A Challenge Accepted
Physician burnout and disengagement has become a well-documented issue. According to Medscape, 42% of physicians suffered from burnout in 2017, up from 40% in 2013. At Cleveland Clinic, the 2014 burnout rate among physicians was approximately 35%. Our 2015 Press Ganey survey data showed that physician and scientist engagement was only slightly higher than the national average, confirming that this challenge had not escaped us. The well-being index of our 2015 Press Ganey survey also lagged behind all other indices for our system.
In response, the Cleveland Clinic’s Office of Professional Staff Affairs empowered a team of dedicated physicians to lead an effort to reinvigorate our culture. This group embarked on a town hall listening tour in 2016 to more clearly identify roadblocks to physician and scientist engagement and factors that contribute to burnout. After assembling the data from this listening tour into themes, we learned that communication topped the list of factors (20%), followed by technology (17%), workplace culture (16%), stress (16%), and staffing (16%).
The group of physicians who stepped up to listen in 2016 formally came together under the Office of Professional Staff Affairs. After undergoing several name changes, this group was organized as the Practice Innovation and Professional Fulfillment Office (PIPF). Supported by the Chief of Staff’s Office, the core team includes four physicians, two contract staff members, and two program managers. Matrixed relationships and a variety of partnerships throughout the enterprise are vital to the success of the Practice Innovation and Professional Fulfillment Office, which comprehensively supports our professional staff (physicians, researchers, and trainees), explores practice efficiencies, and fosters a community that reflects our unique group practice culture.
The goals of Practice Innovation and Professional Fulfillment Office are to remove barriers to practice efficacy, drive cultural change, and reconnect staff to their passion for practice. To address the feedback received during our 2016 listening tour, we identified existing programs and facilitated the development of new initiatives to address the three components of professional fulfillment: culture, efficacy of practice, and personal well-being. In order to provide a framework for identifying values, goals, and motivations and to develop plans for change, we adopted a Cleveland Clinic Coach Approach philosophy to facilitate interactions with members of the professional staff, leaders, work units, and interdisciplinary teams.
The Cleveland Clinic Coach Approach
The Cleveland Clinic Center for Excellence in Coaching and Mentoring was formed nearly a decade ago by two future members of the Practice Innovation and Professional Fulfillment team to address a desire among the staff for guidance in navigating professional challenges and opportunities. Since its inception, this Center has focused its efforts on providing instruction and experience and building a network of coaches and mentors. In addition to addressing communication and stress — important themes from the 2016 town hall meetings — the Center has produced unanticipated benefits such as improved engagement and retention. The Center for Excellence in Coaching and Mentoring is an integral partner of the Practice Innovation and Professional Fulfillment Office.
To date, the Center has enrolled >1000 physicians and scientists in a full-day, CME-accredited, coaching and mentoring orientation course in which the participants are immersed in the Cleveland Clinic Coach Approach philosophy of using active listening and question generation to help their peers gain new insights. Once staff have participated in this overview session, they may elect to serve as peer coaches, mentors, and/or coachees in the Staff Coaching and Mentoring Program.
The peer-based coach-and-coachee dyad works toward strengthening professional, patient, and personal relationships as well as improving engagement, resilience, satisfaction, retention, and academic output. The Center also provides advanced training for peer coaches who want to enhance their skills. Currently, 45 advanced peer coaches work with >70 coachees. In a recent program survey, 25% of coachees and 22% of coaches reported that participation in the program has positively impacted their decision to stay at the Cleveland Clinic. All participants reported significant increases in engagement and resilience.
Much of the success of the Practice Innovation and Professional Fulfillment Office comes from our large cohort of engaged volunteer members of the professional staff, including a strong group of trained peer coach mentors who provide leadership for many enterprise-wide programmatic efforts.
Support for Local Ideas and Solutions
Our 2016 listening tour indicated that communication is a challenge for our staff, and the Practice Innovation and Professional Fulfillment Office responded with personal consultations for leaders, local town halls, a presence at staff meetings, and an open-door policy. The Cleveland Clinic Coach Approach philosophy is employed in all these interactions. In addition, the Press Ganey Engagement Survey provides an opportunity not only to measure progress, but also to engage our leaders in a dialogue on how to interpret the data and continue to develop interventions to enhance our culture and increase engagement.
