Creating work spaces that foster resiliency and wellbeing is critical to building and retaining a strong, compassionate workforce. The fourth season of the STAR² Center Talks Workforce Success podcast focuses on the ways organizations support their employees and empower them to address and prevent the challenges of compassion fatigue and burnout. In this episode, ACU’s Helen Rhea Vernier interviews Dr. Matthew Malek, Medical Director of Provider Experience at Thundermist Health Center in Woonsocket, Rhode Island, about data driven approaches to assessing and supporting employee wellness and actionable strategies for securing leadership support for resiliency and wellness efforts.

Transcript by Amberscript

Helen Rhea Vernier: Welcome to the next episode of the fourth season of the STAR² Center Talks Workforce Success podcast series. I’m your host, Helen Rhea Vernier, training specialist at Association of Clinicians for the Undeserved, or ACU. This season we are focusing on the ways organizations support their employees and empower them to address and prevent the challenges of compassion fatigue and burnout. Creating workspaces that foster resiliency and wellbeing is critical to building and retaining a strong, compassionate workforce, and we’re going to hear about a variety of approaches to doing that. Today, I’m speaking with Dr. Matthew Malek, Medical Director of Provider Experience at Thundermist Health Center in Woonsocket, Rhode Island. Thank you so much for being here.

Dr. Matthew Malek: Thank you for having me. Happy to be here.

Helen Rhea Vernier: Could you introduce yourself and tell us a little more about yourself, your role and your organization?

Dr. Matthew Malek: Gladly. My name’s Dr. Matt Malek, a family medicine physician, and here at Thundermist, I’m the Medical Director Provider Wellness. Thundermist is a federally qualified health center in Rhode Island. We serve approximately 40,000 patients, so we’re moderate to large in size. We have three primary sites and some smaller satellite sites across urban Rhode Island. As a federally qualified health center we provide a variety of services, including primary care, but also dental care, as well as traditional, integrated behavioral health care. Then we have other specialty programming in substance use disorder treatment, gender-affirming care, as well as size inclusive healthcare.

Dr. Matthew Malek: As a federally qualified health center, our population is primarily urban, underserved, low-income individuals from across the state of Rhode Island. That’s Thundermist and then my role at Thundermist, again I’m the Medical Director of Provider Wellness. I have a really fine job of being the leader for organizational change that fosters clinician wellness, and so it’s everything from strategic planning around wellness to leading implementation of wellness surrounding efforts. We’ll talk all about those things today.

Helen Rhea Vernier: Thank you so much. What workforce challenges are you seeing when it comes to burnout, compassion fatigue or a general struggle to maintain wellness at your organization?

Dr. Matthew Malek: What challenges are we seeing? That is a really important question and I would say that the only way you know is by looking at the data. I’m really happy and proud to say that we’re very data first organization and particularly in our approach to provide wellness and so to answer this question, I look at the data a little bit. We do an annual wellness survey of our provider group, which we co administer along with the American Medical Association, and it involves a burnout instrument, the Mini Z, as well as questions about community teamwork and efficiency of practice, and it lets us target our intervention but also know where we need to intervene. What are the workforce challenges that we see? The first one, and I would say the biggest challenge, is that burn out and compassion fatigue are already really common and so largely we’re not even talking about burnout or compassion fatigue prevention. We’re talking about treatment or remediation, which is more difficult and requires a different set of objectives and approaches.

Dr. Matthew Malek: Much like everywhere else, we have pretty high levels of burnout and compassion fatigue at Thundermist, similar to other primary care practices across the country when you look at the data. Now, when we think about the challenges there, the good news is when we follow our data and the data comes first, we’re able to drill down on why that is. Knowing that overall X percent of our provider workforce has burnout is useful to know but doesn’t tell us where we can intervene. One example of what we’ve done is drill down to which provider group is that? Where is it? Let us drill down to knowing the hotbed of burnout, if you will, the place most in need of help, is this one site among the nurse practitioner group at that site and particularly among people earlier in practice.

Dr. Matthew Malek: By going from an overall health center view of how burnout happens to like this one, smaller group really is affected we are able to tailor interventions in terms of building out a mentoring program for that smaller group to address that. The absolute prevalence of it is definitely one of the big challenges, and having data on following the data to drill down on where those problems come from is really useful. There are others which I’m happy to tell you about.

