Stanford Well MD - MedEd Studio with Tait Shanafelt

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Wellness on the organizational agenda

It becomes so tedious. Have you heard it lately? You need to look after yourself. Eat healthy, sleep with good quality and quantity, exercise regularly, and maintain healthy relationships. Puh. This will improve your resilience. Yes resilience - you read correctly.

Though, you actually need to be resilient desperately, particularly in the health care sector. Occupational burnout is a serious problem in Sweden and around the world. In the news media we read and hear about the huge deficit of i.e. nurses or midwifes on a regular basis. Many of them decide to leave the profession all together. Others find new employers that provides better pay and improved working conditions, particularly in the private sector. Lack of nurses has a huge impact for everyone and drives even more deteriorating conditions for patients and the remaining staff. Many hospitals have far too few beds open due to this. Other severe consequences are cancelled procedures or operations. Patients, however, don’t adjust accordingly, and patients remain ill, in need on medical care. The wards become oversubscribed and the threshold to be admitted becomes even higher. Consequently, severely sicker patients with fewer staff. Resilience? Is that really an individual responsibility? Well.

I have been asking myself many times how adequate the different efforts are to improve resilience and coping strategies among individual health care works when it is the organizations that many times are not functioning properly. Would it really be MY responsibility to keep health and stay away from occupational distress if the organizations, its culture, and “fabulous” processes, drives me nuts and make me sick? And what would happen if I got sick? Is the failure om me although I have to pay the prize?

There are some interesting positive examples of how some health care organizations have started to – slowly – realize that there also rests a huge responsibility on the “system level”. A pioneer is Stanford Medicine in the US. Stanford realized that you cannot claim that individual care providers should accept to work in a “broken working environment”. Wellness of the workforce must be one perspective that all strategic decisions have to take into account and consider on the top organizational level. Wellness becomes a part of the standing agenda in the senior leadership team and filters through on all other organizational levels.

Matrices were defined already in 2017 to measure wellness among individuals on an 18-month basis, not as a temperature check but as part of an improvement cycle. These performance measures use “professional fulfillment” and “occupational burnout” as the end points on a continuum. Measures such as how work impacts the work-life balance and life outside work were created, and each organizational unit is analyzed in terms of efficiency, leadership, and work-life balance. This data is now used both to monitor each unit’s wellness profile, identify challenges and indeed to find ways to address problems. One can clearly critic this new focus on system thinking on wellness and even claim that the new “wellness trend” is tokenism, but I remain positive. It is absolutely excellent that organizations start to self-reflect, act and assume responsibility. Wellness of the individual healthcare providers has finally reached the agenda.

All of this given, I would still try to live a sustainable, balanced life and of course remain enjoying my wine. Always. Some things remain on the agenda. Indefinitely.

Summary

Stanford Well MD was launched to drive system change and foster professional fulfillment in healthcare professionals. The need for system change in healthcare was recognized through research and evidence showing high levels of occupational distress and its impact on quality of care and patient experience. Tokenism in wellness efforts can be avoided by creating senior positions with authority and resources to drive change. Creating a culture of wellness involves changing conversations and considering the impact on healthcare workers in decision-making. Stanford's wellness culture is manifested through performance metrics, funding for well-being improvement projects, and allocation of resources. Research is conducted to measure the effectiveness of specific interventions and overall well-being improvement.

Takeaways

Wellness efforts in healthcare should focus on system change and foster professional fulfillment.

Creating a culture of wellness involves changing conversations and considering the impact on healthcare workers in decision-making.

Performance metrics, funding for improvement projects, and resource allocation can manifest a wellness culture.

Research is conducted to measure the effectiveness of specific interventions and overall well-being improvement.

Chapters

00:00 Introduction to Stanford Well MD

01:04 The Need for System Change in Healthcare

04:36 Tokenism in Wellness Efforts

05:11 The Impact of Wellness Officers

06:08 Creating a Culture of Wellness

08:18 Influencing Decision-Making through Presence

10:06 Significance of Stanford's Wellness Culture

13:22 Improvement Projects and Funding

14:18 Research on Wellness Implementation

22:46 Assessment and Improvement Cycles

23:41 Addressing Decline in Metrics

27:23 Recognizing and Rewarding High Performers

29:28 Advice for Implementing Wellness Programs

Transcript

Introduction

In this episode, you're going to meet a pioneer in the field of wellness in healthcare. Dr. Tait Shanafelt is the chief wellbeing officer at Stanford. Stanford was first in the US to address wellness on the organizational level. This was a truly significant change of thinking from focusing on how individual healthcare workers could tolerate and survive in a broken organization to actually start thinking about the organization in which human beings work. Yoga, dietary habits, sleeping patterns, exercise regimes and other coping strategies to enhance individual resilience is clearly not enough. Dr Shanafelt and colleagues started to ask new questions. What is it in the organization that promotes individual wellbeing and what happens when you start to measure it. Here is Dr Tate Shanafelt.