The Practice Innovation and Professional Fulfillment Office offers all our institute and department staff leaders an opportunity to participate in a data consulting session, which utilizes a coaching framework to jointly create actionable strategies that can be managed and implemented at a local level. The Practice Innovation and Professional Fulfillment Office also remains available to conduct town halls and retreats, connect staff to resources, and manage or support the build-out of professional fulfillment programming locally.
Since the fall of 2017, the Practice Innovation and Professional Fulfillment Office has conducted >80 consultation sessions with leaders in nearly every institute and has helped to support >25 instances of local solution development assistance across the entire spectrum of professional fulfillment (i.e., culture, efficacy of practice, and personal well-being). Michael Rabovsky, MD, Department Chair of Family Medicine, emphasized that “PIPF provided invaluable insight in reviewing and assessing the Press Ganey Caregiver Survey for my department. Their subsequent town hall meeting with the department and summary recommendations became my blueprint for efforts to improve caregiver experience and advocate for change. We are so fortunate to have their expertise and enterprise support for their work.”
There has been an overwhelmingly positive response to the original 2016 town halls and the ongoing effort to engage and provide support, and, as a result, empowering staff to identify and implement solutions locally has become a major focus of our programming. By framing the conversation with our staff around finding solutions, we have been able to capitalize on the insights and problem-solving skills of our clinicians and create successful practice innovations.
In the spring of 2017, Andre Machado, MD, Chair of the Neurological Institute, requested a partnership between the Practice Innovation and Professional Fulfillment Office and an Institute Champion. Working with the Institute Champion (renamed the Institute Engagement Chair) has resulted in the development of a civility training curriculum customized to the institute, a local women’s leadership development program, and a regular column on the topic of resilience in the institute newsletter. Amy Sullivan, PsyD, ABPP, Cleveland Clinic Neurological Institute Engagement Chair, noted that “My relationship with PIPF has been vital in the development of the engagement and well-being efforts that I am leading within my institute. Without PIPF and the knowledge that I have gained from other engagement chairs via my relationship with PIPF, my program would not be successful.”
By touting the success of this partnership, Champions or Teams have been added at another seven institutes, and the number continues to grow. The Practice Innovation and Professional Fulfillment Office provides a project management framework and expert consultation to these local Champions and Teams, resulting in a series of projects that tackle the biggest pain points in each area. Local projects touch every component of professional fulfillment, including culture (through projects such as local social events and a kickball league), well-being (through projects such as the development of an online physician portal with resilience and related support resources), and efficacy of practice (through projects focusing on practice standardization across multiple sites, redefinition of support roles, and cross-coverage).
Making the Hard Work of Clinicians a Little Easier
Improving the efficacy of practice is essential to achieving professional fulfillment and is dependent on our ability to optimize systems. Technology and staffing were both identified as major themes in our listening tours, and efficacy-of-practice efforts target both of these areas. Team-based care has been implemented in several practice settings and is viewed as a vital component in high-value care systems. For example, pharmacists, nurses, medical assistants, and administrative assistants now participate in managing clinician messages such as refill requests and prior authorizations. Initiatives for more efficient documentation include wider use of voice recognition software and medical scribes. Optimization of components of the electronic health record is ongoing.
Changing Culture Through the Annual Professional Review Process
Culture is a key component of professional fulfillment and was identified as a major theme by 16% of the staff in 2016. The Annual Professional Review (APR) has been a part of the Cleveland Clinic culture since 1955, when it was instituted to provide a framework for leadership and individual staff members to reexamine mutual values and goals. It also ensures that our Board of Governors, which is made of up members of the professional staff who are elected to 5-year terms, has a voice in renewing all staff appointments. The APR represents an opportunity for members of the professional staff to provide feedback on leadership, as well. Over time, however, the focus of the APRs had drifted, with staff perceiving diminishing attention to personal and professional development.
In 2016, the Practice Innovation and Professional Fulfillment Office was instrumental in the formation and leadership of the APR subcommittee of the Board of Governors to promote a physician leadership culture that values agency and efficacy. The subcommittee updated the APR to reflect the value that Cleveland Clinic places on the professional growth of each of our doctors and scientists in addition to performance metrics. In the first year of implementation, 78% of staff rated the new APR process as good/excellent. The subcommittee continues to convene around continuous improvement for the APR.
