Taking on a high-stakes role such as medical director of clinical wellness at Washington Permanente Medical Group would have been a big challenge at any time. But when family physician Mary Pan, MD, took on the job in April 2020, she was faced with navigating the newly emergent COVID-19 pandemic in addition to the nation’s physician burnout crisis.
While Washington Permanente Medical Group had already been measuring engagement for many years, their first time using a validated tool to measure burnout—the AMA Mini Z burnout survey—came in 2021 during the pandemic. Washington Permanente Medical Group is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
“The pandemic brought these unique challenges of maintaining community and connection,” Dr. Pan said. “And we knew it was not only important to encourage and empower local action, but also to enact systemic changes and build community.
“Also, throughout the course of the pandemic, the movement to focus on organizational and systemic drivers—and the national movement of addressing burnout and moral injury—has become recognized as imperative,” she added. “For us, issues of staffing, scheduling and EHR frustrations continue to be prominent over the last few years, so addressing these at the system level really has been a top priority.”
From 2021 to 2022, the burnout rate fell nearly 6 percentage points at Washington Permanente Medical Group. By comparison, the national physician burnout rate rose 2 percentage points from 2020 to 2021, according to the latest research co-written by experts at the AMA.
“We acknowledge we have a lot to do, but we’re also really encouraged to see improvement in Mini-Z subscale scores and burnout rates,” Dr. Pan said. Washington Permanente Medical Group also added questions from the AMA Organizational Biopsy™ to its survey. “That gives us more depth to the results” and can reveal “progress in areas like culture, practice efficiency and retention.”
In an interview with the AMA, Dr. Pan discussed improvements in burnout and the need to approach every decision with a well-being lens.
AMA: To what do you attribute the improvement in burnout you’ve seen at Washington Permanente Medical Group?
Dr. Pan: It starts with our overall strategy to impact clinician well-being. We used the Stanford Professional Fulfillment model to address three areas of organizational culture, personal resilience and efficiency of practice. In the last year, the National Academy of Medicine also released their health care worker well-being essential elements for an organization, so we have used those recommendations as well—including advancing organizational commitment and strengthening leadership behaviors.
These best practice models drive strategy at the system level while providing support and empowering teams to enact change at the local level as well. This may include evaluating and adjusting policies and practices for enhancing workplace efficiency. We also are starting to look at how local teams can model after the scholars of wellness program and use a wellness lens with quality improvement and practice efficiency.
We believe in a holistic approach that prioritizes culture, community and systemic changes. Some specific examples: We focused on building out change agents—people within the organization to advance the work—across the system and developing a culture of well-being. That would be our Health & Wellness Advisory Group, which is four clinicians with training and expertise in clinician well-being. And they help develop and implement our initiatives and programs.
Then with our Mini Z action planning, we did a three-pronged approach—supporting individuals, teams and then our organizational response. Our Health & Wellness Advisory Group helps expand programs that support individual well-being. For example, we’re building out a peer-support program. Coaching was also something that we heard people wanted, so we developed a women’s leadership coaching pilot.
Our Health & Wellness Advisory Group also equipped local leaders to socialize their team’s Mini-Z results, allowing feedback on what makes the most difference in their day-to-day work and those pebbles and boulders, and consider what they have control over locally.
Then we also made a concerted effort for an organizational response. We didn’t want to say: It’s on the individual or the teams only. Three primary themes that were brought up in the Mini Z were around time, flexibility and community.
One of the things that we did for the community was the community wellness funds, which financially support wellness activities that create community. Some groups used funds for evidence-based commensality groups (similar to COMPASS groups.) But people got pretty creative and used it for all sorts of things that build community—team building retreats and social activities, outdoor picnics, group hikes—things like that.
And then: supporting clinicians. For example, we’re building out a peer-support program. Coaching was also something that we heard that people wanted, and I’m working on a women’s leadership coaching pilot. So again, focusing on culture and community, and then enacting concrete programs to benefit teams and individuals, while also laying the groundwork for systemic change.
