From burnout to involvement of medical staff. Strategies for successful creation of an effective organizational culture in a medical institution (practical cases of the Mayo Clinic)

Abstract

The health care system is changing rapidly in an effort to provide quality care, improve public health, and optimize spending on patients with chronic diseases and the elderly.

Changes affecting clinical practice include new approaches to payment and supply of medicines, electronic medical records, patient portals and public reports on quality indicators. Leaders of the transformation are health professionals, whose daily work is crucial for the success and improvement of the Health Care system.

It should be borne in mind that the consequence of systemic medical changes and the resulting additional pressure may be professional burnout of health workers. To prevent burnout, it is necessary to develop the involvement of staff, which should not be only the personal responsibility of the health worker, but form a comprehensive approach to the interaction of the organization and employees.

That is why the mistake of many medical institutions is to start with narrowed decisions for the formation of staff involvement. For example, through trainings, seminars on stress management, etc. Healthcare professionals perceive these actions as insincere intentions of the medical institution in solving problems. The organization must demonstrate by its actions and example the concern for the well-being of its employees (creation of recreation areas, transparent system of rewards and feedback, optimization / automation of processes to simplify work, etc.). Using the experience of the Mayo Clinic*, this article will discuss 9 effective strategies to achieve this goal.

* The Mayo Clinic is a non-profit organization (an organization that does not have the main purpose of its activities to make a profit and does not distribute the profits among the participants), one of the largest private medical and research centers in the world, founded in 1889. As of 2012, the Mayo Clinic is an exemplary medical center, employing 50.9 thousand people, including 3,800 doctors and scientists. The clinic's revenue in 2012 exceeded $ 8.8 billion; about $ 500 million is allocated for research. Medical facilities under the auspices of the Mayo Clinic operate in 70 cities in the United States, the largest units - in Phoenix and Jacksonville.

Relevance

The challenges facing healthcare professionals often focus only on external threats. This can create "invisible zones" on the way to the realization of internal threats to the health and effective development of the organization.

To successfully address external challenges, not only strong leadership is needed, but also dedicated and productive physicians who work in partnership with managers.

Management often seeks to ensure that its employees are involved, agile, resilient, and help create more effective models of health care, which would increase the productivity and efficiency of the organization [1].

Unfortunately, today's healthcare professionals are facing these challenges, with enough exhausted and desperate health workers. National studies show that at least 50% of physicians experience burnout [2,3].

That is why the interest in introducing well-being and comfortable conditions for those who are hired or trained is quite justified, both for the Health Care system, medical organizations, and educational institutions.

Among the key problems and factors influencing professional dissatisfaction are:

1. Degree of professional autonomy.
2. Effective leadership.
3. Collegiality, justice, support of colleagues.
4. Quality and content of work.
5. Support from Health Care and Colleagues.
6. Salary, income.
7. Problems related to professional responsibility and regulation.
8. Health Care Reform [4].

Occupational burnout is a syndrome characterized by exhaustion, cynicism, and reduced efficiency [5].

The rate of burnout among physicians varies depending on the clinical discipline, with the predominance of specialties that are "at the forefront" of medical care (e.g., family medicine, general internal medicine, and emergency medicine) [2].

A large number of studies show that burnout is associated with work stressors [6] and job dissatisfaction among health workers [7,8]. Overload of the working process (e.g., hours of work, frequency of calls during the night, the ratio of nurses per patient), work-life imbalance, organizational culture (e.g., management culture; poor interaction between doctor and nurse, value mismatch, lack of professional opportunities growth and social support), as well as the deterioration of control, independence, and meaning at work were associated with burnout among doctors and nurses [9-20].

Moral distress resulting from the above factors is expressed in feelings of helplessness, devaluation of their own efforts and achievements, inadequate information, and giving false hope to patients [21], which are also important predictors of burnout among nurses [22].

Consequences of burnout

Burnout of a doctor contributes to the disruption of relationships between health workers, alcoholism, and increased suicide of doctors (Fig. 1) [23-29]. Studies show that burnout affects the quality of care, safety, and patient satisfaction [30-34].

A recent study by the Mayo Clinic estimated the loss of productivity due to burnout as the equivalent of eliminating seven graduating classes in medical schools [35]. Thus, burnout can contribute to a shortage of doctors and a shortage of nurses.

