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Organization-Wide Approaches to Foster Effective Unit-Level Efforts to Improve Clinician Well-Being

      Abstract

      Health care delivery organizations are positioned to have a tremendous impact on addressing the variables in the practice environment that contribute to occupational distress and that, when optimized, can promote clinician well-being. Many organizations are committed to this work and have clarity on how to address general, system-wide issues and provide resources for individual clinicians. While such top of the organization elements are essential for success, many of the specific improvement efforts that are necessary must address local challenges at the work unit level (department, division, hospital ward, clinic). Uncertainty of how to address variability and the unique needs of different work units is a barrier to effective action for many health care delivery systems. Overcoming this challenge requires organizations to recognize that unit-specific improvement efforts require a system-level approach. In this manuscript, we outline 7 steps for organizations to consider as they establish the infrastructure to improve professional well-being and provide a description of application and evidence of efficacy from a large academic medical center. Such unit-level efforts to address the unique needs of each specialty and occupation at the work unit level have the ability to address many of the day-to-day issues that drive clinician well-being. An enterprise approach is necessary to systematically advance such unit-level action.

      Abbreviations and Acronyms:

      CWO (Chief Well-being Officer), EHR (electronic health record)

      Occupational Distress in Clinicians

      Now that the epidemic of occupational distress in clinicians and its consequences for patients, professionals, and the health care delivery system have been recognized, authentic efforts to address the problem have begun.
      National Academy of Medicine
      Action Collaborative on Clinician Well-being and Resilience.
      ,
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      Occupational distress can be manifested in a variety of ways, including fatigue, moral injury, problems with work-life integration, and job-related stress. Burnout, one of the most prevalent forms of occupational distress, is a specific World Health Organization–recognized syndrome precipitated by attributes of the work environment.
      World Health Organization
      QD85: Burnout-out.
      The syndrome is characterized by emotional exhaustion, cynicism, and loss of meaning and effectiveness in work.
      World Health Organization
      QD85: Burnout-out.
      Burnout differs from depression and other mental health diagnoses

      Menon NK, Shanafelt TD, Sinsky CA, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780. Published correction appears in JAMA Netw Open. 2021;4(5):e2115436.

      ,
      • Koutsimani P.
      • Montgomery A.
      • Georganta K.
      The relationship between burnout, depression, and anxiety: a systematic review and meta-analysis.
      and is driven by a mismatch between job demands and job resources.
      • Bakker A.B.
      • Demerouti E.
      The job demands-resources model: state of the art.
      ,
      • Koranne R.
      • Williams E.S.
      • Poplau S.
      • et al.
      Reducing burnout and enhancing work engagement among clinicians: the Minnesota experience.
      Symptoms of burnout occur along a continuum, with studies suggesting that roughly 40% of US physicians, nurses, and advanced practice clinicians are experiencing substantial symptoms in 1 or more of these domains.
      • Shanafelt T.D.
      • West C.P.
      • Sinsky C.
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
      • Dyrbye L.N.
      • West C.P.
      • Johnson P.O.
      • et al.
      Burnout and satisfaction with work-life integration among nurses.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      • Dyrbye L.N.
      • West C.P.
      • Kelsey E.A.
      • Gossard A.A.
      • Satele D.
      • Shanafelt T.
      A national study of personal accomplishment, burnout, and satisfaction with work-life integration among advance practice nurses relative to other workers.
      • Dyrbye L.N.
      • West C.P.
      • Halasy M.
      • O'Laughlin D.J.
      • Satele D.
      • Shanafelt T.
      Burnout and satisfaction with work-life integration among PAs relative to other workers.
      • Halasy M.P.
      • West C.P.
      • Shanafelt T.
      • O'Laughlin D.J.
      • Satele D.
      • Dyrbye L.N.
      PA job satisfaction and career plans.
      • Shanafelt T.D.
      • West C.P.
      • Sinsky C.
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020.
      Occupational distress, by definition, is primarily due to problems with the work environment in which clinicians practice. It is mitigated primarily by addressing those factors, not by pharmacologic therapy or psychotherapy targeting the individual.
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      ,
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      ,
      • DeChant P.F.
      • Acs A.
      • Rhee K.B.
      • et al.
      Effect of organization-directed workplace interventions on physician burnout: a systematic review.
      Health care professionals do not have a resilience deficit,
      • West C.P.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Resilience and burnout among physicians and the general US working population.
      and “resilience training” will not solve this problem. Although worthy pursuits for all human beings, mindfulness, diet, exercise, and enhanced self-care do not address the factors driving higher occupational distress in physicians relative to workers in other fields and are not the primary solution to clinician burnout.
      • Shanafelt T.D.
      • West C.P.
      • Sinsky C.
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      Effectively addressing the problem requires that health care delivery systems, hospitals, and physician employers improve the practice environment by reducing inefficiency, optimizing team-based care, providing resources to support individual clinicians, and driving organizational culture change.
      • Shanafelt T.
      • Sloan J.
      • Habermann T.
      The well-being of physicians.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      • Shanafelt T.
      • Trockel M.
      • Ripp J.
      • Murphy M.L.
      • Sandborg C.
      • Bohman B.
      Building a program on well-being: key design considerations to meet the unique needs of each organization.
      • Ripp J.
      • Shanafelt T.
      The health care chief wellness officer: what the role is and is not.
      • Sinsky C.A.
      • Privitera M.R.
      Creating a "manageable cockpit" for clinicians: a shared responsibility.
      • Shanafelt T.D.
      • Schein E.
      • Minor L.B.
      • Trockel M.
      • Schein P.
      • Kirch D.
      Healing the professional culture of medicine.
      • Sinsky C.A.
      • Willard-Grace R.
      • Schutzbank A.M.
      • Sinsky T.A.
      • Margolius D.
      • Bodenheimer T.
      In search of joy in practice: a report of 23 high-functioning primary care practices.
      Myriad variables and characteristics of the practice environment and professional culture contribute to this challenge.
      National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being
      Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being.
      Some factors are outside the control of any single organization. They include administrative burden created by payers and regulatory bodies, elements of professional culture that support the construct that physicians are supposed to be superhuman and result in a lack of vulnerability and decreased help seeking, and cumbersome electronic health records (EHRs) created and designed with inadequate attention to end user ease of use.
      National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being
      Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being.
      ,
      • Shanafelt T.D.
      Physician Well-being 2.0: where are we and where are we going?.
      Thanks to broad-scale and sustained advocacy from the National Academy of Medicine, the American Hospital Association, the American Medical Association, the American Nurses Association, and a number of other large national bodies, wide-ranging efforts are now being pursued to drive progress in these dimensions.
      National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being
      Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being.

      The Role of Health Care Delivery Organizations

      Despite the important contribution of these national factors, the actions of health care organization leaders often have the greatest impact on the day-to-day work environment of health care professionals.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Shanafelt T.D.
      • Dyrbye L.N.
      • West C.P.
      Addressing physician burnout: the way forward.
      These include the alignment of the organization mission and the values of health care professionals, leadership behavior, teamwork, psychological safety, how compliance and regulatory parameters are interpreted, whether opportunities for input are provided, efficiency of clinical work flows, and work structures that allow flexibility.
      • Bakker A.B.
      • Demerouti E.
      The job demands-resources model: state of the art.
      ,
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      • Shanafelt T.
      • Trockel M.
      • Rodriguez A.
      • Logan D.
      Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment.
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      • Swensen S.J.
      • Shanafelt T.
      An organizational framework to reduce professional burnout and bring back joy in practice.