Conversation

jonas (00:01.07)

So Tate, tell me a little bit more about Stanford Well MD. It sounds to be a very interesting concept.

Tait Shanafelt, MD (00:09.232)

Great to be with you, Jonas. The Well and Decentre at Stanford was launched about seven years ago and is really designed to be a formal element in the organization that is not just promoting wellness at the level of individuals, but to really drive system change and to identify what are the characteristics of the practice environment, of our educational environment.

of the behaviors of our leaders, the way we're managing the organization, and to try to attend to those things to create an environment that fosters professional fulfillment, meaning and purpose for our faculty, residents, fellows, interns, and medical students. And so, you know, in the US, this was actually really the first of...

formal structure at the top of the healthcare organization at any US institution to really be focused on approaching wellness through that system lens, through the organization lens, and not to be focusing on only personal resilience, individual strategies, self -care, support for people in distress, but to acknowledge that there are characteristics about the way we design the work.

the way teams function, inefficiencies in the practice environment, suboptimal staffing, and a variety of other variables that are probably the majority of the factors that influence professional fulfillment for healthcare professionals. And that rather than sort of teach healthcare professionals to tolerate a broken work environment, most of our effort as institutions should be focusing on fixing that broken working.

jonas (02:05.07)

So seven years ago, we're 2024 now. That means that about 2017, the center came about. That would then be two years before the report from the Academy of Medicine was published as consensus paper in which the system issues really pops up on the agenda. So what was driving this kind of early identification at Stanford for the importance of

Tait Shanafelt, MD (02:34.222)

Hmm.

jonas (02:34.286)

not only the individual resilience sort of, you know, the, yeah, you know what I mean, instead of the sort of the system issues.

Tait Shanafelt, MD (02:42.896)

Yeah, well, you know, it's interesting. I would say that in part this journey in the US begin about 23, 24 years ago. And in that sense, if you reflect the National Academy report is really a late event because it was at that point that the National Academy recognized when they launched the collaborative and the collaborative originally launched in around

2016 and I was one of the folks who wrote that consensus paper on the expert panel for the US, but that was a late event. And it was really the outgrowth of at that point in time, we had 15 to 20 years of research, data, science, and evidence chronicling not only high levels of occupational distress in physicians, nurses, and other healthcare workers.

but also robust evidence showing links to quality of care, patient experience, turnover, people leaving the profession, affecting staffing and access for our patients. And so that data and the trends in those dimensions were really what caused the National Academy to say, we have a real problem and we need to think about a national...

framework from which to approach it and to prioritize it. And so I think that really that National Academy effort was sort of the coalescence of all of this data research and evidence that sort of crescendo, if you will, in occupational distress that said we need to actually think about this at a very serious level for the Academy.

jonas (04:36.046)

When I heard about this new wellness officers last year at the AAMC, and this whole group of you that now are popping up both in Canada and in the US, sometimes I'm just wondering how much of tokenism is it? Because culture obviously is super difficult to change, and any effort to change the culture is always welcome. But I can also imagine that there might be many institutions that are trying to...

find not perhaps a quick fix because I'm quite sure they are very serious but what's your take on that?

Tait Shanafelt, MD (05:11.216)

Yeah, it's a great question. And I think the answer is, it depends. So if a role is created as sort of a figurehead position without sufficient authority and resources and not positioned in the reporting structure of the organization the right way, then probably it is a bit of a hollow gesture.

And again, to the extent wellness offices are focused only on creating a portfolio of individual personal resilience offerings, they will not likely make much of a difference. But I think that when the positions that are created are sort of very senior in the organization reporting at the highest level, that they have some authority over what the organization does.

in its critical decision making, where it spends its money, what accountability is put in place for other leaders, it can really have a transformative impact. I think to your question about culture change, and maybe we can spend a bit more time there, because that's something we've studied and written about quite a bit, but maybe just starting with the story that I recall the first board meeting at Stanford that I attended, and I only had been here for a week or two.

jonas (06:24.3)

Mm -hmm.

