In a recent blog I criticized the American Hospital Association (AHA), an organization for which I have profound respect, for its publication of what seemed to me to be a vacuous 5-step "process" and vague "solutions" to the epidemic of burnout that's bedeviling virtually every hospital. Anyone looking for concrete actions or a "how to guide" from the AHA will be disappointed. But the disappointedly weak response by the AHA pales in comparison with the much anticipated release of "Understanding and Preventing Burnout among Public Health Workers: Guidance for Public Health Leaders" by the Centers for Disease Control and the National Institute of Occupational Health (NIOSH). Surely if any entity is going to get it right, I said to myself, it will be NIOSH, the respected government agency that is specifically charged with producing evidenced-based research and guidance for protecting workers in a variety of occupational settings.
My faith was misplaced. NIOSH, too, produced a nothing burger.
The Multi-Part NIOSH Guide
The multi-part NIOSH guide starts off well enough with the following introductory statement:
"Managers and supervisors can play a big role in reducing and preventing burnout. Public health workers experiencing burnout often feel exhausted and cynical. Working in a distressing environment can strain a person’s physical, emotional, and psychological well-being. Workers with burnout are more likely to experience mental health conditions like anxiety and depression. Burnout can also impact employee retention. Workers experiencing burnout may be less engaged at work and choose to leave their job or public health altogether.
Improving workplace policies and practices is the best way to address burnout. While individual-level solutions like self-care and resilience training may help, making organizational changes is necessary. For this reason, managers and supervisors must take action to address this issue. [emphasis added]"
Great, I thought. NIOSH is going to make abundantly clear that burnout arises from systemic noxious conditions in the workplace AND that leaders must act to change those conditions lest burnout continues to compromise the well-being and effectiveness of front-line health workers and compromise the quality of care provided to patients.
That's not what the reader gets. Instead, one will be surprised to learn that at root burnout is fundamentally if not entirely a mismatch between demands and resources. Yup. Just add more resources to match the demands of the job and, voila, all will be well. If that were the case world renowned, resource rich organizations like Johns Hopkins, MassGeneral Brigham, Stanford, Mayo, and Cleveland Clinic would not have any burnout. Apparently, the lead authors of the NIOSH report, Drs. Chris Cunnigham and Kristen Jennings Black, psychologists from the University of Tennessee, have rarely if ever ventured out to talk directly with or to closely observe nurses, physicians, and other front-line staff, at least not in hospitals including the august institutions referenced above. Alas, burnout exists in those places, too. For example, check out the October 6, 2023 JAMA Open Forum article, "Patterns in Physician Burnout in a Stable-Linked Cohort" which provides updated findings from prior surveys in 2017 and 2019 on the rising -- not falling -- incidence of burnout within members of the MassGeneral Physician Organization. This at the flagship teaching hospital of Harvard Medical School which has a research budget alone over $1.2 billion a year.
To be clear, I am not suggesting that increasing the availability of resources to match the demands of one's job doesn't matter. The demand-resource balance -- or imbalance -- clearly matters. But that's only part of the equation.
Take a look at NIOSH's much anticipated "Burnout Intervention Planning Guide (Example)" below. As a framework, it's OK. Indeed, I concur that a comprehensive approach requires looking at burnout and its remediation throuigh individual, group, leader, and organization-wide lens. But left unanswered are so many pressing questions. For example, what about the impact of unimproved EHR's reducing nurses and physicians to glorified data-entry personnel? It's alluded to but what, specifically, should be done about it and where does one go to find out about EHR optimization? What about inefficient processes which make it difficult for staff to get the right resources at the right time to the right patient? It's obliquely implied in their repeated demand:resource matching references. But how does one go about identifying the most salient mismatches and the most cost effective countermeasures? What about administrative duties that have devolved upon clinicians and how can those functions be reduced or eliminated? What about outdated policies or management practices which interfere with or take clinicians' valuable time away from caring for patients? How does one assess the extent and specific mix of drivers of burnout within their organization? If a hospital is losing money -- as many are -- or having trouble recruiting and retaining staff -- as most are -- how do the authors think such hospitals will be able to act on their glib recommendation "(a)dding more staff is another key way to increase resources and reduce demands on current workers". If these are the elements which should comprise a well designed burnout reduction plan, then how and where to affix responsibility for executing the plan; and, how does one know if those efforts are producing the intended effects? Unfortunately, the authors don't say.
Part 1: Burnout Intervention Planning Guide (Example)
Organizational Wellbeing Solutions for Hospitals, Health Systems, and Medical Group Practices: Leadership-Driven Changes
The locus to curing clinician burnout and staffing shortages runs through the c-suite. Here are examples of leadership-driven changes my colleague Paul DeChant, MD, MBA and I often recommend:
regard clinicians as knowledge workers who are given significant latitude to make clinical decisions without unnecessary administrative encumbrances or delays
consistently apply one or more of the improvement sciences (Lean, six sigma, operations research, agile, design thinking) in consultation with front-line staff to improve workflow and reduce delays, waste, inefficiency, and job skill mismatches
expect all leaders, but especially senior executives, to do periodic job shadowing of front-line staff (where observing and deep listening are emphasized) in lieu of "rounding" (a largely ineffectual, if widely practiced activity)
create and require leader standard work (LSW).
develop and deploy a sophisticated, deeply ingrained, and rigorous daily management system (DMS) supported by visual display boards or monitors
judiciously invest in AI/ML solutions -- selected, tested, and endorsed by front-line staff -- that eliminate or at least markedly reduce data entry, administrative requirements, and/or repetitive tasks that are non-value add
support near-continuous optimization and remediation of the EHR (there's no such thing as "it's all set")
get rid of superfluous or outdated policies, procedures, redundant approvals and other stupid stuff (GROSS)
Ready to transform your hospital or workplace?
Are you frustrated by adversarial relationships between front-line clinicians and senior leadership? Organizational Wellbeing Solutions was formed to enable senior leaders to identify the specific drivers of clinician burnout in their organization; and to support leaders in designing and executing a comprehensive plan to stop clinician burnout, increase retention, and improve operating results. A hallmark of our consultancy is correcting the all-too-frequent distrust and alienation clinicians feel toward the c-suite generally and the CEO in particular. Let us help you help your organization and its clinicians develop a more trusting, aligned, and productive working relationship.