      Linzer M, Poplau S, Prasad K, et al. Characteristics of health care organizations associated with clinician trust: results from the healthy work place study. JAMA Netw Open. 2019;2(6):e196201. Published correction appears in JAMA Netw Open. 2019;2(8):e199999.

      • Linzer M.
      • Sinsky C.A.
      • Poplau S.
      • Brown R.
      • Williams E.
      Healthy Work Place Investigators. Joy in medical practice: clinician satisfaction in the Healthy Work Place trial.
      • Linzer M.
      • Baier Manwell L.
      • Mundt M.
      • et al.
      Organizational climate, stress, and error in primary care: the MEMO study.
      There are strong ethical and business cases for organizations to optimize these dimensions, and vanguard organizations have begun to take steps to drive progress.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      Although organizational commitment is an essential first step, the complexity of the problem is a barrier to effective action for many health care delivery systems. Developing a well-crafted organizational strategy along with the tactics to advance that strategy is the critical first step for effective progress.
      • Shanafelt T.
      • Stolz S.
      • Springer J.
      • Murphy D.
      • Bohman B.
      • Trockel M.
      A blueprint for organizational strategies to promote the well-being of health care professionals.
      Once it is developed, successfully executing such a strategy requires establishing the leadership, infrastructure, systems and processes, and resources (people and operating budget) to advance it as well as the metrics to assess progress. For many organizations, this begins with establishing an organization-level well-being center and appointing a Chief Well-being Officer (CWO) to lead system-level improvement. Recent articles have provided a blueprint for developing an organizational strategy,
      • Shanafelt T.
      • Stolz S.
      • Springer J.
      • Murphy D.
      • Bohman B.
      • Trockel M.
      A blueprint for organizational strategies to promote the well-being of health care professionals.
      offered design considerations for well-being programs,
      • Shanafelt T.
      • Trockel M.
      • Ripp J.
      • Murphy M.L.
      • Sandborg C.
      • Bohman B.
      Building a program on well-being: key design considerations to meet the unique needs of each organization.
      described the key role of CWOs,
      • Ripp J.
      • Shanafelt T.
      The health care chief wellness officer: what the role is and is not.
      ,
      • Shanafelt T.D.
      • Sinsky C.
      Chief Wellness Officer road map.
      • Shanafelt T.
      • Farley H.
      • Wang H.
      • Ripp J.
      CHARM CWO Network
      Responsibilities and job characteristics of health care chief wellness officers in the United States.
      • Shanafelt T.
      • Sinsky C.
      Establishing a Chief Wellness Officer position.
      and emphasized the responsibility of all organizational leaders
      • Shanafelt T.
      • Trockel M.
      • Rodriguez A.
      • Logan D.
      Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment.
      and hospital executives
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      for driving change.
      While such top of the organization elements are essential for success, many of the specific improvement efforts that are necessary must address local challenges at the work unit level (department, division, hospital ward, clinic). The pain points and opportunities to improve the practice environment in radiology, surgical practice, and primary care differ.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      Within each specialty, the greatest need may vary by clinic or practice site. The work demands of nurses, pharmacists, advanced practice providers, and physicians are distinct, and the support and resources needed often differ by occupation.
      • Shanafelt T.
      • Trockel M.
      • Ripp J.
      • Murphy M.L.
      • Sandborg C.
      • Bohman B.
      Building a program on well-being: key design considerations to meet the unique needs of each organization.
      Uncertainty or disagreement about how to address this variability leads to major gaps in the improvement efforts of many organizations. Organizations often advance important, cross-cutting initiatives that affect everyone (eg, leader evaluation and development; organization-level teamwork initiatives; transparent communication; efforts to create just culture; system efforts to improve diversity, equity, and inclusion)
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      ,
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      ,
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      ,
      • Dai M.
      • Willard-Grace R.
      • Knox M.
      • et al.
      Team configurations, efficiency, and family physician burnout.
      or provide resources for individual clinicians (eg, mindfulness and personal resilience training, concierge EHR training, peer support programs, commensality groups)
      • Menon N.K.
      • Trockel M.T.
      • Hamidi M.S.
      • Shanafelt T.D.
      Developing a portfolio to support physicians' efforts to promote well-being: one piece of the puzzle.
      • Krasner M.S.
      • Epstein R.M.
      • Beckman H.
      • et al.
      Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
      • Shapiro J.
      • Galowitz P.
      Peer support for clinicians: a programmatic approach.
      • Profit J.
      • Adair K.C.
      • Cui X.
      • et al.
      Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout.
      • Dyrbye L.N.
      • Shanafelt T.D.
      • Gill P.R.
      • Satele D.V.
      • West C.P.
      Effect of a Professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial.
      • Makowski M.S.
      • Palomo C.
      • de Vries P.
      • Shanafelt T.D.
      Employer-provided professional coaching to improve self-compassion and burnout in physicians.
      • Shanafelt T.D.
      • Lightner D.J.
      • Conley C.R.
      • et al.
      An organization model to assist individual physicians, scientists, and senior health care administrators with personal and professional needs.
      • Sexton J.B.
      • Adair K.C.
      • Profit J.
      • et al.
      Perceptions of institutional support for "second victims" are associated with safety culture and workforce well-being.
      but often fail to develop an approach to address the specific work unit challenges that typically have the greatest day-to-day impact on health care professional well-being. Where it occurs, improvement efforts and progress at the work unit level are inconsistent. Robust efforts are pursued by some leaders and in select departments or work units, whereas others preserve the status quo.

      How to Foster Consistent Work Unit–Level Well-Being Improvement Efforts Across the Organization

      Overcoming this challenge requires organizations to recognize that unit-specific improvement efforts require a system-level approach. Although the organization leaves the details of the improvement work to the local unit, the framework, leadership, structure, process, and accountability to accomplish that work can be established by the organization to ensure consistent and effective action across all units. We propose that the following 7 steps be considered as organizations create this infrastructure to improve professional well-being:
      • 1.
        Establish a common organizational framework for action
      • 2.
        Appoint and support a unit well-being leader
      • 3.
        Assess the experience and unique needs of each unit and compare with benchmarks
      • 4.
        Integrate unit-level well-being improvement efforts with the organizational improvement infrastructure
      • 5.
        Create a consistent structure and process for work unit well-being interventions
      • 6.
        Foster progress in the work unit well-being journey by assessing work unit process metrics
      • 7.
        Consider the unit lens when assessing organizational progress on outcome metrics

      Step 1. Establish a Common Organizational Framework for Action

      To catalyze unit-level efforts to improve, organizational leaders should provide a framework for each unit to approach clinician well-being. Providing a shared organizational framework for improving well-being can help guide unit-level conversations and efforts to improve even though the ultimate direction in which these conversations progress cannot be fully predicted (emergent design).
      • Suchman A.L.
      Organizations as machines, organizations as conversations: two core metaphors and their consequences.
      We have found that many organizations use a narrow framework that focuses on personal resilience, stress management, and self-care. This approach fails to address the root causes of clinician distress, suggests the problem is due to a deficiency in the worker rather than in the work environment, and fails to catalyze effective improvement efforts at the work unit level.
      The Stanford Model of Professional Fulfillment (Figure 1) provides a holistic framework that establishes the goal as cultivating professional fulfillment rather than simply eliminating clinician distress.
      • Bohman B.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience. NEJM Catalyst.
      It emphasizes that elements of organizational culture along with structural factors related to the clinical practice environment must be addressed in addition to cultivating personal resilience. The framework also underscores the reciprocity between these 3 domains, provides organizations a foundation for comprehensive action, and promulgates a shared model to approach the problem across units. Establishing such an integrated framework at the system level provides a foundation that ensures all units approach their work consistently and comprehensively.
      Figure thumbnail gr1
      Figure 1Stanford Model of Professional Fulfillment. EHR, electronic health record; OR, operating room.