Tait Shanafelt, MD (06:38.832)

And so at that meeting, I knew nothing about really what was going on in the organization, what sort of the key challenges the board of directors was wrestling with. And so I basically came to the meeting, introduced myself, and they proceeded to talk about the three major strategic challenges on the agenda. And multiple times over the next hour and a half, a different executive,

board member paused the conversation and said, because Tate's sitting here, we should acknowledge the impact of this decision on our people or how it's going to affect the professional fulfillment of our people as they talked about whatever it would be growth or expansion or consolidation or other considerations. And I was very struck by that. That I didn't say anything.

I hadn't done anything yet, but merely the fact of being in the room as a senior leader changed the conversation. And I've often reflected about that experience of how that demonstration and commitment, hopefully we've now begun to do things and establish both credibility and evidence within the organization of effectiveness and to build the relationships to influence and.

and change other leaders. But I think even just at that level, it really illustrates that we can start to subtly change conversations and how the board is thinking about key decisions. So maybe we'll go, I know, a little bit deeper, but I think that was very interesting experience.

jonas (08:18.604)

Hmm.

jonas (08:24.59)

So by you being there, that sort of put the questions on the agenda and that question that then could not then be ignored. Is that the way to interpret you?

Tait Shanafelt, MD (08:34.192)

I think that's right. And we often emphasize that at most of our senior decision -making tables, any decision that is made, we are always thinking about quality of care. We are always thinking about the experience of our patients. And out of necessity, we're always thinking about the economics of our decisions and the cost it's conferring to society and patients.

And our belief is that we should also always think about how the decision is impacting the healthcare worker and the healthcare workforce. No one of these things ever carries the day completely, right? Certain things we would love to do for quality that maybe are just too expensive for society. We have to find a middle ground. But we always should be thinking about all four of those dimensions. And I think...

Historically, it's probably fair to say that 50 years ago, we didn't think about quality very much. We often didn't think about patient experience to the depth we do now. And in that same light, we've matured in those domains. The professional fulfillment, well -being of the workforce has been neglected too long in those considerations. And I think now that's this question of how are we bringing that into the...

the way we approach any key decision for the organization that that dimension is considered.

jonas (10:06.67)

But what would you then say is symptomatic or signifies, I should say, the Stanford wellness culture, well sort of cited in many different papers? What's unique with you?

Tait Shanafelt, MD (10:18.448)

Yeah, yeah, I'll maybe point to a couple things because I'll talk it's easy to talk about philosophically what are we trying to advance but I'll maybe talk first just about You know, what are some of the manifestations of that so You know we just as we have our Highest level performance metrics for the organization Specific quality metrics

specific patient satisfaction metrics being the US, the economic performance of the healthcare organization, NIH funding for research grants being Stanford and a preeminent academic institution. So these are the types of things. We have on that same scorecard for the dean, the CEOs of the hospitals and the highest level of the organization, the...

professional fulfillment scores of every department at Stanford benchmarked relative to that same specialty area nationally. And we look at that annually. We have performance targets that we have for that that we try to advance every year. On the hospital scorecards, there are other.

operational metrics that we consider performance measures of the work environment for the physicians. Optimizing time in the procedural practice would be an example for our surgeons. And so how easy is it for them to get OR space? How quickly do the rooms turn around? Is there consistency in the team that they're working with in the operating room? Or do we just swap out nurses different days? These are examples of things that we...

that we work on and have performance metrics around. Similarly, time spent on the electronic health record after hours and so forth. Our performance metrics we have for the operational administrative leaders of the hospital that they have to perform to and have accountability to the hospital board for. And I think it also translates into how we allocate our money.

Tait Shanafelt, MD (12:32.368)

And so it's not a huge amount, but of the way the dollars are shared from the hospital to the clinical departments in the School of Medicine. We also have about $10 million of that funding, which is a decent number at Stanford. It's about 1 .5 % of the annual funds that go from the hospital departments to both pay the physicians, but also to help fund some of the educational mission and the research mission and so forth.

And there's $10 million flowing that is specifically earmarked for the departments to support well -being improvement work for the faculty by improving the work environment, not resilience classes. They have to actually identify, you know, what is the operational inefficiency that makes a pathologist go home late?

jonas (13:22.894)

Hmm.

