Episode Transcript
Alan Helgeson (announcer):
“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations and real-world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools and partnerships advancing rural health care and strength in care in communities across the country.
Joining us in this episode is Dr. Tait Shanafelt, chief wellness officer of Stanford Medicine, alongside Dr. Heather Spies, who is physician director of clinician experience and well-being at Sanford Health. Together they’ll discuss clinician well-being as a strategy, leadership, culture, and the power of listening in rural health care.
Dr. Heather Spies (host):
Dr. Shanafelt, welcome. Thank you for joining us. I’ve been looking forward to having this conversation with you. I’ve had the honor of knowing you for a few years now, since I took your Chief Wellness Officer course in 2021 at Stanford. So just since then, it’s been such a fun journey to see the evolution of clinician well-being being prioritized by more organizations. And so we’re going to talk about that today.
And then to be able to work with you in many different aspects – meet with other leaders across the country, whether it’s an American Medical Association (AMA) meeting or a national meeting conference on physician health, most recently in Boston – it’s been a joy. You have helped elevate clinician well-being from a nice-to-have to a core essential element of organizational performance, culture, and sustainability. First, thank you for elevating that across the country for so many people. You’ve made a big impact.
Dr. Tait Shanafelt (guest):
Thanks, Dr. Spies. It’s great to be with you. I’ve really been looking forward to this, Heather.
Dr. Heather Spies:
Yeah, that was a long intro and a long thank you, and well deserved. So, I also want to thank you because your work has really changed how we do things and/or helped shape it at Sanford. I’ll try to keep Stanford and Sanford straight throughout the podcast, right, with the difference there.
But how we think about clinician well-being at Sanford Health, not just as a commitment that aligns with, you know, our mission and values as an organization, but really as a strategic investment in the future of care delivery, especially in rural communities which we serve a lot of. So, I’m going to dive into a couple questions here for you.
You began conducting your research on well-being over 25 years ago, and really centered around physician well-being, and we’re one of the earliest leaders in this space. You helped define the role of the chief wellness officer. So, I have two questions related to that.
At that time, what convinced you that clinician well-being was not only a human issue, but a leadership and business issue? And as we look ahead, how do you see that role evolving?
Dr. Tait Shanafelt:
Yeah, no, it’s great. Great question. I think in those early days, several decades ago you know, much of our early work was looking at that intersection between clinician well-being and the care we provide patients, both with respect to quality of care, whether the care is compassionate, whether it’s patient centered.
And I think we begin to see in a number of studies that there were these strong links between the clinician experience and clinical care. Subsequent studies also begin to demonstrate links to turnover in health care workers, health care workers cutting back the amount of time they devoted to clinical care.
And so we begin to have all this evidence that the well-being of the health care workforce was really jeopardizing every, all the things we aspire to in the mission of health care organizations. And that’s the foundation really, that begins to shift organizational thinking and to recognize that this, as you said, wasn’t nice to have sort of in a workforce morale kind of line of thinking but as a fundamental necessity for us to be effective as health care organizations.
And as that recognition begins to take hold, organizations begin to appreciate that if they were going to be effective in addressing that opportunity, they were going to need to establish a leader within the organization who would be responsible for it. Just like we have chief quality officers, chief experience officers, chief nursing officers, that we would need someone who was going to both have some expertise related to this domain and the evidence on how to advance it and could help guide the organization’s strategy, evaluation process, and implementation.
Dr. Heather Spies:
Yeah. Thank you for that. And I know without someone kind of at the helm, and even just sitting around the table sometimes just as a visual reminder is what I learned, right? That hey, are we keeping the well-being of our physicians and our clinicians in mind and, you know, kind of at the heart of the center of all the decisions we make. Because there we have so many difficult decisions in health care all the time every day, right? So that leads perfectly into the Stanford model of occupational well-being. I wanted to bring that up because we’ve really shaped our strategy at Sanford around that. Can you speak to that model a little bit? Kind of how it started, how it evolved also?
Dr. Tait Shanafelt:
Absolutely. The Stanford model is intended to be both holistic but simple. And one of the centerpieces of it is that we’re trying to do something more aspirational than just mitigate distress or occupational distress. We’re trying to foster meaning and purpose and professional fulfillment in people’s work experience.