Helen Rhea Vernier: Please do.

Dr. Matthew Malek: The other challenges that we see in the data, two of them I think, are worth mention, one of them, and this will come as no surprise to any of the listeners and probably not to you either, Helen, is community. The challenge of maintaining community and what happens when community is weakened. Anyone who’s lived through the last two and a half years has felt and knows the strain of pandemic life on relationships and togetherness and community. One notable chain that we’ve seen year over year is a degradation in the sense of belonging or togetherness among our medical staff. We’re working to address that this year, having seen that trend over the pandemic, but that’s definitely one challenge, maintaining community in the era of remote meetings, physical distancing, and masking.

Dr. Matthew Malek: Another challenge that we saw early in the data and this is not unique to Thundermist, I am sure, but one challenge we saw early in the data that was a primary contributor to burn out for us was time spent outside of work, or work-related tasks. In the literature, that work-life interference is the primary generator of burnout. When our work is spilling into our home work and when we first did our wellness surveys, it was glaringly clear that everyone, particular, more burned-out clinicians, were spending gobs of time, exorbitant amounts of time outside of their clinical time, their work time doing work and having that work-life interference.

Dr. Matthew Malek: That challenge is identified, that one we’ve been working on in a variety of ways. The most exciting and largest impact way has been medical scribes. I’m happy I talked more about that as we talk throughout this podcast, but again it was following the data. The data said, yes, we have burnout and here are some of the primary drivers, community, time outside of work, certain subsets of the population that are struggling in particular, and so following that data has let us really drill down on our challenges.

Helen Rhea Vernier: Thank you so much. That’s all excellent. At the STAR² Center, we all also love data and we’re all constantly quoting W. Edwards Deming, who famously said, “Without data you’re just another person with an opinion”. It’s so good to hear that your wellness and wellbeing activities are driven by data. That’s really cool.

Helen Rhea Vernier: It’s driven by data. It’s nice too. Data allows you to see positive outcomes as well. Often, if you rely on anecdote or just another story, you only hear the negatives, and so thinking about that, like one place we see routinely being a real bright spot in our data is that our values alignment between clinical leaders and clinical staff is uniquely high compared to other places that measure it. It’s nice to see. Oh yes, this feels like there’s good value as aliment within the organization and to see that and the data is rewarding.

Helen Rhea Vernier: Oh yes, absolutely, I love that perspective. Can I ask how long you’ve been doing this annual survey?

Dr. Matthew Malek: This will only be our third year so a little while, but not as long as we want. Each year, year over year, data is helpful for us.

Helen Rhea Vernier: Oh, that’s wonderful. Thank you for sharing. All right, so what role do you believe organizations and their leadership play in supporting the wellbeing of staff?

Dr. Matthew Malek: Well, for this one I might use an analogy when I think about what role the organization and leadership play in terms of supporting wellbeing of staff. The analogy that I use when I orient our staff to our wellness efforts is the analogy of a garden. In healthcare, our staff are our seeds or our plants, the organizations are the garden and then our leaders are the gardeners. It follows from there that you can have really resilient seeds, you can have seeds that do yoga and meditate and have the most wonderful mindfulness practices around, but if you drop those seeds on concrete and don’t give them water, they will not flourish. To the contrary, if you give them an environment that’s fertile and ready for growth and supportive, they will flourish. That is just what it’s like in every work environment, but particularly in healthcare. Our staff are our seeds and they will flourish if you build an organization that’s a garden that’s designed for growth.

Dr. Matthew Malek: What role do the leaders play? Well, they’re the gardeners, they make the decisions, make the determinations that decide whether or not that’s the place that people can flourish. They play a huge role. It’s particularly in burnout, driven by that sort of organizational structure that primarily affects how well staff are. The data show this. If you look at data on interventions, in particular for wellness promotion or burnout reduction, interventions focused on personal improvement or personal resiliency, have a benefit, effect size many of them, but it’s relatively small, whereas if you look at the interventions more on organizational changes for burnout, the effect size tend to be larger in terms of the number and extent to which peoples’ burnout and wellness are affected. We take the approach that organizations really get what you grow, you get what you’re designed to produce and our leaders are responsible for making that place a fertile environment.