      Step 2. Appoint and Support a Unit Well-Being Leader

      To drive meaningful and sustained change in a work unit requires establishing the structure and process for change efforts to achieve desired outcomes. The first step is appointing a local leader to serve as the change agent. Division chiefs and department chairs have complex roles. Their behavior and effectiveness as a leader are critical to the well-being and professional fulfillment of those in the unit.
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      ,
      • Shanafelt T.
      • Trockel M.
      • Rodriguez A.
      • Logan D.
      Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment.
      ,
      • Dyrbye L.N.
      • Major-Elechi B.
      • Hays J.T.
      • Fraser C.H.
      • Buskirk S.J.
      • West C.P.
      Physicians' ratings of their supervisor's leadership behaviors and their subsequent burnout and satisfaction: a longitudinal study.
      ,
      • Shanafelt T.D.
      • Wang H.
      • Leonard M.
      • et al.
      Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians.
      Typically, however, they are not able to personally lead the well-being improvement initiatives, given their many other responsibilities, such as setting overall direction for the unit, ensuring quality, securing adequate staffing, managing finances, advancing diversity and inclusion, and attending to professional development. Such leaders typically appoint deputies to oversee these domains and advance the overall effectiveness of their department, division, or work unit. Consistent with this framework, a leader is needed to direct and oversee unit well-being improvement efforts (eg, a Department Well-being Director).
      The qualifications and experience necessary to be successful should be considered in selecting a well-being director. We believe these individuals should be respected by colleagues, have experience in leadership, be trusted by the leader of the unit (whom they will have to influence), and demonstrate both emotional and organizational intelligence. An understanding of improvement science and experience in leading improvement work are highly desirable qualities, although the unit well-being director and unit improvement leader (who may oversee quality improvement efforts) roles are distinct and generally held by different individuals. Although a passion to improve well-being for colleagues is important, well-being directors do not need to be resilience or mindfulness gurus. Effectiveness in the role depends more heavily on organizational intelligence, change management skills, and the ability to lead through influence. Expertise in the field of clinician well-being can be developed through the support that the organization-level well-being center provides more readily than these other skills.
      At Stanford, a well-being director is designated by the chair in each clinical department. The role is an appointed position, rather than a volunteer role, such that it is established on the same footing as other leadership roles in the department. It is expected that the well-being director receives funded time from the department and is a member of the leadership team. Departments at Stanford range in size from 25 to more than 650 physicians. The extent of the funding and time provided may vary according to the size of the department and the extent of the improvement work the well-being director is asked to oversee. A well-being director in a department with 25 physicians (eg, Urology) may require different support than a director in a department with 13 divisions and more than 600 physicians (eg, a Department of Medicine). Several departments at Stanford have a department-level well-being director as well as division-level well-being leaders who also have funded time. The department-level leader helps train, support, coordinate, and oversee the efforts of these division-level leaders and keeps them informed of organization-wide and department-wide well-being improvement efforts.
      To facilitate consistency in the role, responsibilities, and support for Department Well-being Directors, the Stanford WellMD Center has created a detailed job description and specified specific duties for our well-being directors based on the level of funding provided by the department (Supplemental Table 1, available online at http://www.mayoclinicproceedings.org). A derivative job description can be created for division-level leaders in large departments. These division-level well-being leaders are typically provided a more modest level of protected time, but they can apply to receive additional time and funding, depending on the size of the division and the nature of the improvement projects they develop and advance. We have also established expectations about the support well-being directors should receive from the department, the department chair, and the organization-level Well-being Center (Supplemental Table 2, available online at http://www.mayoclinicproceedings.org). A standard job description and clear expectations about expected support bring clarity to the role and responsibilities for Department Well-being Directors as well as consistency in the support provided across departments.
      Although a clear job description and concrete support are more important than the name of the position, titles matter. At Stanford, we deliberately classify these leaders Department Well-Being Directors, not “wellness champions.” We believe this establishes the role as a formal position analogous to other leadership positions in the department. Leaders in other formal positions are not called "champions" (eg, there is not typically a “quality champion” or “education champion”). Where it is used, the term champion typically refers to a volunteer pursuing an area of personal interest rather than an appointed leader in a formal role who is accountable for a specific domain, has relevant authority and resources, and acts on behalf of and with the support of the chair. We believe labeling these well-being leaders "champions" may unintentionally demean their role relative to other leaders in the work unit and convey that they do not have appropriate authority or resources to drive meaningful change in the unit.
      Whereas department-level well-being leaders are tasked with driving unit-level improvement, bringing these leaders together at regular intervals to provide training, share best practices, foster interdepartment collaboration, and provide a support network can increase their effectiveness. Such convenings should be coordinated by the organization-level well-being center and provide professional development, advising, mentorship, training, and tools to foster the effectiveness of these work unit leaders. At Stanford, we convene our Department Well-being Directors twice each month to facilitate these outcomes. The CWO and other leaders from the organization-level wellness center also meet with these leaders individually at regular intervals for mentorship and advising.

      Step 3. Assess the Experience and Unique Needs of Each Unit and Compare With Benchmarks