Physician distress can be manifested in reduced efficiency, increased number of medical errors, reduced patient adherence to therapy, reduced patient satisfaction with medical services [36].

Burnout is also associated with increased turnover of health workers [37-40]. The financial costs of replacing a doctor (employment, training, adaptation) are estimated at 2-3 times higher than the annual salary of a doctor [41,42].

Figure 1. Personal and professional consequences of burnout

That is why any Health Care organization that identifies a systemic problem that threatens the quality of care, reduces patient satisfaction, must quickly mobilize all organizational resources to solve the problem. Burnout is just such a systemic problem [43,44].

Formation of staff involvement as a counterweight to the emergence of professional burnout

Researchers have found that the counterbalance to the emergence of burnout among health professionals is the formation of staff involvement. The concept of involvement includes 3 components: strength, loyalty, devotion to work [45,46].

The misconception of many organizations is that reducing burnout and increasing staff involvement must be the work of staff themselves. But this is a one-way approach to solving a complex problem that requires a comprehensive vision.

What we often see at the level of medical organizations is the exhaustion and despair of doctors and junior medical staff. Any attempts by management and senior management to organize stress management seminars, burnout prevention training are perceived by employees with distrust and are a rather narrow solution to the problems of low involvement, staff exhaustion, and demotivation. That is why the question arises in the formulation of systemic strategies in solving the above problems.

It is worth noting two common myths that can be an obstacle for medical organizations to implement effective measures. The first is the belief that the steps needed to improve a doctor's well-being will go against other organizational tasks. The second is the assumption that all effective interventions aimed at reducing burnout will be unaffordable. The reality is those small investments can have a big impact on achieving institutional goals, and many effective interventions are insignificant in cost.

Broad evidence suggests that organization and the practical environment play a crucial role in whether physicians remain involved or burn out (Figure 2).

Figure 2. Doctor burnout drivers

There are 7 factors that can lead to burnout or engagement of the staff, including workload, efficiency, flexibility/control over work, work-life balance, reconciliation of individual and organizational values, social support/community at work, and a degree value of work (Fig. 3) [47,48].

Each of these dimensions is influenced by individual, work units, organizational and national factors [49]. Given this fact, reducing burnout and promoting involvement is a shared responsibility of individual physicians and medical organizations [43,50,51].

The fact that more than 50% of physicians are now burning out underlines the need for a strategy at the level of the Health Care System [9,52-54]. In this article, we focus on strategies at the organizational level to reduce burnout and promote engagement.

Below are 9 organizational strategies to improve the organizational culture and create a comfortable environment for effective work of medical staff, which was developed and implemented at the Mayo Clinic. The founders of these strategies emphasize that these principles are not exhaustive or definitive. Rather, they represent tangible organizational actions backed by evidence and experience. The following are nine strategies that have reduced burnout by 7% over a two-year period [55].

Figure 3. 9 strategies to promote staff engagement and prevent burnout (Mayo Clinic experience)

Strategy 1 – To recognize and evaluate the problem

This strategy includes the ability to talk openly with management, effective internal communication, followed by a demonstration that the organization cares about the well-being of physicians. Formats of work: video interviews, working groups, broadcast newsletters, etc.

It was found that voicing and speaking about the problem and willingness to listen to the position of employees, contributes to the formation of trust in doctors, managers and promotes partnerships.

It is worth applying the metrics of psychological well-being of health professionals: burnout, fatigue, emotional health (stress), quality of life, satisfaction with the work of a doctor, engagement of a doctor, work-life balance, job satisfaction.

Healthcare managers need to recognize burnout as a systemic problem and promote a culture of self-care among their employees from the top downward. To help achieve this, some hospitals, such as Stanford and Mount Sinai, have created the administrative position of the physician responsible for staff welfare. [56]

Examples of effective internal communication in the institution at the level of the medical team can be: conducting a focus group, special meetings focused on solving work problems and challenges (Table 1).

Before implementing any change in the medical facility, the team conducts an average of 2-3 focus groups (60 min each) with doctors from the same work unit (n = 7-8).