Tait Shanafelt, MD (13:24.592)

or a primary care doctor or a surgeon, or that makes it difficult for them to foster work -life integration, or makes it difficult for them to provide for their patients what they need, and that there are formal improvement projects in every single department supported by those funds from the hospital to incrementally, year over year, address the problems in the work environment. And so that's just...

one example of many, but I think begins to illustrate how we have to have this be these high level metrics that are how all of our leaders are measured and that there are specific and accountability metrics around that. There's real money being invested to try to address those things and that those, you know, that is a manifestation of real commitment as opposed to a slogan.

jonas (14:18.734)

So in terms of this sounds all absolutely fabulous. What type of research has been done in terms of the implementation of all those different efforts?

Tait Shanafelt, MD (14:28.432)

Yeah, quite a bit and both in the specific and then in the aggregate. So, you know, for some of the specific interventions in a given department, what is measured might be tailored very much to the nature of the redesign. So that, you know, for example, in our primary care physicians, as they shifted the care model, changed the ratio of

assistance per physician created different mechanisms to sort of cross cover and deliver care through the EHR and so forth. They would be measuring not just the satisfaction scores and so forth for physicians, but the time people were spending in the electronic health record and some of those type of elements because the target there, I often like to say the first domino, you know, well -being or professional fulfillment is like domino number 10.

But the most proximal domino to that intervention that we were trying to knock over was to decrease the burden on that primary care provider of delivering care to the population they serve. And so that the number of inbox messages that they had to personally address as opposed to have a team -based model was coming down through staffing and redesign of the way the workflows were accomplished. That was the very first thing.

so that their work hours could actually decrease and they could care for those patients with equal excellence, but less on their shoulders personally. And that we have to, if we don't accomplish that, we're probably not gonna get the dominoes flowing to number 10. Another example I mentioned that our department chair in surgery, Mary Hahn, led was this effort to create a more consistent group in the operating room.

And so, you know, being a very big medical center, there were certain very highly specialized surgical areas like cardiothoracic surgery or neurosurgery where they always had the same team. But for the majority of our other surgeons, it's much easier from a scheduling point of view to just draw from the nursing pool, the OR nursing pool. And that creates many limitations.

Tait Shanafelt, MD (16:57.008)

that the team doesn't work together regularly. They don't know one another. It might be harder to speak up in a psychological safety perspective. They don't know what each other likes in a certain case. What instruments are used the way they do a procedure together. It takes longer. The efficiency suffers. It's possible the quality may suffer. And so Mary really led this effort to say you can't always have the same person. People need tight days off and so forth.

But a surgeon should be working with one of three or four people always and not just anyone from the pool. And those folks also will develop their surgical expertise and this different disciplines and so forth. And so that doing that created more work for the schedulers. And we actually had to hire more nurses for the pool because you have. It's not a massive increase, but you have to have a little bit more.

to make it work. And so there is a little bit of a cost there, but the feeling was that we recoup that cost by having the cases move faster, concluding them sooner, being able to do more cases per day, per OR and per surgeon, and that everybody benefits from this. That team makes it a better place to come to work and practice for every member of that team. And so that's another example where we're doing something very specific. The way we measure it has to be specific.

But then in the aggregate, what we're looking at is that year over year improvement in the professional fulfillment score in that specialty relative to their specialty specific national benchmark. And seeing is the department of surgery relative to the same assessment instrument of surgeons nationally having a meaningful effect size statistically significant improvement in their wellbeing.

And that's sort of, again, our aggregate measure at the level of the organization is looking at how many departments do we have achieving that or showing meaningful improvement that will get them there over time. And so we've published that data on what that looks like at the organization and system level. When you sort of are helping each department do the work relevant for them, even as there are some things, teamwork, values alignment.

Tait Shanafelt, MD (19:22.992)

that we might need to do for everybody. But some things, again, are very specific to a given discipline that may not affect you enough.

jonas (19:30.158)

But how do you define it? What metrics goes into well -being?

Tait Shanafelt, MD (19:38.032)

good question. So in the simplest sense for us, we have sort of two high -level measures and then a whole host of variables that we consider driver dimensions or dimensions that are determinants. So for us at the highest level our professional fulfillment is our sort of goal. It's not

joy, it's not life happiness, you know, there are many things that fuel that, it's professional fulfillment. And then the countermeasure is occupational burnout, so that those are kind of our two poles, if you will. But then within, we do measure host of driver dimensions with that we think fuel that, people's perception of values alignment between what they aspire to and care for as a physician or a nurse and what they think.

the values of the organization are and what we actually care about and prioritize. The behavior of our leaders, we have our people evaluate the leader behavior score of by name of that sort of work unit supervisor, the person overseeing 15 to 25 physicians, teamwork, efficiency in the practice environment, which again means something different for a surgeon and a radiologist.

measures of work -life integration or the way work impacts your personal relationships outside of work. And then some are individual variables like the self -compassion sort of growth mindset type of activities. And so we have a scorecard where we actually measure all of these different driver dimensions for each department about every 18 months is our interval.

