Leadership

Professional Fulfillment: Where We Want to Be

Interview · November 7, 2017

Jessica Dudley and Namita Mohta head shots

Namita Seth Mohta, MD, interviews Jessica Dudley, MD, Chief Medical Officer for Brigham and Women’s Physicians Organization.

 

Namita Seth Mohta:  This is Namita Seth Mohta for NEJM Catalyst. I’m speaking today with Dr. Jessica Dudley, Chief Medical Officer for the Brigham and Women’s Physicians Organization, and Vice President for Care Redesign at Brigham and Women’s HealthCare. Dr. Dudley has deep expertise and extensive experience leading teams to improve patient outcomes while also addressing the needs of providers.

Today we will be discussing the creative and innovative work Jessica is leading at the Brigham to realize three critically important objectives: addressing burnout, fostering innovation, and training physician leaders. Let’s start, Jessica, with these three goals. How are they interdependent? Can we realize one without the others?

Jessica Dudley:  First, thank you for having me. I’m excited to be participating in your program. To answer your question, I would say they are intricately interrelated. To be precise, yes, you could have one without the others, but in order to have what I think is the complete package we really need to have all three of them. The overarching umbrella under which all of the three fit is engaging physicians in leading the changes that we need in health care, and that’s how they all fit together for me.

If we rely on our physicians to be those closest to the patients, to understand where the opportunities are, to identify where we can improve outcomes, and also to try to help manage the challenges in rising costs in this country, ensuring that we are training our leaders, fostering innovation, and addressing challenges that they’re facing — one of which right now is burnout — these are critical for us to achieve these goals.

Mohta:  When you talk about engaging physicians as the overarching theme and these three subgoals, if you will, being the tactics to realize that, what are some of the activities that you’re leading at the Brigham to support these?

Dudley:  A number of years ago, we recognized that while we have incredibly talented physicians as clinicians, researchers, and professors and teachers, they were not receiving as robust skill training in leadership as the changing health care landscape was demanding, and it was a real opportunity for us to think about how could we better equip our physicians with the leadership skills that are being demanded by the rapidly changing environment. That has led us to make some pretty significant investments in identifying what skills our physicians need to develop their leadership, and then how to provide them with the opportunities to develop those skills.

We have developed, over the years, a number of what I would call formal leadership training programs, where we have docs who are interested in developing their leadership, or their department chairs are interested in having them develop as leaders, and they will apply for and in some cases be accepted (and others not) for a leadership development program. We have developed one that we’ve been running now for 10 years with Harvard Business School that we call our Brigham Leadership Program. That’s a general overarching leadership program. Then we have a number of additional programs, one for process improvement leadership, one for women’s leadership. We even have a faculty mentoring leadership program, and then some additional, very targeted programs to develop specific skills like organizational change management.

We offer these formal training programs. Many of them are longitudinal, occurring over an extended period of time; a number of them involve a real hands-on project to advance the learning; and all of them have a component of a peer-engagement effort that ends up being of high value to them as they advance in their careers. So that’s a formal set of training programs that we have made investments in and offered.

In addition to those, we have what we call our Frontline Innovation Program. This was in response to recognizing that we had many physicians who had brilliant ideas on where we could redesign or innovate the clinical care we were delivering, but they were not able to frame them in a way that our administrators could embrace or access to then determine whether or not they were worthy of making a real investment.

So we put a framework and a structure in place so that we can solicit ideas from our physicians — they are on the frontlines identifying where the opportunities are to make care better and improve efficiency — and then put them in a framework so that they can be managed more efficiently over time, and so that we can also require their reporting of a return on investment, and then measure their impact and determine whether or not to sustain them over time. We call that program BCRISP, which is our Brigham Care Redesign Incubator and Startup Program, and we’ve been running that now for over 5 years.

Those are two different programs that we’ve put in place to put a framework around developing physicians as leaders and enabling them to help our institutional and physician organization leadership better identify those opportunities that could be ultimately integrated into operations, and we can leverage the expertise of our jobs to better transform how we’re delivering care overall.