      The next step for organization-wide efforts should include holistic assessment of professional fulfillment and various dimensions of occupational distress (eg, burnout, work-life integration, moral distress) with granular analysis at the level of the work unit (department, division, clinic, unit). This assessment is typically led by the CWO and organization-level well-being center. It should not be assumed that the specialties experiencing the highest level of distress nationally are the departments where distress is greatest in your organization. For example, in 2016, one of the physician specialties at lowest risk for burnout nationally had the highest rates of burnout at Stanford. At the same time, one of the specialties with the highest rates of burnout nationally had the lowest rates of burnout at Stanford.
      It is typically helpful to select an assessment instrument for which contemporaneous, occupation, and specialty-specific benchmarks are available to provide context for the organizational experience. Because the overall aim is to improve the practice environment for all members of the unit, not only those in distress, we favor instruments that provide mean scores rather than only the proportion of work unit members scoring favorably or unfavorably (ie, percentage burned out). Using mean scores also provides a more robust approach to evaluate the impact of specific work unit interventions.
      We have previously summarized how to use aggregate, organization-level survey data to drive culture change at the organizational level.
      • Shanafelt T.
      • Stolz S.
      • Springer J.
      • Murphy D.
      • Bohman B.
      • Trockel M.
      A blueprint for organizational strategies to promote the well-being of health care professionals.
      Data from the system level assessment can also be used to create detailed, unit-level reports that inevitably reveal heterogeneity in distress and professional fulfillment across units. Here, we describe the systematic use of department- and division-specific data to address specific issues and problems in the work unit through improvement cycles.
      In addition to assessing overall metrics evaluating professional fulfillment and work-related distress (eg, burnout), organizations must also assess actionable, upstream dimensions that contribute to these outcomes. At Stanford, in addition to assessing burnout and professional fulfillment,
      • Trockel M.
      • Bohman B.
      • Lesure E.
      • et al.
      A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians.
      we assesses leader behavior,
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      individual-organization values alignment,
      • Shanafelt T.D.
      • Wang H.
      • Leonard M.
      • et al.
      Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians.
      teamwork in the unit,
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      psychological safety,
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      perceived efficiency of the practice environment, EHR satisfaction and inbox burden, mistreatment experiences,
      • Rowe S.G.
      • Stewart M.T.
      • Van Horne S.
      • et al.
      Mistreatment experiences, protective workplace systems, and occupational distress in physicians.
      sleep impairment,
      • Buysse D.J.
      • Yu L.
      • Moul D.E.
      • et al.
      Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.
      self-valuation,
      • Trockel M.
      • Sinsky C.
      • West C.P.
      • et al.
      Self-valuation challenges in the culture and practice of medicine and physician well-being.
      and dimensions of work-life integration.
      • Trockel J.
      • Bohman B.
      • Wang H.
      • Cooper W.
      • Welle D.
      • Shanafelt T.
      Assessment of the relationship between an adverse impact of work on physicians’ personal relationships and unsolicited patient complaints.
      We also complement these survey-based measures with objective measures of the efficiency of the practice environment (eg, time spent on the EHR after hours, volume of inbox messages per appointment, operating room turnaround times, proportion of elective cases that have to be performed after hours because of lack of operating room availability).
      Like the variability in burnout and professional fulfillment, analysis of these driver dimensions also typically reveals profound variability across work units (Figure 2). This observation illustrates why efforts to drive improvement have to be tailored to the needs of the work unit. Top-down or one-size-fits-all approaches typically fail to address the most important unit-level needs.
      • Sinsky C.A.
      • Bavafa H.
      • Roberts R.G.
      • Beasley J.W.
      Standardization vs customization: finding the right balance.
      One unit is struggling with teamwork, whereas another unit may be struggling with values alignment, inefficient workflows, or problems with work structure that magnify work-life integration issues. Accordingly, identifying and prioritizing the issues, defining the contributing factors, and developing effective solutions must be work unit based. In this regard, there are many analogies to quality improvement efforts. For example, although aggregate hospital-level quality is important and metrics have been defined to evaluate it, the efforts to improve quality are often unit specific and differ for surgical areas, intensive care units, the emergency department, ambulatory clinics, and hospital in-patient areas, with additional nuance by specialty and the nature of patients cared for in different units.
      Figure thumbnail gr2
      Figure 2Variability in driver dimensions contributing to burnout across units. The variability in various driver dimensions contributing to burnout and professional fulfillment is illustrated. Each column indicates results for the driver dimension indicated by the column header. Each row reflects a different department. The numeric values illustrate the effect size difference in score for each driver domain for a given department relative to the mean score across all departments. For all numeric values, positive values are favorable and negative values are unfavorable. Red colorization indicates a less favorable score in a given driver dimension relative to the organizational average, whereas the green shading represents a favorable score relative to the organizational average. The intensity of red-green colorization reflects the effect size difference as indicated in the legend. Note: Although we also assess the Leader Behavior Score
      • Shanafelt T.D.
      • Gorringe G.
      • Menaker R.
      • et al.
      Impact of organizational leadership on physician burnout and satisfaction.
      for the leader of each work unit as part of the unit profile, holding the work unit leader accountable for that domain and fostering improvement is the responsibility of each leader’s supervisor. Hence, although these data are reviewed by the Chief Well-being Officer and executive leadership team, this domain is outside the scope of responsibility for the Department Well-being Director (ie, it is the score of the person to whom they report), and for that reason, we have excluded it from the figure. EHR, electronic health record.
      At Stanford, once department-specific survey results are available, the CWO meets with the leadership team of each department (ie, department chair, administrative leader, Department Well-being Director, and department quality improvement leader) to review results, assist with interpretation, and provide guidance about the next steps to translate survey findings into action. We view the survey results not as a thermometer providing a “temperature check” but rather as the initial step of a rigorous improvement cycle.

      Step 4. Integrate Unit-Level Well-Being Improvement Efforts With the Organizational Improvement Infrastructure

      To advance their multipronged missions, organizations tend to strive for continuous improvement in a variety of outcomes, including quality, efficiency, and patient experience as well as clinician well-being. These outcomes are products of the interconnected work processes that the organization manages. Because the same set of processes, managed by the same individuals, simultaneously produce all of these outcomes, efforts to improve in any of these dimensions must be well coordinated and integrated with the organization’s overall improvement efforts.
      Most organizations maintain dedicated process improvement personnel and programs to foster progress across these outcomes. It may be tempting for specialists who have responsibility over a specific outcome, such as clinician well-being, to work independently to make changes focused on improving the outcomes for which they are responsible. When this happens, efforts to improve specific elements can quickly become competitive (eg, efforts to improve efficiency can negatively affect quality, and vice versa). Conversely, when well coordinated, changes that improve one outcome can simultaneously improve other outcomes (eg, improvement in on-time procedure start times and scheduling accuracy may simultaneously improve efficiency, patient experience, and clinician well-being). For this reason, it is critical that the organization’s well-being improvement efforts be effectively integrated with the broader improvement infrastructure.
      In keeping with this principle, the unit-level well-being director should work closely with the unit-level improvement leader. Well-being directors should respect the fact that improvement science is a field of managerial practice with its own frameworks, conventions, and methods. The performance improvement leader’s key role is to coordinate process and organizational changes of all kinds, including those that are meant to improve clinician well-being, under the direction of the unit leader (eg, department chair). Accordingly, well-being directors should form a constructive working relationship with the performance improvement leader, who can help facilitate the coordination and implementation of desired organizational changes that improve clinician well-being. Creating specific goals and process metrics for which these 2 leaders have shared accountability to the department chair or work unit leader may help foster partnership and collaboration.
      Change efforts designed to improve clinician well-being should be carried out using methods that align with the organization’s established improvement methodologies. At Stanford, we organize much of our improvement work using the A3 structured problem-solving approach, incorporating elements of Six Sigma’s DMAIC (ie, define, measure, analyze, improve, control) framework as well as aspects of the Institute for Healthcare Improvement’s Model for Improvement.
      • Larson D.B.
      • Mickelsen L.J.
      • Garcia K.
      Realizing Improvement through Team Empowerment (RITE): a team-based, project-based multidisciplinary improvement program.
      Using a consistent approach for unit-level well-being improvement efforts across the organization adds rigor to the well-being improvement work, draws from the improvement expertise in the organization, frames well-being improvement work in the lexicon of the organization, adds credibility to the work in the eyes of other organizational leaders, and improves the likelihood that improvement projects will be successful and have a meaningful impact.
      The ideal relationship between improvement leaders and well-being directors is bidirectional in that the improvement program helps facilitate the success of well-being initiatives while the well-being program helps inform and guide other improvement efforts. Considerations for clinician well-being should be incorporated into efforts to prioritize and execute all process improvement initiatives because seemingly unrelated process changes may have secondary impacts on well-being. For example, projects aimed at enhancing patient experience or increasing clinician productivity can have either a positive or negative impact on clinician well-being, depending on how they are designed and implemented. By advising on how to incorporate balancing measures and secondary goals focused on clinician well-being into all relevant process improvement initiatives, Department Well-being Directors help ensure that a focus on clinician well-being is incorporated into all organizational changes, one project at a time. Thus, to the extent that the improvement leader and well-being director respect each other’s roles and expertise, regularly consult with and advise each another, and visibly support each other, potentially competitive efforts become synergistic in simultaneously improving quality, efficiency, patient experience, and clinician well-being outcomes with limited tension or duplicative effort.