To accompany the changes to our APR, the Practice Innovation and Professional Fulfillment Office developed two educational opportunities: Coach Approach to the APR (for physician leaders) and Getting the Most Out of Your APR (for staff). The Coach Approach to the APR course utilizes the core principles of the Center for Excellence in Coaching and Mentoring to prepare our physician leaders to use an appreciative question-based approach to discuss professional development and performance during the APR. Participants take part in a full-day training session that provides an overview of coaching and mentoring principles and devotes several hours to facilitated skills practice and reflection.
Launched in mid-2017, the course has received enthusiastic endorsement from our leaders, with 94% of participants ranking the course as excellent. As noted by Steven M. Gordon, MD, Chair of the Department of Infectious Disease, “Coach Approach to the APR provided a thoughtful and engaging learning environment to gain new skill sets in coaching as a mindset to enhance the APR process for all staff. Our organization knows its greatest asset is our people, and this course expands my toolbox to help me help my team not only at APR time, but throughout the year.”
The companion course, Getting the Most Out of Your APR, is offered twice a quarter. This 1.5-hour course educates doctors and scientists on the new APR process, sets expectations, and provides an opportunity to ask questions of a panel of leaders with extensive experience in conducting APRs. Getting the Most out of Your APR, like its companion course, provides an opportunity to practice. Participants learn how to talk about individual professional goals within the context of broader organizational goals and practice having difficult conversations. Participants rated the value of the course at 4.84 on a 5-point scale. Melanie Chellman-Jeffers, MD, observed, “I have been participating in APRs for 14 years without anybody ever really explaining how I can make them positive and beneficial for me. It really helped to see the chairman’s side of things. Most of all, I learned to focus my discussion to a few key points and work to have presentable solutions to issues I bring up. I learned to take charge of the discussion for best results.”
Time to Stay Well
The creation of a Well-Being Day for all staff was another effort to shift the Cleveland Clinic culture. Starting in 2017, each professional staff member was granted a Well-Being Day, to be used for any well-being-related purpose — from getting a physical to rejuvenating mental health by spending time with kids, going hiking with the dog, or spending a day at the spa with friends. Granting explicit permission to take care of oneself sends a clear message that well-being is a Cleveland Clinic priority. The program had a participation rate of 32% in its first year.
In an anonymous survey in early 2018, staff members were asked how they utilized their Well-Being Day. The responses were grouped into the following categories:
- Spent time with kids/significant other
- Health care visit
- Medical procedure
- Wedding planning
- Time in nature
- Wellness activities, such as yoga or massage
- Spiritual retreat
- Mission work
Results and Future Direction
Our 2017 Press Ganey engagement survey data demonstrated a statistically significant positive movement in every one of our metrics, including engagement, continuous improvement, well-being, trust, effective communication, and high reliability. In the present article, we have highlighted a few key initiatives that we have instituted to address the feedback that we received during our 2016 listening tour. These initiatives have had a positive impact on all three components of professional fulfillment, and we believe that they could have a similar impact at other institutions.
The full portfolio of activities sponsored by the Practice Innovation and Professional Fulfillment Office includes many more programs, as summarized in the table above. Some of these programs are in pilot phases, others are staples in most large academic medical institutions, and yet others would require a full article to demonstrate their value. Approaching the development of solutions holistically has given us the opportunity to be innovative, test ideas, and support programming that benefits subsets of the 5,000+ professional staff members whom we serve. We know that our work is far from complete. We are committed to an ongoing and dynamic approach to preserving the joy in medicine that focuses on empowering our staff, removing barriers to efficacy, and strengthening the group practice culture that is the heart of Cleveland Clinic.
Acknowledgements: The authors would like to acknowledge other key members of our PIPF team: Steven Schmitt, MD; Elaine Schulte MD, MPH; Rich Frankel, PhD; and Amy Merlino, MD. This work was made possible by the leadership and support of Chief of Staff Herbert Wiedemann, MD; Associate Chief of Staff Bradford Borden, MD; Chief of Staff, Cleveland Clinic London, Brian Donley, MD; and former Executive Director of the Office of Professional Staff Affairs, Michael Michetti, JD.