Mohta:  Jessica, the BCRISP program sounds fantastic and makes conceptual sense. Can you share an example of one of the earlier projects where the doc went through this process and then ultimately there was an idea that demonstrated enough of an ROI that then was integrated into operations?

Dudley:  Sure. We had a couple of our intensivists in our medical Intensive Care Unit recognizing that there were a cohort of chronically critically ill patients who would get cared for very actively in our Intensive Care Unit, and then ultimately would be discharged to a longer-term acute care facility, never actually being discharged to home, and then that same cohort was getting readmitted at quite a high rate. They took a step back to try think about what could they do to better support the care for these patients, and that was a BCRISP that was submitted, addressing the needs of this chronically critically ill cohort of patients, and their solution was to engage a much more robust team around the support of these patients that included a social worker, that included palliative care and goals of care discussions and resources, and then a much tighter relationship, much of which was virtual using technology, with the long-term acute care facility, so that when patients were discharged the receiving facility would know that there was a backup available at our hospital, so that if the patient started having challenges or was not doing as well as anticipated, they could easily reach out to a team here that knew the patient on a 24/7 type basis.

It enabled that facility to be willing to accept those patients even earlier than they might have otherwise, knowing that this backup and this connectivity was there. It was certainly better for the patients and their families, who felt like they were being now managed in a much more cohesive way than previously, and then there was also value to the institution where patients could be cared for at the best and most appropriate site of care given the needs that they had at the time.

That’s an example of one of these programs that brought together resources from our institution and resources from an outside institution to package care better around a patient population that the system was previously failing.

We have other examples where the team recognized that there was another cohort of patients who again were falling through the cracks. These were patients who had abnormalities found on a chest X-ray or early on in an exam, and then they were getting lost to follow-up, and we recognized that these patients needed more close minding and much more rapid access to be evaluated for these findings.

Our pulmonary surgeons, our thoracic surgeons, our pulmonologists helped put together a specific program to better support these patients who had an early detection of a finding to ensure that they wouldn’t be lost to follow-up and that they could get shepherded through the process in a much more efficient fashion.

Mohta:  Taking it back up a level to these initiatives overall, some of the training leadership programs that you talked about, the BCRISP-specific program, what has been the impact to date in terms of any objective or subjective data that you’ve collected? I know I can speak for myself from a subjective standpoint as someone who’s an alum of the ELP program that it was quite influential, and it really has given me a skill set and a network that I’ve leveraged heavily over the years. But I would be interested, as I’m sure our listeners would, about some of the metrics that you tracked to demonstrate the impact.

Dudley:  I wish that I had more current metrics on this. When we developed the program, we knew that the goal of the program was to do two things: develop our leaders and ideally have them develop and help advance work within our own institutions. But similarly, we had an objective that we would be developing leaders and enabling them to advance. And that would mean leading the institution and then moving to a higher-level position outside of the institution.

I don’t have current data on that. Initially, we were successful in both of those. We were successful in growing our leaders internally — folks who were taking the course were then advancing locally within our institutions. And then we had quite a large cohort of leaders who were evolving, moving out onto more senior roles outside of the institutions. I have not tracked that more recently, so I don’t have that data.

Mohta:  It sounds like there is enough momentum now around these programs, as evidenced by the number of applications that you get exceeding the number of docs you have, to suggest that it is definitely filling a need of the Brigham health care providers.

You also mentioned burnout earlier. We’ve talked about training physician leaders, we’ve talked about fostering innovation, and then the other area that you mentioned that’s set into this overall theme of engaging physicians is around addressing burnout. Is your organization specifically addressing burnout, which we know is a very pervasive issue, or is it bundled into the fostering innovation piece and the training piece that you’ve mentioned?

Dudley:  It’s actually an independent effort. It’s something that we came to independent of those other two programs that we were just talking through. It’s not unique to the Brigham. Physician burnout has become a very popular topic nationally, and in some cases globally, for a variety of reasons, but certainly at the national level there’s been a rise even over the past few years, with one of the largest studies showing up to 54% of physicians reporting burnout. So we knew this wasn’t a problem just for our own institution, it was something that has been [known] nationally.