      Step 5. Create a Consistent Structure and Process for Work Unit Well-Being Interventions

      Once the unit’s well-being leader has been appointed and has established a partnership with the improvement leader, they should work together to understand the greatest opportunities for improvement in the unit and make changes to address them. This often begins by reviewing the unit-level survey results with the CWO and department chair as detailed in Step 3. With the approval and support of the unit leader, the well-being leader may subsequently wish to organize a series of “listening sessions” to get feedback as to whether the survey results accurately reflect the unit experience. Listening sessions should be carefully planned to gain deeper insights into the survey results and facilitated to ensure they are constructive and result in improvement ideas rather than evolving into complaint sessions. The Listen-Sort-Empower framework developed by Swensen and Shanafelt at Mayo Clinic
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      ,
      • Swensen S.
      • Kabcenell A.
      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      ,
      • Swensen S.J.
      • Shanafelt T.
      An organizational framework to reduce professional burnout and bring back joy in practice.
      ,
      • Swensen S.
      LISTEN-SORT-EMPOWER: find and act on local opportunities for improvement to create your ideal practice.
      and adapted by the Institute for Healthcare Improvement
      • Perlo J.
      • Swensen S.
      • Kabcenell A.
      • Feeley D.
      IHI framework for improving joy in work.
      can be a helpful way to engage members of the unit to identify dimensions under local control that can be modified.
      Once the issues are identified, they can be mapped on an impact feasibility grid.
      • Swensen S.
      LISTEN-SORT-EMPOWER: find and act on local opportunities for improvement to create your ideal practice.
      The focus should be on first addressing those issues with relatively high impact and high feasibility and, next, those with modest impact that are highly feasible. High-impact but low-feasibility items are worked on during a longer interval. Organizations cannot successfully change in all desired aspects simultaneously. Rather, change efforts need to be prioritized, coordinated, planned, staged, and implemented in an organized way. Poorly organized well-being improvement efforts can have the paradoxical effect of adding to the burden that contributes to burnout without meaningful benefit.
      Using an impact feasibility grid, well-being directors can begin to work with other unit leaders to prioritize 1 or 2 areas of focus for improvement. There are 2 critical steps in prioritization: (1) prioritization of well-being improvement initiatives relative to each other and (2) prioritization of well-being improvement initiatives in the context of other initiatives in the unit. The first step can be carried out by the well-being director and the team of colleagues in the unit they assemble to drive change. The second step should be led by the improvement leader, with input from the well-being director and the support of the chair or work unit leader. For the highest impact, well-being directors should initially focus their work on the unit-specific opportunities that are under local control and that can be modified during a 4- to 6-month time horizon. Broad organization-level improvement opportunities should also be identified for escalation and collaborative improvement work but are considered out of scope for the unit improvement effort. For instance, it is not typically constructive to devote a lot of time complaining about the EHR, the pay scale, the lack of parking, the need for an onsite gym, or other global organizational issues, all of which need to be considered and prioritized at higher levels of the organization (ie, by the CWO and organization-level well-being team). In contrast, identifying inequities in scheduling, problems with cross-coverage, workflow inefficiencies that add time to the workday, opportunities to increase flexibility, administrative factors that erode work-life integration, or issues with teamwork or team-based care is more immediately actionable in the unit and can lead to more rapid change. Focusing on these domains, which often have the largest day-to-day impact on clinician well-being, should be the primary emphasis of the unit-level well-being improvement work and can build momentum to address larger issues in the longer term. We also typically challenge work units to focus on and address issues that are specific to their discipline because others are unlikely to do so. If an oncology division does not eliminate inefficiencies in the chemotherapy preauthorization and scheduling process, it is unlikely that any other area in the organization will address that problem. Similarly, operating room teams concerned about consistent case start times, accuracy in scheduling, and operating room turnaround time should work on those dimensions if they desire to see improvement.
      Unit improvement efforts should employ a structured approach, using established quality and process improvement methods. At this point, if the improvement initiative involves changing work processes or systems or making other organizational changes, it will likely occur under the oversight of the improvement leader. The improvement leader may ask the well-being leader to lead the improvement initiative, but not necessarily. For example, if the source of frustration is a problem with communication between team members, then the improvement leader should look to the most appropriate person to lead a communication improvement initiative. The key point is that the person who identifies the downstream impacts of the problem (such as clinician burnout) is not necessarily the best person to solve the problem (and, in fact, often is not). As discussed in Step 4, integration of well-being improvement efforts with the organizational improvement infrastructure helps facilitate this. Accordingly, once the well-being directors and their team have chosen an issue to address, they should seek guidance and support from the unit improvement leader and apply appropriate structure and tools as they attempt to develop countermeasures and solutions. This approach generally includes defining and understanding a problem deeply. It is important to understand the current state and to evaluate preintervention metrics, including surveys of participants. It is also critical at this stage to engage all stakeholders and develop alliances with operational leaders who share responsibility for the domain to be addressed. With appropriate coaching and capability development, such an approach allows project leaders to identify the root causes and specific drivers of the problems that they have targeted. Such an approach helps create a menu of specific countermeasures and solutions. At Stanford, well-being directors are trained in change management principles so that they are also able to anticipate and mitigate the adverse effects of change on their colleagues and other stakeholders.
      The metrics to assess individual project outcomes should match the actual intervention. For example, an effort to reduce the number of inbox messages physicians need to respond to personally should have the number of EHR messages physicians handle as its proximal improvement measure. More global outcome measures (ie, burnout, professional fulfillment) influenced by this dimension as well as by numerous other dimensions can be assessed in a longitudinal manner at defined intervals and should be considered a global assessment of the impact of numerous interventions and changes rather than the outcome measure of a single project (Figure 3).
      Figure thumbnail gr3
      Figure 3Stepwise process for well-being directors to drive unit-level improvements.

