Connie Savor Price says physician burnout leads to medical errors and compromises the quality of care.

Addressing physician burnout is fundamental to promoting patient safety and care quality, says Connie Savor Price, MD, MBA, CMO at Denver Health.

Physician burnout was widespread before the coronavirus pandemic and spiked during the public health emergency. A study found that from September 2019 to January 2022, overall emotional exhaustion among healthcare workers increased from 31.8% of staff members to 40.4%.

Physician burnout has a significant negative impact on patient care, says Savor Price, who is a member of the HealthLeaders CMO Exchange.

"If a physician comes to work and feels tired or burned out, which is a feeling of disengagement sometimes to the level of despair, that can lead to medical errors," she says. "We know from data that physicians who are experiencing high rates of burnout are more likely to make diagnostic mistakes, treatment mistakes, and medication mistakes. If burnout gets to the point of depression, which is something that physicians who are burned out may experience, that leads to reduced attention to detail, cognitive impairments, and lapses in clinical judgment."

Denver Health has been working intentionally to reduce physician burnout for the past eight years. There is no silver bullet to address the problem, Savor Price says.

"There is not a singular solution to the problem, but we know we must work on it regardless of the challenges," she says. "We must try different things and make continued efforts to move the needle because provider burnout has a big impact on patient safety and quality."

To address physician burnout, healthcare organizations need to know their medical staff and know what factors are contributing most to burnout, Savor Price says.

"At an institution like Denver Health, a major driver of burnout is moral dilemmas," she says. "We have many patients who come into our emergency departments who are uninsured or under-insured. We can't always offer the full spectrum of services to those patients because they do not have the right type of resource to be able to afford services. As a physician, that situation is incredibly distressing."

So, one of the physician burnout initiatives at Denver Health has been to offer patients services for insurance enrollment. "We are doing everything we can to support the patients, which is important for our medical staff," Savor Price says.

Connie Savor Price, MD, MBA, is chief medical officer of Denver Health. Photo courtesy of Denver Health.

Physician burnout initiatives

In addition to helping uninsured and under-insured patients, Denver Health has launched many other physician burnout initiatives.

A primary effort has been to address excessive workload and administrative burdens such as documenting clinical care in the electronic medical record, Savor Price says.

"One of our most successful clinician burnout initiatives that was launched about three years ago has been at-the-elbow support in using the electronic medical record, which is Epic," she says. "We have had Epic 'super users' who are very knowledgeable in how to use the EMR to make themselves more efficient work with other clinicians. These super users have been working with their peers to show them how to efficiently document clinical care."

This at-the-elbow support effort has been conducted in the outpatient setting and the inpatient setting. Denver Health data shows that the initiative has reduced physicians' documentation time after their shifts have ended as well as overall documentation time.

Another primary physician burnout effort has been to promote a collegial environment with organizational support around opportunities for professional development, peer networking events, support groups, and medical staff events, Savor Price says. "We want to make Denver Health a collegial and pleasant place for our clinicians. For many clinicians, it is important to be happy at work and to have friends at work. We know from data that clinicians who have some friendships at work tend to be happier and stay in their jobs."

To select and develop physician burnout initiatives, Denver Health has used the health system's Medical Staff Executive Committee and a subcommittee of that group called the Provider Engagement and Wellness Committee to challenge the frontline medical staff to come up with initiatives.

"One of the proposals that came out of this effort was to create a Women in Medicine Mentoring Group," Savor Price says. "We know that mentorship programs can reduce burnout. A group of 25 female physicians met quarterly to talk about shared challenges, especially challenges that were unique to women. For example, they talked about balancing their careers and outside life. This mentorship program is something we are going to continue to support going forward because of the impact it has had on the first cohort of women, and we plan to expand the program to a new cohort in the coming year."

Other physician burnout initiatives that have come out of the Provider Engagement and Wellness Committee include lunch-and-learn sessions, yoga classes, and task-shifting.

"The task-shifting initiative has included focusing on paperwork tasks that are burdensome and annoying for physicians, who feel their most valued skills are related to clinical work such as diagnostics and treatment," Savor Price says. "In one of our clinics, we hired medical assistants to take on the burden of answering MyChart messages and tackling paperwork that the physicians could offload. This task-shifting has not only improved productivity. It is smart from a business perspective because it promotes physicians functioning at the top of their licenses."