Table 1. The structure of the focus group

No.	Stage	Explanation
1	Introduction: "We are here because ..." (10 min)	Provide a basis for discussion by briefly (2 min) formulating burnout drivers. Employees should clearly articulate work factors that cause stress and prevent more efficient work (e.g., electronic database, refund problems, etc.). Please note that all comments will be taken into account, recorded, and distributed to managers. Most of these problems (for example, improving the electronic database) are not easy to solve, and a limited amount of time (<5 minutes) should be spent on this aspect of the discussion. The goal is to recognize these challenges/problems that are beyond the control of the clinical unit and the advisory group, to share them with senior management in the organization responsible for these aspects.
2	Identification of specific local calls and solutions (50 min)	Ask which of the 7 drivers is considered the most relevant work unit call (for example, inefficiency due to excessive workload). Participants should formulate specific signs of how it manifests (for example, there is no filtering of messages received through the patient portal; slow execution of routine processes in the operating room).
	"What changes can be made to address this issue quickly if your work unit and its managers have made it a priority?"	Making effective comprehensive decisions aimed at change is possible with the help of good facilitation. Simplified solutions (for example, "we need to hire 10 more nurses") should be recognized by both parties and feedback should be received (for example, "This may be appropriate, but it takes time and requires business development. Are there ways to use existing staff to provide this support more quickly? Are there other ways to make progress in solving the problem in the near future until a decision to increase support staff is not made yet? What could we do to improve our lives in the next 2-3 months?").
3	Passing the baton back to the head of the work unit	The advisory group describes to the head of the local unit 1-2 key issues identified during the focus group. The problem of greatest concern is highlighted (e.g., inefficiency due to overwork) with examples of how this manifests, as well as examples of the types of local change that would be most useful from a group perspective. Commitment with the head of the local work unit: to enable the team to develop and implement a single change designed to make progress in this area of ​​the chosen driver. It is the consulting team, not the head of the unit and their team should focus the head of the work unit on the implementation of specific changes that are developed by employees.
4	The head of the work unit promotes change.	The head of the work unit leads the remaining stages of the process and leads the management of changes needed to improve the unit. The consulting group assumes the position of supporting the work of the head of the unit. The team leader provides feedback to his focus group staff on how to solve the problem. Indicates which problem has been identified as a key (one of the 7 drivers), names the person who will lead the task force to implement this change in the next 8-10 weeks.
5	Once the change is implemented, its impact needs to be assessed: “Has the change helped? Do we need improvements/adjustments?”	Even if the result of the implementation of the change did not meet all expectations, the process of working to solve the problem can reduce burnout and promote involvement. All participants felt the importance of their own participation and contribution to the development of the idea, after which they can move on and find another solution and repeat the process from the beginning until they achieve the desired result.

Strategy 2 - Use the power of leadership

An important emphasis should be put on selecting the "right" leaders who have the appropriate competencies.

Among the key skills of a successful leader in the medical field, the Mayo Clinic highlighted:

1. Active listening skills
2. Providing feedback
3. Involvement of doctors
4. Development assistance and mentoring
5. Facilitating the adaptation of new employees
6. Recognition of talents and strengths of each team member
7. Understanding the motivation of the individual doctor.

The development of doctors' autonomy is achieved by the heads of the Mayo Clinic through a clear division of the working day: 80% of the time - the tasks set by the medical organization and management, 20% of the time - the activity that motivates the doctor. For example, educational work, work with interns, students, scientific work, self-education (electronic courses), etc.

Equally important is the assessment of managers by the staff themselves. Assessing a physician's success may include criteria for achieving the organization's goal and evaluating the ways in which that goal has been achieved.

Accordingly, the medical organization must have the courage and sufficient autonomy to change managers in accordance with their performance criteria.

Strategy 3 - Development and implementation of work optimization

Burnout drivers can consist in the presence or absence of effective processes and procedures for internal interaction and problem-solving. For example, paperwork, hospitalization, open access to international protocols, and the latest research.

Also, an important factor in the success of internal processes is the ability to conduct research at the level of various medical departments on the criteria: burnout, involvement, job satisfaction within a separate unit. These criteria allow managers to identify units with "high capabilities". Once such units are identified, management systematically engages them to identify factors that help reduce burnout and increase staff satisfaction. All the interaction between managers and subordinates is based on the principle of joint decision-making [54]. This approach also helps to transform the way doctors think from the victim in a "broken, outdated system" to an authorized partner who works with managers and improves the common future in the organization [57].