      Step 6. Foster Progress in the Work Unit Well-Being Journey by Assessing Work Unit Process Metrics

      The factors that contribute to burnout and professional fulfillment are complex, improvement work to address root cause issues can take time, and favorable long-term outcomes do not happen overnight. Ecological events in the organization or broader practice environment (eg, COVID-19) may also create new challenges that have an impact on outcome measures even though progress is being made in addressing work unit–specific issues. Given these dynamics, we favor evaluating unit progress with structure and process metrics that evaluate whether units are approaching the work in a robust, thoughtfully designed, rigorous, and evidence-based manner. This approach fosters progress in the work unit journey to improve well-being and increases the likelihood of achieving desired outcomes over time.
      At Stanford, we have created a department score card to track the maturity of the structure and process efforts within each unit (Figure 4A). Currently, each department is assessed in 4 domains: (1) survey and metrics, (2) involvement and support for the Department Well-being Director, (3) design and implementation of improvement projects, and (4) integration of well-being considerations into unit leadership and decision-making. For each of these 4 domains, transparent criteria are used to categorize the maturity of the department’s efforts as beginner, intermediate, or advanced. The overall maturity of department efforts is assigned on the basis of the domain with the lowest level of proficiency (ie, for a department to be considered intermediate maturity overall, maturity in all 4 domains must be at the intermediate level or higher).
      Figure thumbnail gr4a
      Figure 4A, Evaluation domains and maturity criteria for department well-being improvement efforts at Stanford. B, Maturation of Stanford department efforts to improve well-being in the four individual evaluation domains over time. C, Progress in overall department maturity.
      Figure thumbnail gr4b
      Figure 4A, Evaluation domains and maturity criteria for department well-being improvement efforts at Stanford. B, Maturation of Stanford department efforts to improve well-being in the four individual evaluation domains over time. C, Progress in overall department maturity.
      Figure thumbnail gr4c
      Figure 4A, Evaluation domains and maturity criteria for department well-being improvement efforts at Stanford. B, Maturation of Stanford department efforts to improve well-being in the four individual evaluation domains over time. C, Progress in overall department maturity.
      We evaluate each department’s maturity using this scorecard annually as a core component of the holistic assessment of the department’s efforts to improve quality, patient experience, and value. This approach helps the organization understand which departments are engaged in meaningful change and which are struggling to initiate action. It also helps guide the unit well-being and improvement leaders identify opportunities to focus on as they continue to build their respective programs. System-level assessment of each unit also brings “positive peer pressure” for units to engage in substantive well-being improvement efforts.
      At Stanford, members of the organization-level well-being leadership team meet with the Department Well-being Director and department improvement leader at 3- to 4-month intervals to review improvement projects, identify and troubleshoot roadblocks, provide support and advising as these leaders identify priorities for future unit-level well-being improvement targets, and assess department efforts to advance maturity in each of the 4 domains. All of these efforts are designed to create engagement, accountability, and a mindset of shared ownership across the clinical operational and improvement leaders within the department. The journey of Stanford Medicine departments during the 3 years after this scorecard was introduced is shown in Figure 4B and C.

      Step 7. Consider the Unit Lens When Assessing Organizational Progress on Outcome Metrics

      How should organizations measure collective organizational progress? We recommend assessing occupational well-being outcome measures, such as burnout and professional fulfillment, longitudinally at defined intervals. At Stanford, our assessment interval is 18 months (Figure 5). We have arrived at this frequency on the basis of experience with intervals ranging from 2 to 3 years to annual surveys with quarterly pulse checks. In our experience, a cycle longer than 2 years is too infrequent to create accountability and to build momentum. A 12-month survey cycle is too short to allow meaningful improvement projects to occur. It takes 2 to 3 months to deploy the survey, to collect data, and to analyze results (ie, months 1 to 3 of an 18-month cycle). It takes an additional 2 months to distribute individual reports to each work unit and for the CWO to meet with the chair and members of the leadership team from each department to discuss local results, their implications, and next steps (ie, months 4 and 5 of an 18-month cycle). During this interval, the Department Well-being Directors also begin to socialize the department-specific results and hold listening sessions with members of the department as described previously (Step 5). Thereafter, plans are made and projects designed in partnership with improvement leaders to address 1 or 2 of the dimensions prioritized during these sessions (ie, months 5 and 6 of an 18-month cycle). This allows a roughly 1-year interval for the improvement projects to be implemented (months 7 to 18 of the 18-month cycle) before the next global outcome assessment.
      Figure thumbnail gr5
      Figure 518-month assessment and improvement cycle. FY, fiscal year. CWO, Chief Well-being Officer.
      Much like the quality movement, making progress is a journey rather than a destination. Although many institutions use organization-level scores to measure progress, this approach has serious limitations. First, it tends to prompt organizational leaders to focus only on the generic issues relevant to all but that may represent the critical few for none. Second, the results are inherently driven by the experience of large departments which may be mistakenly interpreted as organizational progress (rather than large department progress) or may obscure meaningful progress in many smaller departments (because of a lack of progress in a few large departments).
      At Stanford, we design our metric of overall organizational progress around our work unit structure. Overall organizational progress is determined by the number of departments that either score favorable to specialty-specific benchmarks or demonstrate substantial improvement during the previous cycle. Institutional targets based on the number of departments meeting these criteria are set to drive year-over-year gains. The ultimate goal is to have all departments above benchmark or showing meaningful incremental improvement. Figure 6 shows the trends in professional fulfillment for Stanford physicians relative to national benchmarks at multiple time points. The aggregate data for Stanford physicians overall (Figure 6A) suggest that physicians across the organization are similar to benchmark at the 2020 time point and favorable to benchmark at the 2021/2022 time point. Figure 6B provides far more granular information and illustrates that, at the 2020 time point, physicians in some departments were doing much better than their specialty-specific peers nationally, whereas those in other departments were doing much worse. Although all departments trended favorable relative to national benchmarks at the 2021/2022 time point, the magnitude of change varied greatly. Furthermore, physicians in 16 departments had scores meaningfully favorable to benchmark (>0.2 SD), whereas 2 did not. Similar data for changes in burnout scores are provided in the Supplemental Figure (available online at http://www.mayoclinicproceedings.org).
      Figure thumbnail gr6
      Figure 6Evaluating outcome measures at organization vs work unit level. Figures compare professional fulfillment scores for Stanford physicians relative to national data for US physicians at similar time points as assessed by the professional fulfillment subscale of the Stanford Professional Fulfillment Index.
      • Trockel M.
      • Bohman B.
      • Lesure E.
      • et al.
      A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians.
      Stanford faculty completed surveys in September-October 2020 (time point 1)
      • Shanafelt T.D.
      • West C.P.
      • Sinsky C.
      • et al.
      Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020.
      ,
      • Shanafelt T.D.
      • Dyrbye L.
      • Sinsky C.
      • et al.
      Imposter phenomenon in US physicians relative to the US working population.
      and April-May 2022 (time point 2). National benchmark scores for physicians in the same specialty were collected November 2020–March 2021 (time point 1)

      Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. Published online September 14, 2022.

      and November 2021–January 2022 (time point 2).

      Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. Published online September 14, 2022.

      A, The pooled data for professional fulfillment scores of Stanford physicians across 18 departments relative to the national data for physicians of all specialties. The standard deviation difference in mean professional fulfillment for Stanford physicians relative to national samples of physicians in the same specialty is shown on the y-axis. A standard deviation value above 0 indicates that Stanford physicians are scoring favorable to benchmark (ie, higher professional fulfillment), whereas a standard deviation value below 0 indicates that Stanford physicians are scoring unfavorably (ie, lower professional fulfillment). Differences in standard deviation values greater than 0.2 or less than −0.2 are considered meaningful. B, Professional fulfillment scores for each of the 18 departments of Stanford Medicine relative to the national benchmark scores for physicians in the same specialty. In 2020, 3 Stanford departments scored unfavorable to specialty-specific national benchmarks(<-0.2 SD), 13 scored similar to specialty-specific national benchmarks (±0.2 SD), and 2 scored favorable to specialty-specific national benchmarks (>0.2 SD). In 2022, 16 Stanford departments scored favorable to specialty-specific national benchmarks and 2 scored similar to specialty-specific national benchmarks (none scored unfavorable to specialty-specific benchmarks).
      Structuring the evaluation of organizational progress in such a work unit–specific manner also allows senior leaders to identify struggling work units and to allocate greater attention, energy, and resources where needed. Furthermore, it allows senior leaders to work in partnership with local leaders to provide coaching and mentorship as well as to hold them accountable for what is happening in their units. The approach enables the system to target high opportunity units, build momentum, create a growing coalition, and more effectively drive progress.