And we use that then to say, how are we doing for those overall outcome measures? Which of these drivers seem to be the challenge for a given unit? Because for some, it's the efficiency of practice. For others, it's the work -life integration, impact of work on relationships. For some, it might be a leadership issue. And it is quite interesting when we get that data, the heat map is very matrixed of each unit has sort of its own.

Tait Shanafelt, MD (21:54.608)

profile. And so then that data is shared with the leader of the unit. There's sort of a well -being improvement leader who that leader has designated. They engage in some dialogue with the unit. Here's our results. Do these reflect our experience? It looks like if we were going to focus on something over the next year, this would maybe be the domain. Is that correct? And then within that domain, what are the things that we could revise, change, and develop a different way and pilot it?

to make a difference and then implement and reassess. And that's why for us it's an 18 month cycle because we find to do the assessment, to share the data with the unit, to socialize that data takes us about three months. And then it takes about three months for them to pick a target, develop an improvement project, and then we have 12 months for them to implement it before we do the next assessment.

jonas (22:46.254)

But it sounds a little bit like the clinical learning environments review done by the ACDME in terms of maybe you have certainly different metrics here and different dimensions to look into, but as a 24 -month cycle, I believe, and you then can actually track to see how trends actually, if you improve in certain areas and if you decline in other areas, is that the same for you?

Tait Shanafelt, MD (23:11.236)

Conceptually the same. I think you want the assessment intervals to, you know, it's not just a temperature check, right? It's a step in an improvement cycle. And so I think that's exactly right that we design it with that intent.

jonas (23:23.95)

Right.

jonas (23:31.15)

But are the consequences, I mean, if you have a clinic where you see a decline in numbers on certain metrics, would it be any punishments or any consequences?

Tait Shanafelt, MD (23:41.36)

I think punishment might be not quite the right framing. You know, the ACGME's work has expanded a little bit to consider faculty, but mostly about accreditation for training programs. And so they have, you know, sort of a very specific mission around making sure that organizations are creating good experiences for learners. I think for us, you know,

jonas (23:54.966)

Yep.

jonas (24:05.504)

Yep.

Tait Shanafelt, MD (24:07.576)

Right now, although we can talk about there's some movement for our crediting bodies for the hospitals across the US, but right now most of the action and accountability is within the organization. And so for us, when we see a unit that is struggling, the first piece is to try to understand why that might be. And sometimes it's intuitive.

the pandemic hits and the emergency department is getting crushed and dermatology might be working less and It's you know obvious in a sense why the emergency department is under threat But other times it's less obvious You know what is going on in the unit? And so I think the first question is to go down and really understand what's happening and as you might imagine

It's everything under the sun. Sometimes it is a leader who's toxic. Sometimes it's toxic individuals in the environment. Sometimes it's suboptimal interaction between disciplines, a bit of a battle between the techs and the nurses or the nurses and the physicians or some other element. And then sometimes it's just that the workload has become overwhelming. And sometimes that happens in insidious ways.

And again, a nice example of that would be the way the pandemic in the U .S. transitioned our population to virtual care very rapidly. And now the number of messages from patients directly to their physician via their cell phone increased 50 % in the first month of the pandemic.

And then it continued to increase. We actually, philosophically at Stanford, believe that we can deliver some very effective care through that platform in a very timely way, in a manner that meets the patient's needs. But we didn't design a system to deliver care that way. It just got added on to everything else. And so you might imagine with that one month, boom, 50 % increase, and that's at the level of the nation.

Tait Shanafelt, MD (26:24.496)

And there's never gone back down that all of a sudden being a primary care doctor or an oncologist, the experience changed and the workload changed and these metrics might change and we might not intuitively know why. And so then we have to go down and understand it. And that one, again, being a nice example, you know, we now have as a number of us organizations do very robust, highest level of the organization.

groups who are bringing together the leaders to say, how are we going to redesign our care models, including hiring and staffing to account for this work, or if nothing else, to measure the time and to give physicians credit for that work so that it's not just on their personal time.

jonas (27:12.974)

But what about those departments that then outperform? You see that there's been a massive increase in satisfaction of various kind. Do you award them in one way or another?