AMA: Are there any specific trends or improvements that you’ve seen?
Dr. Pan: One of our primary care clinics had high burnout and low Mini Z scores last year, so we worked specifically with that group and a couple of the specialties that had the highest burnout as well. Facilitating a team-building retreat was one tactic the team employed, which contributed to improvement in retention and Mini Z scores this year.
But regarding the specialties, unfortunately many with the highest burnout in 2021 continued to have that trend. Part of the challenge, and something that we really haven’t solved for, is that it can be difficult to engage local action planning with groups that are already experiencing high burnout and low engagement.
The systemic changes that are needed can take time, and the last thing we want to do is burden those teams with more tasks. We want to hear from them what matters to them, but a lot of those teams and specialties—a lot of it is systemic interventions that we’re working on to try and benefit them.
AMA: What is the biggest challenge to further improvement?
Dr. Pan: One of the biggest is the fact that most interventions that can make the biggest difference are largely organizational, cultural transformation—even broad systemic health care issues—and can take time.
Over the last three years since I took this position, we’ve focused on getting leaders and stakeholders to understand that the issue is a systemic one. So now the biggest challenge is ensuring everyone understands that it’s not an either-or situation—it’s both.
We need to have an eye on the long-term changes that can make a difference as the national movement is really gaining momentum to support health care worker well-being. But at the same time, we need to be providing support to the individual and to the team, and building a culture and the systemic improvements that we can at the organizational level. That tends to be the biggest challenge.
AMA: In an article you wrote in January, you noted that to combat burnout, it is necessary to apply a wellness lens to every decision. How do you do that?
Dr. Pan: This is about embedding wellness throughout the organization so that every leader is thinking about how each of their decisions will affect the well-being of clinicians on staff. The health-and-wellness team can’t change the culture of well-being alone. It takes all of us.
My goal is to educate, inspire and empower our leaders to choose a wellness lens. That may mean connecting with our executive medical director of operations, or our chief medical informatics officer, about what policies and practices are being enacted and encourage a wellness lens to be applied.
Along with our senior medical director of Equity, Inclusion and Diversity, I now attend all the board meetings and provide regular reports to our board of directors with an eye toward how clinician well-being will impact the strategic imperatives of the organization.
And one method of breaking down silos and formalizing partnerships is our cultural transformation oversight group. That is made up of senior executive and operational leaders, practice leadership& development, communications, the chief financial officer and a board member. That gives them this opportunity to hear about why wellness matters and shed light on interdependencies in our work streams.
It’s laying that groundwork for each individual leader to think about how wellness impacts their decisions and their work streams.
AMA: What are some ways to establish an organization’s cultural transformation to support well-being?
Dr. Pan: When our cultural transformation group got started, we enacted a cultural advisory group that has individual contributors—what we used to call front-line clinicians and employees—from across the organization. And we elicit their feedback on major organizational changes, including our organizational response to our wellness surveys.
The thing is, when you ask clinicians what they need to provide the best care for their patients, they’ll tell us. And they often come up with the most innovative solutions. They want their voices to be heard and leaders to be responsive. That helps establish that cultural transformation that we’re looking for.
A big thing is the bidirectional communication. It’s critical to maintain transparency and communication around initiatives and progress. People want to feel heard, but they also want that feedback loop closed. That’s always something that we’ve focused on improving.
There’s also been movement with leadership behaviors here to lead with humility and authenticity. And that builds trust too.
AMA: How is the AMA helping you address physician burnout?
Dr. Pan: The AMA has been very supportive and responsive, mostly related to the Mini Z burnout survey. But also STEPS Forward® toolkits like scholars of wellness. We’re not adopting that entire program, but we’ve used it heavily to structure our local response with the wellness lens.
The AMA Joy in Medicine™ Health System Recognition Program framework has also been huge. We are actually using it across all Kaiser Permanente regions as a scaffolding to say this is what we need to do to move this work forward. That’s been very helpful.