Helen Rhea Vernier: I love that analogy, both as a staff person, not of health center, but as an organization, and also as a gardener myself. When we were setting this interview up, you mentioned your organization has a three-pronged approach of systematically improving clinical leadership, efficiency of practice, and community. Can you tell us more about this approach?

Dr. Matthew Malek: I can tell you lots about that approach. It’s what I live and breathe and do every day. We’re Thundermist, and so we make thunder themed things. This is our thunder plan for provider wellness, and I’d like to do lightning and thunder sounds afterwards. We got a thunder plan for providing wellness really takes the effect of it, and our thunder plan comes out of institutional planning. It’s important to plan as an institution if you want to get at a certain result. Our thunder plan is those things you mentioned, clinical leadership, efficiency of practice, and community, and I can talk a lot about all of them, but let me start with clinical leadership.

Dr. Matthew Malek: Why clinical leadership? I like the old HR saying that you don’t leave your job, you leave your boss, and that is true in clinical practice as well. The contrary is also true. There’s nice data from the Mayo Clinic that shows that the more mentoring and supportive supervisory task that a clinical leader does to their clinical staff, the less likely the staff is to be burned-out and the more likely they are to be satisfied with their job. It’s a kind of research that tells us something we already knew, and so clinical leadership for us particularly has focused on clinical leadership for our medical providers that are new to practice, coming out of training or coming out of early career.

Dr. Matthew Malek: Coming out of training in particular, I should say you go from a really supportive environment to one where often there’s just nothing and you’re left to practicing independently without any structured support, and so that came through in our data, particularly from some of our more burned-out providers. Sense of just falling off a cliff after training, where there is nothing structured to support you, and so our clinical leadership has focused on hiring the additional clinical leaders needed to do mentorship for our new providers and then building out structure, protected, paid time for mentoring activities between new graduates and our clinical leaders.

Dr. Matthew Malek: That’s what clinical leadership means and where our focus has been on that domain. Efficiency of practice is everything that we do every day. Efficiency of practice refers to the idea that a 40-hour job should fit into a 40-hour week and that when there’s work-life imbalance and your work spills into your life, everybody is miserable and burnt-out and makes that garden very infertile. What do we do there? We do some things that are just best practice, which I imagine many listeners here do and/or really want at their organization. We work on that crushing administrative burden and administrative tasks that can be done by non-clinician and having someone do those. Things like prior authorizations, medication refills, routine forms and building out the organizational structures to help those be done by someone else that’s not the clinician do that quite well.

Dr. Matthew Malek: The other one that everybody focuses on is making your electronic health record amazing. Everybody wants an electronic health record that doesn’t burn out their clinical staff. Pretty sure none exist that don’t burn out their clinical staff, and so we can’t make it perfect, but we can at least take away some of the really silly things. We do work on EMR optimization. Then the two big things we do that are unique and I think worth mentioning, the first one is a real-time suck that can be a big driver of inefficiency of practice and that one is covering for your colleagues when your colleagues are out on vacation.

Dr. Matthew Malek: When I go out on vacation we give our providers a delightful amount of vacation, when you go out on vacation someone’s going to do the work there. The patients are still there, the phone calls are still coming, the form you’re still coming, the results are still coming and someone has to do that clinical administrative work. Historically and at most practices it’s the colleague, it’s the person sitting next to you, it’s the person on your team that picks up that one, sometimes two hours a day of extra work, while your colleagues on vacation goes to say that doing that for six weeks of vacation a year will burn you up pretty quick. When you’re working in extra 10 hours, those weeks to cover for your colleague, and I’ll make you resent your colleague and when you go on vacation, you’ll feel guilty because you’re dumping on your colleague.

Dr. Matthew Malek: Vacation coverage can be quite a generator of extra work and inefficiency of practice. What we’ve done is develop a dedicated cross coverage team, and our cross-coverage team is now to the size of five nurse practitioners employed explicitly for covering medical providers when they’re out in vacation. Instead of having that be something that they just need to do on top of their regular job, it is their regular job and so they have time built into their schedules to do coverage for people who are at the office. What that means is that people who are in the office are doing coverage very rarely and when you come back from vacation your coverage is done superbly by someone whose job it was to do it while you are gone. Having a dedicated cross coverage team is unique and has been a fun innovation over the last years.