Another physician burnout initiative that has come from the feedback of frontline clinicians is a plan to step up efforts to provide public recognition, Savor Price says.

"I am working with our communications department to profile some of our doctors," she says. "There are inspiring stories that come from patients and the peers of clinicians. I want to highlight clinicians who do community service. We will highlight these clinicians internally and externally. We can celebrate them on social media and other venues to help them know that we are proud of the work they do. Whether it is a single provider or a group of providers, we want to take advantage of telling their stories."

Measuring initiative impact

It is important to measure the impact of physician burnout initiatives, Savor Price says.

For several years, Denver Health has been using the Mini Z survey, which is an annual survey used to measure burnout. The health system plans to poll physicians and other staff members on a quarterly basis with two of the Mini Z survey questions, Savor Price says. "The first question is, 'Overall, I am satisfied with my current job.' Respondents answer the question on a five-point scale, which goes from strongly disagree, disagree, neutral, agree, and strongly agree. The second question is, 'I feel a great deal of stress because of my job.' The second question calls for the same five-point scale."

Savor Price acknowledges that Denver Health "has a long way to go" in addressing physician burnout.

"We have been largely stagnant on the annual Mini Z survey; and during the coronavirus pandemic, we slid backward," she says. "In the last survey, we made great progress, especially in addressing workload and stress. In terms of the national average for physician burnout, we were at the national average before the pandemic, slid to above average during the pandemic, and returned to average after the pandemic. Meeting the national average is not our goal—we need to do better."

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The burnout rates for Allegheny Health Network physicians and nurses are below national averages. Here's how its CMO did it.

At Allegheny Health Network (AHN), a six-year journey to improve the well-being of physicians, advance practice providers, and other staff is generating positive results.

There are three primary reasons why CMOs should be concerned about clinician well-being, says Donald Whiting, MD, CMO at AHN and president of Allegheny Clinic. Promoting well-being is essential for retention of clinicians, clinician well-being has been linked to the overall quality of patient care, and well-balanced clinicians perform their jobs better than clinicians who are struggling with well-being, Whiting says.

"As the CMO, you want your clinicians to come to work and put all of their energy toward taking care of their patients," Whiting says. "To do that, you need to address both the basic and advanced needs of your clinicians."

About six years ago, Thomas Campbell, MD, MPH, proposed creating a physician wellness program to Whiting. At the time, Campbell was serving as chairman of emergency medicine at AHN. He is now vice president of wellness at the Pittsburgh-based health system.

"I wanted to launch a physician wellness program because I had been doing research on burnout," Campbell says. "Dr. Whiting wanted to include more than just physicians, so our decision was to create a program for physicians, residents, advanced practice providers, and nurses. The intent was to grow the program to include all employees."

After launching dozens of wellness initiatives, AHN has made significant progress in boosting staff well-being. In recent years, physician burnout has trended 10 percentage points lower than the national average. In 2023, AHN earned recognition from the American Medical Association for demonstrating a commitment to promoting clinician well-being through proven efforts to address work-related stress and burnout.

"For our physicians as well as our nurses, we have been below the national averages for burnout," Campbell says. "In national surveys, there has been physician burnout as high as 62%. Our highest burnout rate for physicians has been about 52%."

To promote clinician well-being, CMOs and other leaders need to start with understanding the environment clinicians are in and the stressors that they are facing, Whiting says. "When we launched our well-being program, we started by surveying our physicians and advanced practice providers in several categories around the components of Maslow's Hierarchy of Needs. There were specific questions about safety at work, hours of work, the ability to take time for meals, and the respect of peers."

Well-being interventions

AHN began its efforts to promote clinician and nurse well-being by focusing on "low-hanging fruit," Campbell says.

• The health system's first annual wellness survey indicated that many clinicians and nurses were not aware that they could reach out for behavioral health help. Leaders publicized the fact that behavioral health services were available to all employees through AHN's Employee Assistance Program, which also was made available to non-employed independent clinicians.
• AHN's internal behavioral health group created a 24/7 help line for employees. "That was a great success, and it has continued since the beginning of our wellness program," Campbell says. "It is a foundational program."
   