And we view that as really a three-legged stool. That there are these individual factors and things that we can do to take care of ourselves and promote our own professional well-being. But that, in addition to that, there are the organizational characteristics and then the efficiency and daily experience in the work environment that are also very critical to fostering that outcome. And that, when we think about the organizational characteristics that really drive a great workplace, much of it centers on dimensions like the behavior of leaders.
What does good leadership mean at Sanford? Do we have that well-defined? Do we select leaders with those qualities? Do we help our leaders develop those skills? Do we measure them? Do we give them feedback? Do we foster an environment where people have an opportunity for voice and input into decisions? Do they have some flexibility? Is there a sense of connection and community within the team? Are we fostering these things?
And, and obviously to the extent we do, it can really change the experience for the workers. And then when we think about efficiency, we often think about that topic from the vantage point of being able to serve a higher volume of patients or delivering a greater volume of care.
But we can expand that thinking to consider how simple or burdensome it is for a nurse to provide for their patient what they need. And are we creating a lot of friction for that process? Or are we removing unnecessary steps or the things that get in the way of that so that it can be you know, a well-oiled machine, and for the worker and they can devote their time and energy and attention to the parts of care that are most critical?
Dr. Heather Spies:
Yeah. Thank you for that. I agree. It’s such a balancing act and such a commitment from all people involved, right? Not just the individual, but from the organization. And that’s where we like to focus too, at Sanford, is saying, what are we doing as an organization to help support our people?
And burnout’s a big component of that, right? We hear burnout a lot more, I think, especially since COVID. But you know, as a practicing OB/GYN, and you know, as our physician director of clinician experience and well-being, we’ve really focused on burnout because we know it affects the quality of care for our patients.
And it’s taken years, but with some intentional strategies, we’ve seen an improvement in burnout in our physicians. You know, as you’ve watched this field closely over decades, what have you observed most recently specific to burnout and kind of focusing on the organizational kind of responsibility that is there for that?
Dr. Tait Shanafelt:
It’s a great question, and I think a really important one as well because it’s easy for us to look at our current organizations, our current daily experiences and still recognize that we have a long way to go, but we sometimes add to that. And nothing has been done, or nothing has changed. And that last bit is just a profoundly inaccurate statement.
And when we look back to 25 years ago, and the state of things at that point in time, to a large extent, organizations just ignored this whole domain. About 15 years ago, it begins to be well appreciated that there was an issue. It was having consequences for organizations that mattered. And we sort of shifted to this era where organizations started to recognize the importance.
In many cases, they did start to assess both burnout, engagement, clinician well-being, teamwork, other characteristics that influence our work experiences. But to a large degree, there was not a well-structured process to follow through on what we learned. And that organizations largely responded by resilience training and stress reduction approaches, you know, sort of generic ways of trying to boost morale that weren’t really addressing root cause.
And I think it’s really been here in the last seven or eight years that organizations have begun to approach this in a more robust way that begins to think about addressing the root cause contributors that create unnecessary work burden or that create friction between teams or that begin to reimagine team-based models of care delivery that better meet the work as we’re doing it today.
And so I think that is where most of us recognize the need for much more action. But we have come a long way from sort of a time when there was largely either ignorance or neglect of this domain to a time where there was awareness, but the ways we were intervening were largely individual focused to now a more sustained organizational attention and beginning to think about developing structures and processes to redesign the work itself and make us more effective in it.
Dr. Heather Spies:
Absolutely. And that’s perfect. I was going to talk about one of those ways. And, you know, in your course years ago, one of the things I took away from that and really learned from was tools to use as one of the leaders trying to lead this work forward. And the listening session was one of those things that was just extremely helpful to me.
So you have kind of a listening model, and it’s developed over time. But it’s really been, I think, a cornerstone for a lot of organizations to be able to help create that culture of well-being. So as you’ve seen this implemented across organizations, can you share some insights about that and how that’s kind of changed leadership assumptions or kind of revealed some blind spots maybe?
Dr. Tait Shanafelt:
Yeah, it’s a really great question. And I think we first started down this road, I guess it was 16 or 17 years ago. I was at Mayo Clinic at the time, and we had very robust organization-wide survey data. And that information was pointing us toward which units and teams, divisions were struggling and even gave us some insight into maybe some of the challenges.
But what we felt and found was that that survey data, while really important and helpful to identifying where the opportunities were, was sort of generic. And that when you looked across maybe 25 units that were being identified as needing additional time and attention we didn’t really understand what the unique challenges were in those units and what the opportunity was. And it was really out of recognition that we said we need to go down and just ask a lot of questions and listen and better understand the challenges.
