Todd Caulfield, MDMedical Director, Providence Cardiology West

President, PSVMC Medical StaffChair, Oregon Region Provider Wellness Committee

Moving the Tracks of the Modern Healthcare Train: A System Based Approach to Provider Wellbeing

Modern Healthcare:

And Now:Then:

Work after Work (Pajama Time)

EPIC Provider Efficiency Profiles:

Notes:• Scheduled day = 7 am to 7 pm• More efficient often equates to less patient facing time• Scribe utilization about 70% during this sample

The Darker Side of the Problem

Stat News July 26, 2018Wellness officers? Code Lavender teams? Mindfulness meditation? These aren't the solutions to physician burnout and moral injury.

The moral injury of health care is … being unable to provide high-quality care and healing in the context of health care.

Loss of Stewardship of the Doctor – Patient Relationship

Providence Oregon MinistriesPress Ganey Engagement/Alignment/Burnout

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30

40

50

60

70

80

90

100

PSJH PSVMC PPMC PNMC PWFH PMH PHRMH PMMC PSH

Percentile Results

Engagement Alignment Burnout

Press Ganey SurveyPSVMC – Deeper Dive

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10

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70

Employed Allied Non-DO/MD Male Female

Percentile Results

Engagement Alignment Burnout

Cutting Professional Effort

• Assess physician burnout and satisfaction Mayo Clinic longitudinally 2011 and 2013 (n>2500)

• Independently monitor changes FTE payroll records

• Burnout and satisfaction predicted reduction in FTE over next 24 months– On MV analysis, each 1 point increase burnout OR 1.43 (p<0.001)

– On MV analysis, each 1 point decrease satisfaction OR 1.34 (p=0.03)

• Change burnout and statisfaction 2011 to 2013 predict reduction FTE following 12 months– On MV analysis, each 1 point increase burnout OR 1.28 (p=0.01)

– On MV analysis, each 1 point decrease satisfaction OR 1.67 (p=0.003)

Shanafelt, Mayo Clinic Proceedings, 91:422

Professional & Personal Consequences

JAMA 296:1071, JAMA 304:1173, JAMA 302:1294, Annals IM 136:358, Annals Surg 251:995, JAMA 306:952, Health Psych 12:93, JACS 212:42, Annals IM 149:334, Arch Surg 146:54

Stanford Chief Wellness Officer Course, June 2018

Copyright© 2016 Board of Trustees of the Leland Stanford Jr. University. All rights reserved

Efficiency of PracticeWorkplace systems, processes, and practices that promote safety, quality, effectiveness, positive patient and colleague interactions, and work-life balance.

Culture of WellnessOrganizational work environment, values and behaviors that promote self-care, personal and professional growth, and compassion for ourselves, our colleagues and our patients

Personal ResilienceIndividual skills, behaviors, and attitudes that contribute to

physical, emotional and professional wellbeing.

Framework for Professional Fulfillment

Stanford WellMD Model

• Reflection of Organizational Values• Explicitly stated • Supported from highest levels of

leadership

• Providers valued as humans and professionals • Appreciation• Peer support, compassion• Autonomy

• Community and Collegiality• Intentional

• Leadership Development

Take Home Message #1:

“Never set out to change the culture of your organization. Instead, define the problem, and understand if culture is a headwind or a tailwind.”

- Tait Shanafelt, Stanford CWO Training Course, June 2018

Organizational Culture

• Collection of tacit assumptions

• 3 levels

Tacit Assumptions

Espoused Values

Artifacts

Espoused Values and Artifacts can Contradict

• We Say…• Self care is important

• To err is human

• We have a supportive community

• Physicians are professionals

• Physicians are most important resource

• High quality care is our top priority

• Behavior…• Long hours, work first

• Culture of perfectionism

• Lack of vulnerability with colleagues

• Pre-auths and documentation

• High clerical burden, inefficient care systems

• Current systems drive fatigue, burnout, decreasing QOC

Espoused Values and Artifacts can Contradict

• We Say…• Leadership is important to

organizational success

• We value physician engagement and alignment

• Behavior…• Training and development is reserved

for senior leadership

• Feedback is limited

• Dedicated time is sparse

• Limited access to senior leadership

• Limited contribution by physicians to strategy

Physician Leaders: Maslach Averages

Emotional Exhaustion (EE) Personal Accomplishment Depersonalization

84.89%Moderate to high

66.91%Moderate to high

53.95% moderate to high

N=139

Providence Physician Leadership Retreat, 2018

Take Home Message #2:

“Pay attention to the long game.”

- Tait Shanafelt, Stanford CWO Training Course, June 2018

Take Home Message #3:

“Leaders are our most important lever. We need to support our leaders (our people caring for patients). We need to care for each other for our patients.”

- Steve Swensen, MD Stanford CWO Training Course, June 2018

The Five Leader Index Behaviors

• Include:• Nurture a culture where all are welcome and psychologically safe

• Inform:• Transparently share what you know with the team

• Inquire:• Consistently solicit input and ideas of coworkers

• Develop:• Support professional development and career aspirations of staff

• Recognize:• Express appreciation & gratitude in meaningful way to colleagues

Shanafelt, Swensen. Using the Annual Review to Reduce Burnout and Promote Engagement. Am J. Medical Quality 2017

Providence Oregon Region Provider Wellness(Last 12 months)• Leadership Retreat, with Provider Wellbeing as focus• PWC at PPMC, PSVMC• Oregon Region PWC• Collection of ministry based survey data, system wide, including burnout• Development of peer to peer support systems• Development of CISM programs by spiritual care• Advancement of IT efficiency solutions: Dragon Med One, RFID• Expansion of personal resilience strategies

• Compassion• Gratitude• Mindfulness

What Does Wellness Mean?

Shanafelt Definition:“Well-being goes beyond the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life.”

Lemaire and Wallace Definition:“Well-being reflects the extent o which and individual finds meaning, and is authentically able to express their self in their life and work, which is indicated by an overall satisfaction and balance in one’s life.”

Lebenso Definition:“Wellness can be defined as an active process of making choices in … dimensions of body, mind, and spirit that lead to healthier living.”