• The early annual wellness surveys found that some basic needs were not being met. Staff members were not taking meal breaks and they were getting dehydrated from not taking a break to drink water. "We made a big push among physicians, residents, and the nursing staff to get people focused on meal breaks," Campbell says. "Our parent organization, Highmark, gave us a grant to create water stations in our hospitals at convenient locations."
   
• The annual wellness survey found female clinicians had higher burnout scores than male clinicians, which matched national data. There were cultural responsibilities impacting female clinicians such as the need to get children to school in the morning, so the health system implemented flexibility for start times and job-sharing capabilities.

Over time, after the low-hanging fruit had been grabbed, AHN began tackling more challenging aspects of promoting well-being, Campbell says. "We are working on initiatives that are much more difficult such as creating a caring culture to care for each other. We are trying to find ways for people to still take their breaks despite staffing shortages. We are trying to make sure physicians can take their vacations without checking patient messages in their electronic in-boxes."

Some AHN well-being initiatives launched during the coronavirus pandemic have become permanent.

"We now have 'decompression rooms' that people can go to when they are stressed out. These are quiet rooms with massage chairs and resources for people to reach out if they need help," Campbell says. "We also created another 24/7 help line for people in the emergency department and critical care. In addition, we started a peer support program for physicians and nurses so they could get help when they were at the end of their rope—if they were hesitant to reach out to a clinical professional, they could reach out to a peer."

In recent years, AHN has launched several new and innovative well-being initiatives.

The health system hired a wellness officer for each institute on the medical staff, Campbell says. "These wellness officers are my panel of experts for fields including surgery, obstetrics-gynecology, family medicine, and internal medicine. Almost all of these wellness officers have gone to programs on burnout and completed Stanford Medicine courses on well-being."

Last year's AHN wellness survey found improvement in the burnout scores related to electronic health record work, Campbell says. "We asked specific questions about the in-box because we knew that was a driver of burnout. What we found was that burnout from the EHR in-box got better for our physicians but a little worse for our advanced practice providers. What I think happened is that some of the work got pushed to the APPs, and now they need help."

For the clinician resident group, AHN has posted a couple of recent successes, Campbell says. "For example, the residents have complained that they have a lot of administrative tasks and other things that make their life difficult such as interruptions in their workday. Instead of equipping them with pagers, we got them cellphones, so they could be reached by text, which is less disruptive than a page, especially when they are at home. We also have provided healthy food in the resident lounges."

For the APPs, AHN has launched several initiatives because they are critical to getting work done, Campbell says. "We created an APP council, so their voices would be heard. In addition, every hospital medical staff executive committee has an APP representative, so their voice is heard in those forums. They have become more integrated with the leadership of the institutes."

Successful healthcare organizations can distinguish between the patient experience and the customer experience.

Healthcare organizations need to focus on both the patient experience and the customer experience. And yes, there are important differences.

The contrast between patient experience and customer experience is largely a difference in perspective, says Sarah Way, MD, JD, chief quality and medical officer at Texas Health Dallas, a hospital operated by Texas Health Resources.

Patient experience is related to when someone receives medical care in the moment, says Way, an emergency medicine physician. For example, receiving treatment from an emergency room clinician is a patient experience.

"A customer experience is when you look at an interaction more broadly, when somebody is engaging with the healthcare system, but it is not the provision of medical care in the moment," Way says. "In the emergency department, customer experience includes how somebody is checked in at the front desk and how they are discharged. The customer experience also includes family members and how they perceive a patient's visit to a care setting."

Patient experience and customer experience are different engagements with the healthcare system, and one person can be both a patient and a customer, says Amy Goad, managing director at Sendero Consulting.

While someone is a patient when they receive care directly from a provider, that person is a consumer when dealing with other aspects of the healthcare system outside of direct medical care.

"You are a customer when you are trying to schedule an appointment, when you are trying to coordinate insurance, when you are trying to find lab results while navigating a patient portal, and when you are conducting research on who you want to be your provider," Goad says.

Identifying different strategies for different forms of engagement

One difference between the patient experience and the customer experience is that patients are much more vulnerable and want to spend time with their healthcare providers, Goad says.