And so the listening sessions are structured really to provide qualitative insights that give us much greater understanding of, if we’re talking about inefficiency or if we’re talking about suboptimal teamwork, we’re talking about a work structure that makes work-life integration – we really have to understand what are the characteristics of the structure that are making that a challenge? How is that affecting you in your day to day? What opportunities do you see for a different way of doing the work?
And the people in the team or in the unit are those who have the best insights on those fronts. And so it was really out of a desire to try and do something meaningful for 25 different diverse units and recognizing we really didn’t have the data we needed to be able to do that.
Well, that led us to the listening sessions. And then I think what is the key is that many organizations have created channels for feedback. And that’s important. But that listening session is really one component of a multi-step process to take that input and try to translate it into effective interventions to address the concerns that then make that unit function more optimally.
And so I think that the listening sessions are a critical first step, but it’s really building out the rest of that apparatus to help translate what is learned into meaningful action. That is the key.
Dr. Heather Spies:
Yeah. And then closing that loop, right? So listening, but then taking away the things that are maybe those top priorities for a particular department. Because they’re going to be different, like you said, for different ones. And then, coming back, you know, committing to a time to come back.
This is what’s being done. This is just what can’t be done right now, and this is why. And those kind of things.
So, you know, after learning about these certain type of listening sessions at your course, of course you get to network and develop relationships with fellow alumni from the group. And so, Dr. Sarah Richards, from University of Nebraska Medical Center, and I ended up at another conference soon after. And so she was kind of moving them forward in her organization. So we partner together and use them. So that’s the thing I love about our work Dr. Shanafelt, is that we can share with each other and lift each other up. And it’s less of a competitive area of medicine. It’s a place where we all want to lift each other up together. So that’s been really rewarding for me. So, just wanted to share that.
Dr. Tait Shanafelt:
It’s so well said. And I think one of the best qualities of getting to do work in this field is that there are really passionate colleagues who care a great deal about addressing this issue, and it tends to be a very generous group of people. As you said, these aren’t state secrets.
It’s sort of, you know, much like the quality improvement movement that we all just believe that this is the heart of the work we do, and if one of us has insights to create higher quality and better outcomes for patients, we should be generously sharing that across organizations. And I think this domain is very much the same, and it’s still a very nascent field as well. There’s still so much to learn that doing it together and encouraging each other and sharing what we learned is critical to accelerating progress.
Dr. Heather Spies:
Yeah. Yeah. I agree. And ultimately, it does affect the patient care, like we’ve said, and we’re getting to see more and more evidence of that, which is helpful for us data-driven folks. Right. So one of the things I wanted to kind of lead up to next was, you know, when we started implementing these listening sessions I then shared the structure of this session with our physician executive leaders and then one of the groups took it as a project, shared it, and it really started to spread system-wide.
So I think it’s such a great example of how you can take one structure and find ways to scale it. And so that’s been something fun to see. So turning that insight into improvement, how do we scale it? I think that’s one of the biggest things I hear across other health systems is how do we start and then how do we scale it?
So I just wanted to share the three questions we asked because back to what you said earlier about engagement surveys and things like that. This group that did the project, they did the survey. They looked at their survey data before the listening sessions, then they did the listening sessions, and they just asked the three questions: What’s going well for your department? What are the top three things affecting your daily practice? Which issues can we act on now and which are outside our control? And then they had that discussion, right?
They had that hour set aside to go through those things, really address them together as a department. And then they came back after they went through the process of figuring out what they could do and then came back and did survey data a few months later and found a significant improvement in engagement and well-being, decreased burnout. So I would love to just hear, you know, if you’ve heard that what type of similar things you’ve seen and done across the country.
Dr. Tait Shanafelt:
I love you describing it because there’s so many important ingredients that you described Dr. Spies that I think are easy to miss. You know, then, one of the first pieces that there’s a strong evidence for from leadership walk round is starting with appreciative inquiry.
You hinted at what’s working well in this unit that other units could learn from. And there’s actually evidence that beginning on that type of a note actually is really important. Before we focus on the things that aren’t working to acknowledge that there probably are good things in this unit. Let’s celebrate them. We want to build on those strengths and so I love the way you’ve incorporated that.
And then I also really like the way that the third question you articulated of which of these things are most actionable now, or are things that we control locally and can change the fastest, even as we maybe identify the things that we’re going to have to work on for a longer period of time, or maybe just now isn’t the right time?