Dr. Matthew Malek: The other efficiency of practice thing that we do well and have done increasingly over the last year is the use of medical scribes. Medical scribes are not new. Medical scribes are not unique, but implementing them can be challenging. We’ve gone from four medical scribes to about 40 over the last year and it’s been a really exciting growth. If you look at a lot of the efficiency of practice literature, having a medical scribe is the single largest effect size intervention you can do for a provider and takes out so many of those other burdens that come with EHR use. We’ve been really excited by the growth in our scribe program and we use remote or virtual scribes exclusively at this point which have been really useful and scalable intervention.

Dr. Matthew Malek: Then last, we’ve done a lot, I could talk for a long time. As I said, I warned everybody that I could talk for a long time about this, but we did clinical leadership, efficiency of practice and I shouldn’t forget community and I mentioned that community from our data is a place that’s been struggling over the last two years. That is a focus for us in this year and we started out by just building in some paid monthly time for community building activities and I think there’s a couple of parts of paid monthly time that’s important to know.

Dr. Matthew Malek: One is recurring. It’s not just one-off events for community building and then two it’s paid. It’s not time that’s in addition to it’s not saying great, but why don’t you stay after work and build community? We really wanted to be time that was involved in an existing job schedule, and so we’re just experimenting with what to do during that time. There’s lots of things that we’ve done and hoped to do, but getting that time carved out has been important first step in getting our staff to have that sense of belonging. That’s my relatively long-winded answer to what is the systematic approach that we take of clinical leadership, efficiency of practice, and community, and that’s what we do.

Helen Rhea Vernier: That all sounds amazing and I want to know more about all of it, but we don’t have time for that. If I may, one follows up question, how are you funding the paid monthly time for community building activities?

Dr. Matthew Malek: Yeah, how do you pay for question is a really important one, and I think at some point we talk about tips for people starting out, but having a financial model that’s sustainable is important from the beginning. It’s important for lots of reasons, one is for sustainability, but two for getting buy-in. How do we fund all the things that we do? We look at it as a book of work, and so one part of us planning strategically is that you can consider all different wellness activities as one book at work, and within that some wellness activities are income generating, some wellness activities are income neutral, and some wellness activities cost money.

Dr. Matthew Malek: Thinking about the paid time during the day, in particular, the way we minimize the cost with that it was actually repurposing low yield time that people had for a different sort of meeting. There was another meeting occurring regularly that if you asked staff, they’d be like, well, why am I going to that meeting? That’s a useless meeting, and so this was a repurpose of existing time, which makes it free. For other things they are very expensive. Medical scribes, for example, when you have 40 medical scribes, is a big budget line-item and so how do you pay for that? For that one in particular, for example, we do add a small number of clinical visits that each provider sees in a week if they have a medical scribe, so that it takes very few extra visits to pay for the service. Definitely few enough that it’s a net benefit. Doing that allows us to make sure that the program pays for itself and that it doesn’t become a target for budgetary cuts or things like that. It also allows the scalability much quicker.

Helen Rhea Vernier: Thank you. I think having those concrete examples is really helpful as people start to think about how they could implement something similar at their own organization. I really appreciate your sharing.

Dr. Matthew Malek: I can offer one other example actually.

Helen Rhea Vernier: Oh yes, that’ll be great.

Dr. Matthew Malek: I can offer one other example of cost neutrality, and that’s in our cross-coverage providers. It would be very expensive to hire someone to just provide coverage without seeing patients. What we do is we consider that person’s overall productivity and change their financial goals, and so we might have a goal that in a year a provider has a net positive revenue of take your pick, $200,000 they’re going to earn this much money for the health center in that once you pay for their salary and benefits and support staff. Organizations are very good at saying, that’s income and income’s good, but what if we did make it just even by giving some time for these really important wellness efforts? We might get down to, they’re net even for the year, they don’t earn us any money, but they don’t lose us any money, and that is budget neutral and allows us to have the position without in effect costing anything.

Dr. Matthew Malek: Budget neutrality for each provider has been one way that we can get providers to have time for things like cross coverage. The other thing I’ve mentioned, which is way back, and so I almost forgot to mention it. When anyone’s starting work on this, particularly organizational and strategic planning about it, making the financial argument upfront is really important. The financial argument when you start to calculate out the cost of provider turnout, becomes apparent and palatable to financial people. When you consider that the costs of turnover of one medical provider is somewhere in the range of 500,000 to a million dollars and you can calculate that at your organization, see how many visits were lost, see how much time it took to get the new person, et cetera.

