Applying Systems Thinking to the Healthcare Provider Burnout Problem

A recent opinion piece* in JAMA Online First caught our attention.  The authors urge the healthcare industry to apply lessons learned from safety and quality initiatives to the healthcare provider burnout problem. They state the problem clearly: "Burnout is now widely recognized as a systems-level threat that erodes quality, undermines safety, reduces access, and destabilizes the very workforce on which health care depends.  Yet awareness alone has not delivered the pace or scale of change required.”

Their overarching recommendation is to apply systems thinking.  They also present six specific lessons learned, summarized below, from the industry’s safety and quality experience.

Do Not Treat Improvement as Discretionary

Excessive focus on cost management can compromise safety and quality, and lead decision makers to consider burnout initiatives as non-essential.  However, burnout creates its own cost consequences including staff turnover, medical errors, and reduced productivity.  It is imperative to address the burnout problem.

Elevate Workforce Well-Being to a High-Accountability Organizational Aim

Workforce well-being must be more than an abstract goal.  Improvement activities must be evident and effective.  Healthcare organizations and accreditation agencies should develop and apply assessment models that evaluate whether organizations have the structures, leadership, and systems needed to actually improve workforce well-being.

Focus Measurement to Drive Action: Avoid Measurement Megalomania

Burnout measurement must include more than metrics that quantify burnout symptoms in the workforce.  Assessment should also address the work system components that cause burnout, including workload, workplace efficiency, and culture.  These root causes should be the focus of workforce well-being improvement initiatives. 

Redesign Systems of Work to Improve Both Health Workforce Well-Being and Financial Performance

Workforce well-being and operational excellence are compatible, not competing, goals.  Strategies such as reducing unnecessary documentation, eliminating low-value administrative tasks, strengthening team-based care, and improving workflow efficiency can lead to improved morale and higher productivity.

Culture Is a Core Intervention, Not a Soft Add-On

Culture is foundational to workforce well-being.  Cultural attributes include leadership behaviors and role modeling, teamwork within and across departments, respect for individuals, and opportunities for learning and growth.  A just culture creates an environment where all members are encouraged to speak up about errors, unsafe conditions, or unmanageable workloads.

Accelerate Improvement Through Structured, Trusted Peer Learning

The authors describe a model for identifying and evaluating improvement initiatives.  Basically, teams should be empowered to redesign work.  They should test interventions and share data and lessons learned with other teams.  Multiple teams working in parallel can identify the most promising possibilities and limit investment in low-yield approaches.  Peer groups can document their interventions for implementation by later adopters.

Our Perspective

First, we applaud the authors for pressing several of our hot buttons, including culture, safety, and systems thinking.  We have been promoting the essential interrelationship of these key concepts for years.

Second, they have done a good job at mining healthcare’s safety and quality improvement initiatives for lessons learned in terms of processes, attributes, and goals.  Their focus on work design is proper – the specification of tasks, their arrangement in flows, and the attributes of the task environment are the building blocks for attaining organizational goals and providing workforce satisfaction and motivation.

That said, we can expand their model with an eye toward creating a more complete and nuanced system model of a typical healthcare organization (e.g., a large hospital).

For starters, we have posted about healthcare on several occasions.  In particular, see our Nov.6, 2019 post about worker burnout and how it leads to errors and our Mar. 10, 2023 post about applying systems thinking in the emergency department.  Press the healthcare label in the right column to see all our related posts.

Following is an example of how systems thinkers might consider two of the subjects mentioned in the article: goal conflict and organizational culture.

The authors say workforce wellbeing should be a top-level goal of the organization and is not incompatible with other organizational goals.  We agree but they are not the same goals.  The reality is that goal conflicts, e.g., cost vs. safety vs. quality, exist in almost all organizations and pull the organization in slightly different directions.  How are priorities set, resources allocated, and goal conflicts resolved?  How are decisions made? 

A major driver of decision making is the organization’s culture - the members’ shared assumptions about reality (how the world works), values, and norms.  While it’s true the culture needs to be aligned with preventing burnout, there are many factors that contribute to culture, or try to influence it.  Many of these factors are not adverse to workforce well-being but they are primarily interested in promoting their own agendas.  Internal factors include the power, interests, and status of workforce sub-groups, e.g., staff unions and physician guilds; trust in management; and the degree of expected deference toward upper levels of the organization’s hierarchy.**  External factors include the social, legal, political, and competitive environments in which the healthcare organization operates.  The personalities of top leaders must also be considered.  A CEO who is hired to grow the business, and is incentivized to do that, will focus on that goal more than others.***  All of these factors need to be considered in a full systems model of organizational culture.

An additional feature of systems is that they are dynamic.  System components are growing or shrinking; their links with other components are being established, holding steady, or withering; and feedback loops along the links send reinforcing, neutral, or attenuating signals throughout the system.  The authors recognize this when they mention perverse or unintended consequences of interventions but the dynamics of the system are perhaps more ubiquitous, unapparent, and powerful than they realize.

Finally, we need to consider why changes occur in organizations.  Obviously, change can be forced by top management.  But change that affects workforce well-being is more likely to be accepted if it comes from the bottom up.  That means empowering lower level members to contribute to the change content and process, which is a big step, sometimes too big, for many top managers and existing cultures.      

Bottom line: This is an emphatic opinion piece and you should read it, but it does not present a complete picture.   

 

*  Dyrbye L.N. and Burstin H., “Accelerating Workforce Well-Being—Lessons From Safety,” JAMA (Published online April 27, 2026).  doi:10.1001/jama.2026.  JAMA is the journal of the American Medical Association.

**  These factors can promote siloing and strong reactionary forces (aka resistance to change) when work design changes are proposed.  Simple inertia suggests that no-change is a common state.

***  That’s why Safetymatters has always advocated for executive compensation plans that reward, i.e., pay for, achieving safety goals.