And I think it’s easy for us to sit around point to all the things we don’t control, you know, payment models for health care in the United States. I mean, we’re not going to fix that in three months. And yet there are many other actionable things that we can do to make this unit a better place to practice.
And so helping the team identify the things in that second category and saying, “let’s advance those even as we wait to work on these other things” is important. And then also to think about being transparent when now is not going to be the time to do something, even if it is under organization control or local control, it just isn’t the right time because we have a different initiative, there’s a different priority this year, budgets are held flat.
And that we are just very transparent with. That is another evidence informed component of this, that if we don’t close the loop on that, there’s a common outcome where people feel like they’ve given us feedback and then they assume that we’re going to follow through. And if we come back and we haven’t followed through, they assume we ignored the feedback. And that can breed cynicism because you asked me for my input, and yet you didn’t do anything.
And so that’s why closing the loop of we heard you. We went and explored that. Turns out right now, we’re not able to act on that. We’ve still got it captured for when the time is right. Keep the ideas coming because we want to identify those we can act on now. But that one isn’t going to move forward at this time. That, again, helps people feel that the feedback that they’re providing is being taken seriously.
Dr. Heather Spies:
Yeah. I think that’s so important. What do you find is the most important? I know we’re talking about ways to get things started, some of these tools to use, I think a lot of leaders that are listening to this are probably measuring burnout. They’re starting to implement some things and have strategies in place.
What do you think is the biggest, the most important mindset or capabilities shift that you would think about to just help organizations sustain that future movement or that forward movement is what I should say of progress?
Dr. Tait Shanafelt:
Yeah, it’s a great question. I think the first suggestion would be to make sure you’re seeing the intersection between clinician well-being and quality access, cost of care delivered, you know, most of these other outcomes because it can create opportunities for us to advance two things at once.
And that within a quality improvement project, by slightly expanding the scope and thinking about, let’s also then think about how does this affect the team doing the work? And if we were not only going to create a better outcome for patients, but simultaneously make the work easier or better for the people doing it, we can often do two things at once.
Some people wonder, does that just happen naturally in a quality improvement project? And I would say, no, it does not. It can, but it is often by chance. If we aren’t very deliberately asking some of those questions, we might only get 10% of the benefit where we could get a much greater amount.
But that also brings the wellness improvement work into the quality improvement work, or the effort to expand access or to deliver more care. And so instead of being one more thing when all our leaders have limited bandwidth, we’re incorporating it into those other projects. I think that’s one important element. And I think it can also break the zero-sum-game thinking.
It goes without saying that these are challenging times in health care. You know, reimbursement, there’s pressure on reimbursement. We’re trying to cut costs as health care organizations, we’re trying to expand access and it’s tempting to say, I really wish I had the opportunity to work on some initiatives to improve well-being in the department or in the clinic or in the hospital. But because we have these other priorities right now, we just can’t.
And I think that – or even worse to say that there’s a mindset that advancing well-being would undermine our ability to simultaneously expand access or to advance quality. And that, again, is that zero-sum-game line of thinking. And to recognize that you probably won’t be able to effectively achieve your access goals if you aren’t also attending to thinking about the well-being of the workforce.
Because you might in the short term, but we have just robust evidence that turnover goes up, people cut back, and so thinking about these things together as a non-zero-sum-game problem is also really important for leaders because there’s just so much attention right now on some of these other priorities that rather than viewing well-being as antithetical to them, seeing that they interdigitate and need to be advanced together.
Dr. Heather Spies:
Yeah, I’ve seen that come so far, even just in a handful of years. Right. You know, from that MA calculator for the cost of burnout and how many physicians are going to turn over and what that’s going to cost in our organization. And the ROI, I remember, of course, learning those elevator speeches about that.
But now I feel like there’s – people are looking at that with an open mind and saying, yes, we definitely see the connection between reduced work hours or earlier retirement. I mean, that is going to affect the access to care that we have and the quality of care that we can provide.
And especially for us here in Sanford, in the middle of the country with our rural areas, it’s extremely important that we’re paying attention to taking care of our clinicians so that we continue to be able to provide care.
I’m going to connect it back a little bit to leadership. We talked about that at the beginning. You know, why does physician leadership development have such an outsized impact, do you think, on how we do with our engagement and the well-being of our clinicians? Because we’ve really invested in it at Sanford, and I feel like we’ve seen some good returns on it. So just would love to get your perspective on that.