"That vulnerability creates a different bond with your care provider than the situation when you are trying to order a prescription or schedule an appointment," Goad says. "When my health is in question and it feels risky, the patient relationship becomes a bigger priority than the customer components."

On the other hand, Goad says, a health system's customer experience strategy should focus on convenience and ease of use.

"As customers, people do not want the heavy engagement that they need when they are patients—they want to be bothered as little as possible," Goad says. "Customers are convenience-focused and transactional. You want convenience in your interactions, which you want to be quick and simple."

A health system that fails to distinguish between patient experience and customer experience will see the effect in negative satisfaction scores, Goad says.

"When I'm wearing the hat of the customer and somebody tries to treat me like a patient, it is going to wear me out—you are trying to take up too much of my time, and I am going to go somewhere else where it is easier," Goad says.

"When I'm wearing my patient hat and I'm feeling anxious about my pregnancy and want to spend more time with my doctor, if I get treated as a customer such as quickly getting in and out of an appointment, I am going to feel frustrated," Goad says. "I am going to feel that I am not a known entity and that there is no one investing the time to make sure I am OK."

Conversely, Way says, a CMO must understand that the healthcare experience is about the whole person, both the patient and the customer. Failing to recognize and address both types of engagement, Way says, could lead to fractured care or a feeling of disconnection with the health system.

"You need to provide the right medical care in the moment, but you also need to recognize that if you do not address the customer experience you are not going to get the best result for the person you are serving," Way says.

Serving both the patient and the customer

Key components of the customer experience in healthcare involve taking steps beyond the provision of medical care, such as providing resources for follow-up care or health and wellness services, Way says.

"We need to recognize that there is more to serving people than providing medical care in the moment," Way says. "For example, if you write a prescription, you need to consider whether the pharmacy is open, whether your patient has transportation to get to the pharmacy, and whether your patient can afford the medication."

For the customer experience, healthcare organizations need to recognize the resources people need to build their overall health even when they are not sick, Way says.

"One of the big initiatives across the country is to look at social determinants of health," Way says. "We need to be gathering information about what our patients are struggling with such as food insecurity and housing. If a patient is struggling with food insecurity, healthcare organizations need to help patients find resources in the community such as food pantries and connect patients to those resources."

Ensuring patients have transportation is another element of generating a good customer experience, Way says.

"If a patient is discharged from the hospital and there is a high likelihood that the patient is going to need outpatient care or come back to the hospital, you need to ask the patient how they are going to get to their appointments," Way says. "If transportation is an issue, the next question you need to ask is what can we do to help you get transportation. There are community resources that provide transportation."

If transportation is problematic, healthcare organizations also should be able to provide appointments via telemedicine, Way says.

Navigating between patient experience and customer experience

Healthcare providers need to understand the full health journey and be able to differentiate between the patient experience and the customer experience, Goad says.

"When a care provider is sitting in an exam room with someone, they need to recognize they are dealing with a patient," Goad says. "When someone is at the front desk, they are likely to want more of a customer experience versus a patient experience."

When health systems are looking to invest and innovate, if they are trying to innovate on a patient experience but focus more on consumer-centric factors such as billing and scheduling, they are missing the mark, Goad says.

"Examples of investing in patient experience include having more clinical trials and hiring more clinical staff so clinicians can have more time with patients," Goad says. "Health systems need to understand how they are investing in these separate experiences to get better efficiencies and outcomes."

Healthcare organizations need to know that patient experience and customer experience are equally important, and they cannot be disconnected, Way says.

"We are having to shift as physicians and providers from the idea that providing medical care is enough for the people we serve," Way says. "We also have a responsibility to ensure that the medical care we provide is received and accessed in the right way. It is not enough to be great physicians in the technical sense—we also must be good communicators, we have to work in a system that reaches out and provides good access, and we have to address needs beyond the provision of medical care."

Historically, clinicians have focused on the people they serve as patients, but that focus is too narrow, Way says.

"We must expand that zone to also think about the people we serve as customers," Way says. "This is not a skill set we are taught in medical school—healthcare organizations need to build the skill set of their providers to include dealing with people as patients and customers. We want the care we provide to be recognized as good because it is received well."