Strategy 4 - Forming a community at work

Healthcare professionals address complex and critical issues related to the quality of life and health of patients. It is the frequent occurrence of medical errors or abuse of office. In addressing all of the above challenges, it is important for the employee to focus on the support of colleagues. This support can be expressed in a wide range of measures. These include celebrations (awards and appreciation ceremonies), addressing clinical challenges related to patient death, medical malpractice, litigation, or workshops where ideas are exchanged to improve effectiveness and performance. An important factor in such an association of people is the common mission and purpose of work, cooperation for the benefit of the reputation of health professionals, and the prestige of the clinic in which they work.

In recent years, there has been a decrease in personal interaction between doctors. Increasing requirements for documentation and increasing electronic resources have led to the fact that physicians are spending more and more time on computer systems. Lack of space for health professionals (e.g., restrooms, dining rooms, stress rooms) contributes to a culture of isolation and distrust in the medical organization [58].

A good example is the Mayo organization, which since 2012 has introduced meetings on every other week with colleagues outside the medical organization. Namely, a working group of 6-8 people, every other week chooses a restaurant/cafe for a joint lunch break. This meeting lasts about 1 hour. The first 20 minutes of the meeting are spent discussing ideas for improving the working conditions of the doctor, ways to reduce burnout, difficulties in medical practice, the rest of the time is devoted to casual communication at lunch. A randomized study found an improvement in the importance of work indicators and the level of professional satisfaction, reducing burnout [59].

Based on these indicators, the Mayo Clinic made the COMPASS groups available to all 3,755 physicians and scientists in all branches of the clinic. More than 1,100 health workers joined the groups in the first 10 months.

Thus, the data show that encouraging the solidarity of doctors reduces burnout. When Mayo's doctors engaged in one hour of small group discussions each week, they experienced a significant reduction in depersonalization and emotional exhaustion [60]. One of the easiest ways to facilitate the interaction of doctors can be to create a space for coffee and snacks for health professionals. Stanford has recently taken a more creative approach, paying a group of doctors for a joint dinner at local restaurants [61].

Strategy 5 - Use of rewards and incentives

Many Healthcare systems motivate physicians with financial rewards by adjusting physicians' salaries based on productivity (i.e., income generation), or by distributing performance bonuses [62]. Often doctors increase productivity and income by:

1. reduction of time spent on the patient
2. ordering more tests/procedures
3. extension of working hours.

The first 2 approaches can worsen the quality of care, and the third approach increases the doctor's risk of burnout and therefore may be unwarranted in the long run. It can be concluded that compensation is based on productivity, increases the risk of burnout [63,64].

Other indicators of a doctor's success can be measurements of patient satisfaction and quality of services provided [65-68]. But here another problem arises - productivity indicators may decrease, and financial indicators can be assessed only in the long run. There are 3 problems - the doctors’ salary which is based on their productivity, increases the risk of fatigue and burnout of doctors.

Wage compensation models are a way to overcome this issue [65]. Other innovation centers have begun to include indicators of self-care and the organization of their own well-being by health workers as part of the formula for calculating pay based on productivity. This solution can prevent fatigue in further work.

It is important to note the significance of rewards and bonuses for employees in the form of a more flexible working day, or encouraging the allocation of working time to implement personally important aspects of work (e.g., quality work, public education, research, education, or mentoring) can allow more productive doctors to form their work to promote personal and professional growth. In contrast, the use of simple financial incentives may be less effective [68-70] and contribute to overtime.

After all, there is no right or wrong compensation model. However, it is important to weigh the potential risks of each model in order to further improve individual and organizational health in the long run.

Strategy 6 - Formation of values and strengthening of the corporate culture

Most Healthcare organizations have an altruistic nature of mission statements that focus on serving patients and providing them with the best care possible.

The culture of an organization, its values, and principles largely determine whether it will achieve its mission. It is important to understand the factors that influence the formation of culture, test values and to align values and actions accordingly.