      Conclusion

      Health care delivery organizations are positioned to have a tremendous impact addressing the variables in the practice environment that contribute to occupational distress and that, when optimized, can promote clinician well-being. Although many organizations are committed to this work and have clarity on how to address general, system-wide issues and provide resources for individual clinicians, uncertainty of how to address variability and the unique needs of different work units is a barrier to progress. Here, we have outlined 7 steps by which organizations can foster consistent and effective unit-level efforts to improve clinician well-being. Such unit-level efforts to address the unique needs of each specialty and occupation at the work unit level have the greatest ability to address the day-to-day issues that drive clinician well-being. An enterprise approach is necessary to systematically advance such unit-level action.

      Potential Competing Interests

      Dr Tait D. Shanafelt, section editor of the journal, had no role in the editorial review or decision to publish this article. Dr Shanafelt is co-inventor of the Well-being Index instruments and the Participatory Management Leadership Index. Mayo Clinic holds the copyright for these instruments and haslicensed them for use outside of Mayo Clinic. Mayo Clinic pays Dr. Shanafelt receives a portion of any royalties received. As an expert on the well-being of healthcare professionals, Dr. Shanafelt frequently gives grand rounds/key notelecture presentations and provides advising for healthcare organizations. He receives honoraria for some of these activities.

      Supplemental Online Material

      References

        • National Academy of Medicine
        Action Collaborative on Clinician Well-being and Resilience.
        • West C.P.
        • Dyrbye L.N.
        • Erwin P.J.
        • Shanafelt T.D.
        Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
        Lancet. 2016; 388: 2272-2281
        • World Health Organization
        QD85: Burnout-out.
        https://www.who.int/mental_health/evidence/burn-out/en/
        Date: 2019
        Date accessed: August 25, 2020
      1. Menon NK, Shanafelt TD, Sinsky CA, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780. Published correction appears in JAMA Netw Open. 2021;4(5):e2115436.

        • Koutsimani P.
        • Montgomery A.
        • Georganta K.
        The relationship between burnout, depression, and anxiety: a systematic review and meta-analysis.
        Front Psychol. 2019; 10: 284
        • Bakker A.B.
        • Demerouti E.
        The job demands-resources model: state of the art.
        J Manage Psychol. 2007; 22: 309-328
        • Koranne R.
        • Williams E.S.
        • Poplau S.
        • et al.
        Reducing burnout and enhancing work engagement among clinicians: the Minnesota experience.
        Health Care Manage Rev. 2022; 47: 49-57
        • Shanafelt T.D.
        • West C.P.
        • Sinsky C.
        • et al.
        Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.
        Mayo Clin Proc. 2019; 94: 1681-1694
        • Dyrbye L.N.
        • West C.P.
        • Johnson P.O.
        • et al.
        Burnout and satisfaction with work-life integration among nurses.
        J Occup Environ Med. 2019; 61: 689-698
        • Shanafelt T.D.
        • Boone S.
        • Tan L.
        • et al.
        Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
        Arch Intern Med. 2012; 172: 1377-1385
        • Shanafelt T.D.
        • Hasan O.
        • Dyrbye L.N.
        • et al.
        Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
        Mayo Clin Proc. 2015; 90: 1600-1613
        • Dyrbye L.N.
        • West C.P.
        • Kelsey E.A.
        • Gossard A.A.
        • Satele D.
        • Shanafelt T.
        A national study of personal accomplishment, burnout, and satisfaction with work-life integration among advance practice nurses relative to other workers.
        J Am Assoc Nurse Pract. 2020; 33: 896-906
        • Dyrbye L.N.
        • West C.P.
        • Halasy M.
        • O'Laughlin D.J.
        • Satele D.
        • Shanafelt T.
        Burnout and satisfaction with work-life integration among PAs relative to other workers.
        JAAPA. 2020; 33: 35-44
        • Halasy M.P.
        • West C.P.
        • Shanafelt T.
        • O'Laughlin D.J.
        • Satele D.
        • Dyrbye L.N.
        PA job satisfaction and career plans.
        JAAPA. 2021; 34: 1-12
        • Shanafelt T.D.
        • West C.P.
        • Sinsky C.
        • et al.
        Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020.
        Mayo Clin Proc. 2022; 97: 491-506
        • Panagioti M.
        • Panagopoulou E.
        • Bower P.
        • et al.
        Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
        JAMA Intern Med. 2017; 177: 195-205
        • DeChant P.F.
        • Acs A.
        • Rhee K.B.
        • et al.
        Effect of organization-directed workplace interventions on physician burnout: a systematic review.
        Mayo Clin Proc Innov Qual Outcomes. 2019; 3: 384-408
        • West C.P.
        • Dyrbye L.N.
        • Sinsky C.
        • et al.
        Resilience and burnout among physicians and the general US working population.
        JAMA Netw Open. 2020; 3e209385
        • Shanafelt T.
        • Sloan J.
        • Habermann T.
        The well-being of physicians.
        Am J Med. 2003; 114: 513-517
        • Shanafelt T.D.
        • Noseworthy J.H.
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Shanafelt T.
        • Trockel M.
        • Ripp J.
        • Murphy M.L.
        • Sandborg C.
        • Bohman B.
        Building a program on well-being: key design considerations to meet the unique needs of each organization.
        Acad Med. 2019; 94: 156-161
        • Ripp J.
        • Shanafelt T.
        The health care chief wellness officer: what the role is and is not.
        Acad Med. 2020; 95: 1354-1358
        • Sinsky C.A.
        • Privitera M.R.
        Creating a "manageable cockpit" for clinicians: a shared responsibility.
        JAMA Intern Med. 2018; 178: 741-742
        • Shanafelt T.D.
        • Schein E.
        • Minor L.B.
        • Trockel M.
        • Schein P.
        • Kirch D.
        Healing the professional culture of medicine.
        Mayo Clin Proc. 2019; 94: 1556-1566
        • Sinsky C.A.
        • Willard-Grace R.
        • Schutzbank A.M.
        • Sinsky T.A.
        • Margolius D.
        • Bodenheimer T.
        In search of joy in practice: a report of 23 high-functioning primary care practices.
        Ann Fam Med. 2013; 11: 272-278
        • National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being
        Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being.
        National Academies Press, 2019
        • Shanafelt T.D.
        Physician Well-being 2.0: where are we and where are we going?.
        Mayo Clin Proc. 2021; 96: 2682-2693
        • Shanafelt T.D.
        • Dyrbye L.N.
        • West C.P.
        Addressing physician burnout: the way forward.
        JAMA. 2017; 317: 901-902
        • Shanafelt T.D.
        • Gorringe G.
        • Menaker R.
        • et al.
        Impact of organizational leadership on physician burnout and satisfaction.
        Mayo Clin Proc. 2015; 90: 432-440
        • Shanafelt T.
        • Trockel M.
        • Rodriguez A.
        • Logan D.
        Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment.
        Acad Med. 2021; 96: 641-651
        • Swensen S.
        • Kabcenell A.
        • Shanafelt T.
        Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
        J Healthc Manag. 2016; 61: 105-127
        • Swensen S.J.
        • Shanafelt T.
        An organizational framework to reduce professional burnout and bring back joy in practice.
        Jt Comm J Qual Patient Saf. 2017; 43: 308-313
      2. Linzer M, Poplau S, Prasad K, et al. Characteristics of health care organizations associated with clinician trust: results from the healthy work place study. JAMA Netw Open. 2019;2(6):e196201. Published correction appears in JAMA Netw Open. 2019;2(8):e199999.