Tait Shanafelt, MD (27:23.898)

We don't reward them in any specific way other than to often hold them, you know to acknowledge them and to hold them up as You know groups that are doing a lot of things right that other groups might want to learn from And we have a couple of those groups at Stanford who? I'm just always amazed that every time we survey them There's some that are just such a massive effect size Favorable to their specialty specific experience

outside of Stanford. And every time we serve them, they also are getting better. And, you know, I'll say that what are some of the secret ingredients? What always appears to be the case is there's a very effective leader in that unit who's attuned to this whole domain and thinks a lot and works hard with their team about...

professional development, the experience of the faculty, identifying what we need to work on and empowering the team to do that. And coming back to something where we haven't maybe gone quite as deep, but the culture question that you often also hear a lot about the culture of the unit and the way that people in the unit treat each other, interact with each other, support each other.

and have this mindset of ownership, shared ownership of their unit and that they are going to keep making it a better place. And when those units that just are green scorecard across the board, these are the types of things we often hear.

jonas (29:06.638)

So, Tate, if you were to give advice to someone around the world who wants to perhaps not copy what you do, but they want to bring wellness on the institutional agenda based on your massive experience and all the work you've done with the National Academy and many other places, what would that advice look like?

Tait Shanafelt, MD (29:28.56)

I think, you know, obviously it starts with the commitment at the highest level of the organization. So, you know, the dean created the center. I report directly to the dean as an associate dean, and that gives me different authority and ability to drive change than if I was, you know, not positioned in that way. So I think, you know, the...

If your organization is already at that place where it's ready to commit, make the most of it. If not, I think that the first step is to sort of build the coalition of leaders in the organization who are thinking about this, care about it, believe there's an opportunity and bring that group together and then see if you can engage other leaders with that sort of.

group of leaders who are trusted and respected in the organization to see if can we commission a task force? Can we commission this group to think about how it might look at the Karolinska and be designed in a way that meets our structure and the way we operate here? And so then to think about that, we often find, we say that there's usually one of sort of five cases that.

are compelling to an organization. The one is sort of the business case which encompasses quality and effects on turnover and cost of care. There's the tragic case of a suicide that sort of shakes an organization. There's sort of a regulatory case, things like the ACG and other accrediting bodies that

that come into play. There's sort of a recognition case of we want to be viewed as the institution others look to for solving these types of problems. And that is you think about what's going to be motivating to my organization. I think we usually say reflect a little bit on what

Tait Shanafelt, MD (31:46.48)

Which of these is most aligned with the other priorities? And if your organization right now is very focused on quality improvement, you want to become very familiar with the extensive body of research on how the clinician well -being interfaces with quality. If instead it's patient experience or it's cost or it's we don't have enough staffing and people are leaving, then you want to become familiar with that evidence.

Because then you can go to your leaders and say, as we've looked at this, we think that it is going to be integral to our efforts to address this staffing crisis, to retain our people or recruit people or to address our quality effort. And now you've hitched the wagon, if you will, to one of the other organizational priorities and are able to help elevate this as part of the other priorities.

that the organization is trying to advance. And so I think that's something to think about if it isn't yet sort of at the highest level of reflecting on that process. We've written some guides on how to do that that are AMA steps forward modules that the American Medical Association has free online to sort of think about that. And then also once you kind of do that, what might that task force do? And so I think that

That's sort of one thing of building that coalition to sort of help elevate this in the organization. The last thing I'll say there is work at the highest level for which you have support. So if you have support from the dean or the chief executives of the hospital, then obviously you're off to the races. If you don't have that, but you have support from the department chair, then you should be working very hard at the level of what can be done in the department. If you don't have that, but that division,

leader is very bought in. There still are many effective things you can do in the division. And so work at the highest level that you have support and that what often will happen is as one or two divisions that really are working on this have success. Other division leaders say we want to follow your path. And then a department chair might say I've got these two or three divisions that are really

Tait Shanafelt, MD (34:10.768)

suddenly demonstrating positive change. I would like all of you to be doing that. And or as a couple of departments have success that again breaks through this common cynicism that it's too complicated a problem. There's nothing we can do at the level of the Karolinska. Only the Swedish government could do something meaningful, which is false. It's not the case that there are.

The most important things often are at the level of the organization and the department and the division. And so just start where you have support and let that be sort of the example. Others will want to follow the lead and that can build momentum.

jonas (34:56.238)

Well excellent, well thank you so much for joining us today, Tate Chanafels. This has been absolutely fabulous, thank you.

Tait Shanafelt, MD (35:03.28)

Thanks, Jonas, good to be with you.

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