Would patients be admitted, or people be allowed to come to work, in a hospital that had Legionnaire’s disease spreading through its HVAC system, or cryptosporidium in its water supply?
When there is an unusual smell associated with headaches and nausea in a surgical unit or emergency department, do people continue to work there and show up for their next shift as though this is status quo?
Of course not.
[NOTE: There are exceptions, as we learned in early 2020. During the existential threat of the Covid pandemic health systems had no choice but to have clinicians work in a toxic environment. Clinicians saw it as a moral imperative to assume significant risk for the greater good of society.]
Why is it different for burnout?
Burnout manifests as emotional exhaustion, depersonalization (cynicism), and a sense of inefficacy. It progresses to serious sequelae for clinicians, as they develop depression, substance abuse, and family dysfunction. For 3-400 physicians each year as these problems worsen, it leads to death by suicide.
Shouldn’t workplaces that are causing such significant morbidity and mortality be considered toxic workplaces? Doesn’t this deserve a significant response?
A Key Cause of Burnout
A key cause of burnout is placing highly motivated professionals into a clinical workplace in which they have inadequate support, and in which they cannot care for their patients properly without constant vigilance and focus. The level of vigilance and focus required is unsustainable over the long term.
Put otherwise, the work to be done is essentially undoable in the current work environment. Eventually this takes its toll and burnout ensues.
According to Christina Maslach, PhD the workplace drivers of burnout include:
Work overload
Lack of control
Insufficient reward
Breakdown of community
Absence of fairness, and
Conflicting values
These conditions are endemic in most clinical workplaces. When placed in these conditions, over half of physicians manifest the symptoms of burnout and are at high risk to progress to the serious sequelae noted above. A piece in The Saturday Evening Post, published over five years ago, explores this in great detail.
Why is there so little action by healthcare leaders to address toxic workplaces?
In March of 2017, before the pandemic ravaged hospitals and clinics, 11 CEOs of major US health systems posted a Health Affairs Blog titled, “Physician Burnout Is A Public Health Crisis: A Message To Our Fellow Health Care CEOs“.
I have worked with over 50 health care systems sharing my message about burnout, its root causes, its impact, and, most importantly, what these systems can do to address the root causes and reduce burnout. Most chief medical officers and medical directors are fully engaged. Most process improvement teams are also engaged.
It’s a different story for the rest of the administration, particularly the non-clinical members of the C-suite. More often than not, they acknowledge that burnout is a top concern that is impacting staffing and productivity.
Yet the common CEO approach is to treat burnout reduction as a project assigned to a direct report, or equally likely, to someone one step further removed – someone reporting to a direct report of the CEO.
I can understand some of the reasons why:
CEOs are under significant pressure to ensure the financial stability, and enhance the strategic position, of their organizations.
They have to make choices about which meetings to attend and which stakeholders to spend time with to address these needs.
These become the priorities.
CEOs Are Not Properly Responding to Burnout
Most CEOs understand that burnout in their medical staff is one of the greatest financial and strategic threats facing their organizations. Many have misdiagnosed the cause of the problem as a lack of sufficient resilience in the clinicians. They respond by appointing a Chief Wellness Officer, thinking this alone will solve the problem. A CWO can help, but even the best CWO can't do it alone.
Why don’t CEOs pursue more effective responses?
Is it because:
they have not recognized the real impact – Burnout-related turnover costs the average health system between $10-50M a year in lost revenue, but “lost revenue” does not show up as a line item on the income statement.
they don’t know what actions to take to reduce burnout – resilience training makes a minimal impact. Too few leaders understand the effectiveness of investing in workflow redesign to lower work overload and changing the management system and culture to empower and align clinicians.
addressing the challenge will require them to change their management approach – it’s hard for anyone to change how they work, especially when they have done so for decades, and it has helped them achieve success. Yet, what worked in the past does not work in the complex challenges healthcare faces today.
We all know that change which isn’t easy for anyone. Most of us won’t change until the pain of the current condition is worse than the perceived pain of the change. It's true for CEOs as well as for the rank and file workers.
What too many CEOs miss is that they need to be personally involved in leading the change. They need to do things differently themselves, demonstrating their personal commitment to fixing the workplace.
What do you think?
How much worse will these toxic workplaces have to get, and how many more physicians will have to experience depression, substance abuse, family dysfunction and suicide, before health care leaders feel enough pain and we see effective responses from all health care CEOs?
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