Dr. Tait Shanafelt:
Yeah, it’s such a great question and I think it is in part because so much of the experience within a team is shaped by the leader and we have many studies that have found that the behavior of leaders is one of the strongest drivers of professional fulfillment. And I think there are multiple reasons.
We have sort of proposed this construct of wellness centered leadership that says that, well, there’s an element that is caring about people, always recognizing that they have different interests, different career aspirations they want to develop in different ways. And so recognizing that as the leader and sort of investing in the growth and development of the individual people reporting to, to you as a leader is important related to that theme.
But I think some of the sort of magnified effects are that leaders also have a lot of effect on how teams work together. Just is there a sense of connection within the team? Are people working together in a way that’s supporting one another? Does the team have a shared sense of vision? So even though each of us might have individual career aspirations and developmental goals, we’re also a part of a team that has a job to do, and the leader can often help that team have that shared sense of vision and then also help advance change in the areas where it’s possible.
And so some of these outgrowths of the listening sessions we were talking about, if we identify a way we’re scheduling, a way we’re cross-covering, a way the workflow is happening that makes it more burdensome, if the leader isn’t empowering the team to say, well, why don’t we explore a different way we could do it? And to, with the right guardrails, bring a team together to think about how we could try it differently and then pilot it and see if it worked. And iterate that those types of changes won’t go forward without the support of the leader.
And so I think there’s so many ways in which leaders help individuals feel seen and validated and developed. Help teams have a shared sense of purpose and support one another in very emotionally demanding work. And then also have this belief that they can have input. They can help identify better ways of doing things. And even though we can’t do everything, we will take that feedback, we’ll prioritize across the team what we want to, where we want to start, and then there’ll be a path for us to try to effect change.
And, you know, those characteristics are just so critical in whether individuals feel like they are working in a maybe imperfect environment, but one that is supportive and is receptive to feedback and is changing for the better incrementally over time. Or they’re just in that unit where things aren’t optimal and nothing’s ever going to change. And that experience, even though they might be starting in the same place, can be very different. And much of that is determined by that local work unit leader.
Dr. Heather Spies:
Yeah. We see that so much. Thank you for that. And I think that gives so many good ideas in there of how leaders can just sometimes pause and focus on what can I do to encourage my team, make sure they know I care? And then some real actionable things in there too that you mentioned. So thank you for all of those.
I could talk all day. There’s so many different things we need to start wrapping it up. So I’m going to just kind of go into the finale here. We’ve covered a lot of ground today from listening and action to leadership, culture, and well-being.
What I’d like to focus on, just to kind of leave our listeners today, is kind of what matters most looking ahead. So, if you could offer one piece of guidance to health care leaders to improve clinician well-being and organizational performance, what would you suggest?
Dr. Tait Shanafelt:
Yeah. I think change is possible. That would be the first thing. I mean, we have to believe that, or otherwise it’s just a problem we care about but are unable to solve. So I think that, you know, just have that sense of belief that we can do better. And so I think that’s the most important because nothing moves forward without that.
But you know, then if there were some simple add-ons, I would say, you know, use a system approach. We’ve been talking about some components of that, and what you’ve described and how you’re using listening sessions at Sanford and across Sanford is an example of that. So use a system approach, recognize those interconnections with the other priorities so that you can advance them together. Don’t take on that zero-sum-game thinking but recognize how they work together and then focus on what’s possible now.
And, you know, even though that might be some incremental wins, those do start to really add up and over time, and even beyond the incremental gains themselves, that spirit of, we are a team that is taking ideas and identifying those we can advance now and moving them forward. That sort of spirit is therapeutic, independent of what the specific thing we’re trying to improve is. And so, I think those would be some of the points of reflection for leaders who are in the midst of this work.
Dr. Heather Spies:
I love that. So well said. Every part of that is going to be so helpful to our listeners I think today. Thank you so much for being here with us today, Dr. Shanafelt, and I know people can dive in further if they’re interested in some of your work and your course and all the different things that are out there. Looking forward to continue to work alongside you in lots of different ways in the future. I agree. I think the future is bright and I think we have seen change and we’re going to continue to see change.
Thank you so much for being here.
Dr. Tait Shanafelt:
Thanks Dr. Spies, great to be with you.
Alan Helgeson:
Thank you for listening to “Reimagining Rural Health,” a conversation series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, or news.sanfordhealth.org
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