At Mayo Clinic, the core value of “patient needs as a priority” is built into the principles of physician leadership, the payment system, the partnership of physicians and administrative staff, a multidisciplinary approach, a limited leadership period for all departments (including the CEO), and organizational policies that promote long-term care and low staff turnover.

A systematic assessment is made among employees of the extent to which the declared values are met and the necessary conditions for their implementation are created. In case of difficulties at any level of implementation of values, a working group consisting of managers, health professionals, and scientists is created to identify the problem and to find a solution.

This process of monitoring existing values contributes to [54]:

• forming a partnership between the organization and doctors, each of whom works for a common goal;
• providing feedback on where improvements are needed;
• creation of a document that sets out the principles that are fundamental to the partnership between the Mayo Clinic and its staff. This document is further used to recruit new employees, forms the basis of internal communication, and a source of principles for implementing joint decision-making.

Strategy 7 - Work-life balance

The medical field has many drivers for the professional burnout of health professionals. Given the driving impact of these stressors on the health and effectiveness of physicians, the quality of care, it is necessary to monitor systematically.

In the United States, research has shown that doctors are almost twice as likely to be dissatisfied with work-life balance than workers in other fields. This problem is probably due in part to differences in working hours. Approximately 45% of physicians work more than 60 hours per week compared to less than 10% of workers in other specialties in the United States [2,3].

Evidence suggests that reducing working hours may help health workers recover from burnout [71]. Depending on the specialty and the number of organizations, it is not always possible to implement. However, organizations should strive for this. Taking into account the projected "staff shortage" in the next 10 years [72,73], it is important to provide the necessary conditions for doctors in a timely manner due to a flexible work schedule [47,74]. This can help to implement a recruitment and retention strategy. For example, to allow doctors to start work earlier / later or work more hours on one day of the week and less on others. This simple method can greatly facilitate the life of the doctor, due to the ability to fulfill individual obligations without reducing labor effort.

This method can be useful and win-win for organizations where doctors work part-time.

The institutions should also review the structure of available benefits on leave, coverage of life events (birth of children, illness/loss of loved ones, etc.). Another solution to this problem may be to allow doctors to spend more time on their favorite aspects of work (such as patient care, education, administration, or research). Doctors who spend at least 20% of their time on the part of their work that they consider the most effective significantly reduce the chances of burnout [75].

At the individual level, physicians can work to improve time management skills. Solving the problem of time management, which is inefficiently used at work, allows spending more time at home.

Strategy 8 - Providing resources for sustainability at work and developing a culture of self-help

Mental health remains a taboo issue among physicians, and many of them are reluctant to seek treatment because of potential risks: shame, loss of income, or licensing [76]. Organizations should focus their efforts on breaking this stigma, developing a culture of self-help among physicians, and turning to specialists in case of psychological problems.

It is important to note that individual strategies for coping with stressful situations in the workplace should be part of a broader strategy that demonstrates that the organization also does its best to create the necessary conditions for health professionals.

Such resources may include measures to maintain a work-life balance. For example: providing healthy food in cafeterias, access to crisis psychological services in case of stressful situations at work or at home, the development of physical culture through the provision of membership in local gyms [77]. In addition, physicians may be provided with additional time to implement these self-help measures [47,78-80].

It has been proven that doctors who take better care of their own health provide more effective counseling and examination of their patients. That is, encouraging such behavior of its employees, the organization receives a double benefit: on the one hand, the growth of service quality, on the other - the growth of satisfaction of health workers and the prevention of burnout [81,82].

That is why it is important to conduct training of stress resistance skills on a systematic basis, solving difficult work situations, forming communicative competence of the doctor, etc. [82-86].

Strategy 9 - Assistance in organizing the development of science

Understanding the need for an evidential base for the medical field actualizes the investment of resources in the development of science (randomized trials, analytics, availability of resources for study and publication). In particular, the example of Stanford University School of Medicine, which made a financial contribution to the launch of a program to study distress factors among health professionals and promote the growth of medical well-being.

The main focus of such programs is to create new knowledge and evidence on how to reduce burnout and promote the involvement of physicians through organizational science.

Considering the good effect of this program on the well-being of doctors, improving the quality of care, patient satisfaction, such knowledge will be critical to the health and viability of the national health care system [87].