The CMO of Northwell Health is developing a specific care strategy for the fastest growing segment of the nation's population.

With seniors comprising the fastest growing segment of the American population, Northwell Health is developing an "age-friendly" strategy aimed at improving clinical outcomes.

According to the Population Reference Bureau, the number of Americans who are 65 or older is expected to rise 47% over the next three decades, increasing from 58 million in 2022 to 82 million by 2050. During this period, the share of the total population of Americans who are 65 or older is expected to increase from 17% to 23%.

Healthcare providers need to step up efforts to serve that population, says Jill Kalman, MD, CMO, deputy physician-in-chief and executive vice president at Northwell Health.

"They are complex with multiple chronic conditions," Kalman says. "We need to take care of this growing part of our population. Both the 65-and-older and 80-and-older patient populations are growing."

Northwell has joined 29 other health systems in launching the Institute for Healthcare Improvement's Age-Friendly System-Wide Spread Collaborative. The collaborative is designed to accelerate and spread evidence-based care for older adults. A primary goal of the collaborative is to push adoption of four evidence-based elements of high-quality care, known as the 4Ms: medication, mobility, mentation, and what matters most to older patients and their families.

Kalman says Northwell has embraced the 4Ms at the health system's 21 hospitals and 900 ambulatory practices:

• For medication, Northwell is focused on how an older adult metabolizes certain medications, which can be significantly different with younger patients, especially if there is kidney disease, liver disease, or heart disease. Clinicians take great care with medications that can be harmful for older adults such as benzodiazepines and opioids. Those medications are used when necessary, but doses are adjusted and clinicians are intentional about the medications they choose.
   
• Mobility is of the utmost importance in the inpatient and outpatient setting.  For example, clinicians need to be aware of a patient's mobility for risk of falls. In the outpatient setting, Northwell is encouraging physical therapy and mobility activities that can be specifically tailored to an older patient's co-morbidities.
   
• Mentation and cognition may decline naturally over time, and there are diseases that impact mentation such as Alzheimer's. Northwell is focusing on how patients can improve their mentation with specific activities such as games or social interactions.
   
• Northwell is focusing intently on what matters most to the health system's older adult patients and their families. For example, patients are asked about what matters to them as they advance in an illness and about their goals in care.

Age-friendly care delivery and CMOs

Kalman says CMOs have an obligation to address quality of care, and the delivery of age-friendly care is part of that mission.

"It is important to deliver on quality metrics for older patients," she says. "I am focused on making sure evidence-based forms of care are used and making sure we are minimizing harm in everything that we do. I understand that older adults often have multiple chronic conditions that need to come into play when we are looking at the complexity of care for these patients."

The primary quality metrics in the care of older adults include the 4Ms, length of stay, and hospital readmissions, Kalman says.

"I monitor dashboards for our age-friendly health system that look at multiple metrics across our hospitals and ambulatory practices, so we can continue to understand how well we are doing in the evidence-based delivery of care," she says.

A CMO must recognize that older adult patients also have different needs and risks when it comes to surgery, Kalman says.

"Someone coming into a hospital for an appendectomy at the age of 80 is going to have different needs than someone coming in for an appendectomy at the age of 25," Kalman says. "It can be extremely different. Even the least complex surgery can be complex in an older adult, particularly in the recovery phase."

CMOs who are committed to age-friendly care delivery should make sure their health systems pay attention to medication management, delirium screening, and the goals of care, Kalman says.

"These factors need to be put together to drive the best outcomes," she says. "If we can drive the best outcomes in the outpatient and inpatient settings, we also work toward preventing some of the frailty in the older adult [and supporting] a better health span. We can also reduce length of stay and reduce hospital readmissions."

Value of age-friendly care delivery

The benefits of age-friendly care delivery are considerable, Kalman says.

"It is all about the quality of life and quantity of life, if that is what the older patient desires," she says. "The combination of health span and life span is extremely important. The benefits of age-friendly care include driving good clinical outcomes."

"The drawbacks of not providing age-friendly care delivery are poorer outcomes," Kalman says. "For health systems, there are financial drawbacks from not providing age-friendly care delivery. If you provide the best care and achieve the best outcomes, it will drive the financial health of your organization as well."