I will say, locally here, after transitioning to a new electronic medical record and having some other more locally-based, state-based environment challenges with increased pressure on our physicians and our institutions as we shift into alternative types of care payment models, there certainly seem to be a rise in folks, a sense that our physicians are experiencing burnout — and that ultimately led us to complete a survey.

We selected a survey that Stanford had designed, not because it just measures burnout but because it measures both burnout and professional fulfillments, and we were very focused not just on identifying that our docs were burned out — we know that’s a national problem — we were looking for solutions to get us to where we want to be, which is professional fulfillment. And the survey they had designed enabled us to look at both burnout as well as professional fulfillment and not just quantify it but give us a little bit of a magnifying glass as to where to focus.

We surveyed our docs earlier this year. We had a terrific response rate, and that was largely driven by our hospital and physician leadership making it clear that this is a priority and something that they wanted to support. We had a 64% response rate on our survey — this is more than double what our normal survey response rate is — and we have begun looking at the data at an institution-wide level. We know that our burnout rate is around where we had expected. It’s lower than the national average that I cited for you; although our tool is different than the one used in the national survey, it’s validated against that survey. And then our professional fulfillment rates were not as high as we would like them to be. So we have opportunity both in reducing burnout and in improving professional fulfillment.

Mohta:  And I have no doubt that you all will be aggressive in making sure to address those concerns.

When you look back at the beginning years of these leadership programs, when you look back at the beginning years of the innovation programs, BCRISP for example, what were some of the biggest barriers to implementing these programs, and how did you overcome them? The reason I ask this is to help some organizations across the country and internationally who are interested in doing this anticipate some of the challenges as they grow their own innovation platforms and their own leadership platforms within their organizations.

Dudley:  It’s a great question. We’re a bigger institution, so in some instances we have the luxury of having a bigger platform with probably initially larger amounts of resources. I do think a lot of the efforts that we’re putting in place can be done even in smaller institutions.

Part of the way I would think about prioritizing it would be first being very intentional about it. Intentionally acknowledging that some type of formal training is helpful, and that can certainly be done locally. Tapping into resources that are available — we connect with others even in our local market who have experience with what people call adult learning or executive learning, — leveraging the skills to better communicate to adult learners, using group-based methods, case-based methods. These have all helped us to help transfer skill knowledge to our participants. Being intentional about designing programs where folks can access the learning in efficient ways is really important.

All of our programs end up having a peer-cohorting component to them. I think that’s really helpful, and I’ll say now that we’ve been so focused on addressing the burnout and professional fulfillment issues, the role and importance of peer groups and peer programming I think is even that much more important. I would be designing a program that also focused on making sure there was a peer component to it. That’s important for the formal training programs.

Tapping into resources: I don’t think everybody needs to reinvent this. There are a couple core components that are helpful to have in a leadership development program, and those are ones that you would want to include.

For the innovation program, doing something like that probably does require a little bit of resource upfront. It doesn’t have to be a large amount, but if the institution or the group of docs collectively are willing to pool some resources and then create more of a competition for applying and then being selected to receive those resources and being held accountable to delivering on it, that’s also really important.

We also do resource that program with some infrastructure, so a little bit of infrastructure like a project manager or data analyst can help hold people accountable and get the work moving forward. That that’s been very important for our frontline innovation program.

In the burnout area, I do think a survey is critical to opening up the dialogue and raising awareness, and I think that that’s the first step in this. We used a very robust survey — I don’t think you have to. There are now many different survey options out there. But picking a tool, having leadership commit to advancing it, getting folks to answer it, and then being willing to sit down and review the data and engage in discussion is pretty critical.

Those would be the components that I would suggest for advancing the work, even in a much lower-scale way than we’ve had the fortune of being able to do at our institution.

Mohta:  Jessica, thank you so much for taking the time to speak with NEJM Catalyst today. We appreciate it. Thank you.

Dudley:  Sure, my pleasure. Take care.

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