Burnout prevention among medical students

In addition, it should be noted that the problem of burnout should be addressed from the beginning of education in a medical university, as often new employees come to the hospital with signs of burnout. This factor is reflected in the quality of medical care. In particular, residents (junior doctors) in Ireland who showed signs of burnout had 22% more medical errors than those who did not have burnout [88]. It is also important to note that the new generation of physicians, are more vulnerable to criticism and work challenges, are less focused and impatient [89-91].

There are examples of successful cases of burnout prevention among medical students. One of them is the Medical School of Vanderbilt University, which implements a health program where students promote healthy habits and form the responsibility of self-care [90]. Perhaps the most drastic changes have been made to St. Louis University Medical School (SLU), where the curriculum has been redesigned over the past decade to reduce student stress and create a less toxic educational environment. Changes included the introduction of a system for assessing gaps/failures, reducing unnecessary requirements for term papers, and introducing electives during the preclinical years. As a result, university students experienced a reduction in depression, stress, and anxiety, while maintaining a stable level of academic performance [89].

Conclusion and recommendations

Occupational burnout has become a major problem for many countries, bringing significant challenges and losses to 21st-century medicine. If left untreated, the burnout epidemic may continue to spread to the detriment of both patients and health care workers (Table 2, [91]). The experts of the Mayo Clinic have identified good strategies to solve this problem, and it is time for Ukrainian medical institutions to start implementing the necessary actions in this direction.

Management should take the initiative to understand the problems of achieving the well-being of the doctors, offering more sound evidence-based solutions and timely verification of their effectiveness. This includes timely examinations using a variety of evidence scales that quickly measure the physical, emotional, and mental exhaustion of clinicians. The data obtained can help to understand the areas for improvement and will serve as a basis for comparing future similar surveys.

Strengthening the role and influence of the Human Resources Management (HRM) department should focus on reducing the administrative burden on physicians, including filling out medical records, accompanying patients for diagnostic examinations, etc. These tasks can be delegated to other health professionals, such as health care assistants, who acquire the necessary education. In this way, physicians will significantly improve the quality of communication with patients and build partnerships to promote adherence to treatment.

In such an intensive condition as emergency care or resuscitation, managers should keep in mind the schedules of doctors. Physicians are constantly surrounded by situations of morbidity and mortality, so the risks of exhaustion are high. Timely breaks and weekends should be carefully planned. In addition, physicians should be encouraged to engage in relaxation techniques such as yoga, meditation, crisis psychological help, etc. This can help them return to work recovered, increase their efficiency, and improve performance.

Table 2. Burnout risk factors and strategies to reduce burnout risk

No.	Risk factor	Example	Risk reduction strategies
1	Workload	Work requirements that exceed the employee's limited resources, and time to recover. Loading stress, including work with terminal patients, frequent traumatic events and deaths in the workplace.	Time planning strategies, providing conditions for self-help and recovery.
2	Control	Vague and nontransparent expectations from management cause role conflict, lack of understanding of the direction of work, loss of independence at work, reduced control over the work environment, inefficient use of time due to administrative requirements and loss of support from colleagues, noncompliance patients.	Defining clear roles and expectations of management.
3	Reward	Inadequate financial, institutional, social reward, lack of recognition from stakeholders (patients, colleagues, managers).	Providing feedback to co-workers, introducing a transparent and clear reward system, providing access to training and development, a flexible work schedule.
4	Medical community	Inconsistency of conditions for quality social interaction at work; inconsistency in the development of conflict resolution skills, insufficient conditions for mutual support, lack of teamwork.	Involve medical staff in joint decision-making, problem solving, and other organizational processes.
5	Justice	Management prejudice, inconsistency of the efforts of the medical worker to the received assistance.	Transparency in decision-making, recognition, stability, flexible work schedules, professional growth and adequate supervision.
6	Values	Individual values differ from organizational ones.	Assistance in assessment, formation of adequate expectations.
7	Personal incompatibility with the workplace	The employee does not meet the requirements of the organization in terms of functional (professional) and non-functional competencies.	Transparent profile of competencies, availability of resources to measure and align work responsibilities with personal and professional expectations (HR department).

Additional information

Conflicts of interest

The authors declare that they have no conflicts of interest to declare.