        • Linzer M.
        • Sinsky C.A.
        • Poplau S.
        • Brown R.
        • Williams E.
        Healthy Work Place Investigators. Joy in medical practice: clinician satisfaction in the Healthy Work Place trial.
        Health Aff (Millwood). 2017; 36: 1808-1814
        • Linzer M.
        • Baier Manwell L.
        • Mundt M.
        • et al.
        Organizational climate, stress, and error in primary care: the MEMO study.
        in: Henriksen K. Battles J.B. Marks E.S. Lewin D.I. Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings). Agency for Healthcare Research and Quality, 2005
        • Shanafelt T.
        • Goh J.
        • Sinsky C.
        The business case for investing in physician well-being.
        JAMA Intern Med. 2017; 177: 1826-1832
        • Shanafelt T.
        • Stolz S.
        • Springer J.
        • Murphy D.
        • Bohman B.
        • Trockel M.
        A blueprint for organizational strategies to promote the well-being of health care professionals.
        NEJM Catalyst: Innovations in Care Delivery. 2020; 1
        • Shanafelt T.D.
        • Sinsky C.
        Chief Wellness Officer road map.
        https://edhub.ama-assn.org/steps-forward/module/2767764
        Date: 2020
        Date accessed: November 25, 2022
        • Shanafelt T.
        • Farley H.
        • Wang H.
        • Ripp J.
        • CHARM CWO Network
        Responsibilities and job characteristics of health care chief wellness officers in the United States.
        Mayo Clin Proc. 2020; 95: 2563-2566
        • Shanafelt T.
        • Sinsky C.
        Establishing a Chief Wellness Officer position.
        https://edhub.ama-assn.org/steps-forward/module/2767739
        Date: 2020
        Date accessed: November 11, 2022
        • Dai M.
        • Willard-Grace R.
        • Knox M.
        • et al.
        Team configurations, efficiency, and family physician burnout.
        J Am Board Fam Med. 2020; 33: 368-377
        • Menon N.K.
        • Trockel M.T.
        • Hamidi M.S.
        • Shanafelt T.D.
        Developing a portfolio to support physicians' efforts to promote well-being: one piece of the puzzle.
        Mayo Clin Proc. 2019; 94: 2171-2177
        • Krasner M.S.
        • Epstein R.M.
        • Beckman H.
        • et al.
        Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.
        JAMA. 2009; 302: 1284-1293
        • Shapiro J.
        • Galowitz P.
        Peer support for clinicians: a programmatic approach.
        Acad Med. 2016; 91: 1200-1204
        • Profit J.
        • Adair K.C.
        • Cui X.
        • et al.
        Randomized controlled trial of the "WISER" intervention to reduce healthcare worker burnout.
        J Perinatol. 2021; 41: 2225-2234
        • Dyrbye L.N.
        • Shanafelt T.D.
        • Gill P.R.
        • Satele D.V.
        • West C.P.
        Effect of a Professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial.
        JAMA Intern Med. 2019; 179: 1406-1414
        • Makowski M.S.
        • Palomo C.
        • de Vries P.
        • Shanafelt T.D.
        Employer-provided professional coaching to improve self-compassion and burnout in physicians.
        Mayo Clin Proc. 2022; 97: 628-629
        • Shanafelt T.D.
        • Lightner D.J.
        • Conley C.R.
        • et al.
        An organization model to assist individual physicians, scientists, and senior health care administrators with personal and professional needs.
        Mayo Clin Proc. 2017; 92: 1688-1696
        • Sexton J.B.
        • Adair K.C.
        • Profit J.
        • et al.
        Perceptions of institutional support for "second victims" are associated with safety culture and workforce well-being.
        Jt Comm J Qual Patient Saf. 2021; 47: 306-312
        • Suchman A.L.
        Organizations as machines, organizations as conversations: two core metaphors and their consequences.
        Med Care. 2011; 49: S43-S48
        • Bohman B.
        • Dyrbye L.N.
        • Sinsky C.
        • et al.
        Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience. NEJM Catalyst.
        • Dyrbye L.N.
        • Major-Elechi B.
        • Hays J.T.
        • Fraser C.H.
        • Buskirk S.J.
        • West C.P.
        Physicians' ratings of their supervisor's leadership behaviors and their subsequent burnout and satisfaction: a longitudinal study.
        Mayo Clin Proc. 2021; 96: 2598-2605
        • Shanafelt T.D.
        • Wang H.
        • Leonard M.
        • et al.
        Assessment of the association of leadership behaviors of supervising physicians with personal-organizational values alignment among staff physicians.
        JAMA Netw Open. 2021; 4e2035622
        • Trockel M.
        • Bohman B.
        • Lesure E.
        • et al.
        A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians.
        Acad Psychiatry. 2018; 42: 11-24
        • Sexton J.B.
        • Helmreich R.L.
        • Neilands T.B.
        • et al.
        The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
        BMC Health Serv Res. 2006; 6: 44
        • Rowe S.G.
        • Stewart M.T.
        • Van Horne S.
        • et al.
        Mistreatment experiences, protective workplace systems, and occupational distress in physicians.
        JAMA Netw Open. 2022; 5e2210768
        • Buysse D.J.
        • Yu L.
        • Moul D.E.
        • et al.
        Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.
        Sleep. 2010; 33: 781-792
        • Trockel M.
        • Sinsky C.
        • West C.P.
        • et al.
        Self-valuation challenges in the culture and practice of medicine and physician well-being.
        Mayo Clin Proc. 2021; 96: 2123-2132
        • Trockel J.
        • Bohman B.
        • Wang H.
        • Cooper W.
        • Welle D.
        • Shanafelt T.
        Assessment of the relationship between an adverse impact of work on physicians’ personal relationships and unsolicited patient complaints.
        Mayo Clin Proc. 2022; 97: 1680-1691
        • Sinsky C.A.
        • Bavafa H.
        • Roberts R.G.
        • Beasley J.W.
        Standardization vs customization: finding the right balance.
        Ann Fam Med. 2021; 19: 171-177
        • Larson D.B.
        • Mickelsen L.J.
        • Garcia K.
        Realizing Improvement through Team Empowerment (RITE): a team-based, project-based multidisciplinary improvement program.
        Radiographics. 2016; 36: 2170-2183
        • Swensen S.
        LISTEN-SORT-EMPOWER: find and act on local opportunities for improvement to create your ideal practice.
        https://edhub.ama-assn.org/steps-forward/module/2767765
        Date: 2020
        Date accessed: March 24, 2022
        • Perlo J.
        • Swensen S.
        • Kabcenell A.
        • Feeley D.
        IHI framework for improving joy in work.
        • Shanafelt T.D.
        • Dyrbye L.
        • Sinsky C.
        • et al.
        Imposter phenomenon in US physicians relative to the US working population.
        Mayo Clin Proc. 2022; 97: 1981-1993
      3. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. Published online September 14, 2022.