Dr. Matthew Malek: Just calculate out one of them. Calculate how much it costs to lose, Doctor Jones, and get Doctor Jane. If you figure out just one and how much money that costs your organization and show that to the CFO. He’d say, wow, maybe $10,000 for that meeting is reasonable. I think starting with a cost analysis and understanding how much provider turnover related to burn out affects your organization financially positions the promotion of wellness in a good spot.

Helen Rhea Vernier: Absolutely, and thank you so much for bringing that up. I will just take this opportunity to plug a tool that the STAR² Center has, which is the financial assessment tool, the purpose of which is to assist folks in really realizing the actual costs of provider turnover. These costs can include direct costs such as advertising and recruiting services, but also indirect costs like staff time dedicated to finding locum tenans and permanent providers. The tool really attempts to quantify those tangible costs involved in provider turnover so just a little plug for one of our tools.

Dr. Matthew Malek: That’s great. Everyone should use it. They usually get a very big number.

Helen Rhea Vernier: Yes, all right. Thank you so much for that. That’s very enlightening. Onto the next question and you’ve kind of already spoken to this, but I’ll ask anyway, how can organizational change improve staff wellbeing and combat burnout and compassion fatigue?

Dr. Matthew Malek: Yes, I think that summarizes a lot of the things we’ve talked about. Organizational change is our mantra over self-improvement and organizational change is creating that garden where our medical providers, medical staff can thrive. I think it’s just very important to always come back to, we get what we create in our organizations and not relying too much on the healers to heal themselves.

Helen Rhea Vernier: I love that. That’s beautiful. My final question is, what advice, strategies or tips would you give to other health centers or PCAs beginning to work in this area?

Dr. Matthew Malek: I mentioned a few, but I do have a few tips, lessons learned along the way. One which is not super exciting to talk about, but is incredibly important is strategic plans and annual goals for an organization, and they’re boring and they usually have a lot of meetings involved and you make an annual plan and perhaps it’s not looked at it all that often or maybe you make a strategic plan and you say just a strategic plan. Making clinician wellness a part of the strategic plan is absolutely essential. If it’s not there, there’s nothing to fall back on, there’s also nothing to drive the organization to say, okay, how will we reach the strategic goal? As unexciting as it sounds, making sure that clinician wellness is front and center in a strategic plan, or at least part of a strategic plan is really important for health centers and PCAs that are working in this area.

Dr. Matthew Malek: We’re often inclined to start with intervention and to just start fixing things, and that’s good because change is good, but it’s often hampered if we don’t first take some of those really hard but important steps of getting our organization to commit to the strategy of clinician wellness. As much as possible making it a strategic priority of putting it in the annual plan, tying it to leader incentives and goals allows for the organization to invest in it in a different way. The second one that I was thinking of as a tip as to make the financial argument upfront, which I think we just spoke about. It is really important at first to do the cost analysis and say just how much is this costing your organization, because it makes a lot of the spending much more palatable to the leaders who decide to spend.

Dr. Matthew Malek: The last one, and this is something that your organization would definitely favor is that you got to find people who have done this before. The space has been active for a long time, the wellness space, and there’s people who have done practiced transformation and can guide you on this, and so going it alone is definitely not necessary. It can be as simple as someone in your state or someone in your community that you know has been working on it. You can talk to them, you can be much bigger in terms of a practiced transformation organization, often who will provide you guidance along the way in mentorship. I think not reinventing the wheel and really getting some input from people who have done this before and having a partner that you can rely on for advice is important as well. Then my last tip, I guess, would be bold and be brave. If your administration says yes to everything, you’re not asking for enough. Be bold and brave in the asks you make for wellness, and the more you push generally, the more that will happen.

Helen Rhea Vernier: Fantastic. Those are great tips. Doctor Malek, thank you very much for joining us today and listeners, thank you for turning in. We hope today’s conversation provided you with ideas, suggestions and insights into ways you can approach, encourage and organizationally support employees through burnout and compassion fatigue mitigation. Be sure to check out all of our free workforce tools and resources found at chcworkforce.org. Have a great day.