes that bear fruit both now and in the future. These tactics can be tied to other pandemic recovery efforts and include:
- Identify the root causes of burnout in the organization. Techniques to help cope with stress in its most extreme form, like mindfulness, physical activity, and a gratitude practice, will all help from both a physical and mental health and well-being perspective at the individual level. However, no amount of meditation can offset the root causes of burnout, such as woefully inadequate staffing levels or technology that creates more work. Unless the factors which led to the conditions that resulted in burnout at scale are accurately pinpointed, much time and money can be spent to no avail, exacerbate the problem, and leave staff losing faith in the organization.
- Talk to staff, clinical and nonclinical, at all levels of the organization, and truly listen. Then summarize learnings and identify themes. Those closest to the work at each level of the organization are often the ones most likely to have the ideas which prove to be effective (and less costly) solutions and come with staff buy-in. Aggregate what is learned, so themes can emerge. This approach allows leaders to filter out one-off opinions and instead focus on what matters the most and to the most people. As individual conversations converge to emerge as themes, they can be linked together such that themes can cascade down into specific pain points. For example, “staffing shortages” as a theme can be sub-divided into the impacted departments or teams, and further cascaded down to the number of positions which are vacant within each department or team (we use “staffing shortages” as an example, but any theme that emerges can be classified similarly.) As strategies are developed to address root causes, granularity will be critical to designing key performance indicators (“KPIs”) to track the progression and pace of impact.
- Find out what others are doing and leverage best practices. Some organizations have mapped out strategies and tactics organizations can implement, including:
- Review current processes/policies and technology workflows. When millions have been already spent on technology systems, the idea of stepping back and figuring out how to make the system work best for users may not be popular. However, organizations must conduct a periodic comprehensive review which focuses on identification by clinical and nonclinical staff of ways to make work more efficient, patients safer and more satisfied, and to help alleviate workforce burnout by minimizing the need for workarounds. “Workflows only work when work flows,” thus ongoing optimization of how people, processes, and technologies are integrated and/or automated is part of the required maintenance to keep staff satisfied and feeling empowered. And adding the right complement of nonclinical staff support to help reduce the administrative burdens and alleviate time pressure on providers can have an outsize positive impact on job satisfaction.
Accelerate movement to reimbursement models which support the quadruple aim. The fee-for-service (FFS) system is no longer a viable long-term strategy. In the short-term, it may maximize revenue for a select group of individual providers and systems. But for everyone else (as well as for the select group at some point), quantity over quality is no longer a sustainable plan. Value-based care (VBC) models are one path which helps to align incentives and enable investments in tools which can help mitigate workplace stressors and provider burnout (e.g., protected physician downtime to focus on patient management, care coordination tools, risk stratification of patient panels, etc.) But regardless of the model, success is dependent on a genuine belief in its key principles and not just a half-hearted hedge, with one foot still in FFS. Simply signing on to VBC does not guarantee success. It requires investment at levels to effectively transform workflows, policies, staffing models, and technology, and involves both clinical and nonclinical staff at every step of the way.
- Leverage advances in technology and increased adoption of additional care delivery options. Telehealth is one example of a care delivery option that was in a relatively nascent stage prior to the pandemic, but the approach was quickly embraced during it, boosted by state licensure waivers, reimbursement at the same level as in-person visits, and the safety of being able to stay at home rather than be exposed to COVID. Additionally, satisfaction levels are high among patients, and some providers report greater work satisfaction with the incorporation of telehealth into their practice. Lastly, in some instances, telehealth has improved access for populations underserved by the healthcare system. To maximize the positives and minimize some of the potential downsides, it is important to balance telehealth encounters with in-person visits to avoid "Zoom Burnout" and ensure optimal scheduling for time management and documentation tasks.
It is important to understand the appropriate level of investment required to sufficiently address burnout and improve satisfaction. Underfunded initiatives can ultimately exacerbate problems, because of increased provider frustration in the process and the perception that workforce needs are not being heard by leadership and/or administrators or they simply don’t care about the health and well-being of clinical and nonclinical staff.
The COVID-19 pandemic has exacerbated longstanding provider burnout and taken it to new highs. As the most acute stages of the pandemic have now receded, organizations have a red-hot opportunity to accelerate recovery by truly addressing the problem. Not taking action can have negative consequences with regard to patient safety, clinical outcomes, and the financial well-being of the enterprise that can potentially be catastrophic.