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Use of a Feedback Survey as a Part of a Wellness Champions Program to Improve Academic Faculty Satisfaction and Burnout: Implications for Burnout in Academic Health Centers

Background Faculty and trainee well-being at academic medical centers is a nationwide concern. In response, the University of Utah Health created a system-wide provider wellness program that used individual faculty champions who were empowered to 1) examine the unique needs of their department or division using a lens of quality improvement, 2) design projects to address well-being, and 3) measure impact of projects addressing well-being. One team used a feedback tool to attempt to improve the well-being of Family Medicine faculty by better understanding challenges and developing a roadmap for action. Objective Evaluate the effectiveness of an anonymous feedback tool on faculty well-being. Methods The Division of Family Medicine developed and implemented a quarterly anonymous faculty survey to facilitate an ongoing improvement process for faculty wellness in 2016. The faculty survey identified thematic concerns, which were used to develop constructive solutions and systemic changes. Results A closed loop feedback structure provided rich faculty input into impacts on burnout and professional well-being. Sense of control (good to optimal) over workload among faculty increased significantly (p = 0.011) from 10% to 42% over one year exhibiting a large effect size (Cohen’s h = 0.751). Faculty burnout, using a single item emotional exhaustion question validated to the Maslach Burnout Inventory, was reduced from 48% to 25% showing a medium effect size (Cohen’s h = 0.490 with p = 0.097). Work related stress was reduced from 72% to 50% demonstrating clinical significance (Cohen’s h = 0.465) but not statistical significance (p = 0.154)—an effect which was more noticeable when comparing means between years (Cohen's d=0.451with p = 0.068). Response rate was 100% in 2016 (29/29) and 92% (23/25) in 2017. Conclusion This faculty survey, which has since been adopted by other groups at the University of Utah, could help improve well-being in a variety of health care professions.


Introduction
Burnout among academic medical center faculty is a major concern nationwide. 1 Despite receiving significant attention, effective solutions aimed at reducing burnout have been difficult to identify and implement. In 2016, the University of Utah Office of Wellness and Integrative Health examined burnout and well-being across all School of Medicine faculty using a modified version of the American Medical Association's (AMA) Mini-Z survey tool. Burnout was measured by a single item burnout question that had been previously validated against the emotional exhaustion portion of the Maslach Burnout Inventory. 2,3 Results were reviewed with each department, highlighting possible targets for improving faculty well-being. Departments were encouraged to select a faculty or group of faculty to serve as Wellness Champions who would examine the particular needs of the group. Champions were supported in choosing and implementing a quality improvement-based project aimed at impacting faculty well-being. 4 Champions did not have additional funded time for these projects.
The 2016 well-being survey conducted by the University of Utah Office of Wellness and Integrative Health demonstrated that burnout among Division of Family Medicine (FM) faculty was particularly high: 48% compared to 30% among other School of Medicine faculty and 29% physicians nationally. 4 Perceived control over workload in the division was rated as 10%. At that time, the FM Division was experiencing high faculty turnover and difficulty recruiting. The University of Utah's FM Division focuses primarily on resident education and clinical care. Faculty provide clinical services at three clinics, teach and supervise residents, conduct clinical research, and teach a variety of students (e.g., physician assistants, nurse practitioners, medical students and others). Using the Wellness Champions project format, FM Division leaders (Division Chief and their leadership team) and the four division Wellness Champions developed a process to better understand and address the sources of this burnout.
Multiple system issues can lead to either burnout or the opposite, engagement. 5 FM Wellness Champions chose to focus on improving the mechanism for communication within the FM Division as a primary strategy to improve well-being, drawing on several established models of burnout. First, organizational communication is a major mediating variable between organizational culture (the values, vision, and beliefs present in an organization) and employee engagement; in other words, organizational communication links the organization and the individual (Figure 1). 6 Second, in the model developed by Shanafelt and Noseworthy, 5 effective communication impacts several of the proposed driver dimensions of well-being, particularly a sense of control, organizational culture, and sense of workplace community. Both effective communication and perceived organizational support are critical protective factors against burnout in workplace settings. 7,8 A tailored approach can best meet the needs of diverse groups. 9 The University of Utah FM Residency Program had previously developed a successful model of communication using an anonymous feedback survey with closedloop feedback for residents' concerns. 10 The acceptance of this model among residents and faculty, alongside the already-developed infrastructure, made a similar survey for faculty concerns easy to implement. Thus, communication was chosen as a cost-effective and achievable focus of addressing well-being. The hypothesis was that providing honest frequent feedback to leadership about pressing issues would allow a clearer plan of action to improve faculty well-being. This plan was made in partnership with champions and department leadership.
This paper looks at the impact of a local intervention, use of a survey feedback tool, by a single wellness champions team. The Wellness Champions' goal during the first year of the survey implementation was to reduce burnout among FM faculty/providers to the average rate among all University of Utah faculty (i.e., from 48% to 30%), as well as to improve a sense of control over work. They aimed to accomplish this by addressing local issues contributing to burnout and lack of control.

Methods
In order to facilitate two-way communication between faculty/providers and leadership, the FM Wellness Champions developed and implemented a quarterly anonymous survey of all FM providers, including physician and non-physician faculty, and advanced practice clinicians (APCs) in 2016. The feedback survey was designed to identify and address high priority areas of faculty/provider dissatisfaction. Using a Plan-Do-Study-Act model, the process was regularly evaluated and modified based on feedback from participants. This paper reviews the first year's full PDSA cycle, although small changes in the survey and discussion of results happened throughout the first year. Participants were asked to anonymously identify areas of concern and suggestions for improvement within each of the following areas using free-text responses: administration, clinic, personnel, scholarship, teaching, wellness, service, and responsiveness to concerns. Free text comments from the surveys were distributed to the Wellness Champions and division leadership. The Wellness Champions examined the comments thematically and created over-arching recommendations, which were reviewed and acted upon by division leadership. The recommendations and action items were presented to the entire faculty group on a quarterly basis at division meetings, with unedited survey comments distributed beforehand. See Table 1 and Figure 2 for additional description of the survey process.
Impact of the survey on faculty/provider burnout was measured by annual administration of the anonymous modified Mini-Z survey. The four Family Medicine Wellness Champions were supported by the systemwide Wellness Champions program which provided regular coaching, sessions on professional well-being and value improvement, and administered the annual wellbeing/burnout survey.

Results
Using the modified Mini-Z survey results for the years 2016 and 2017 on burnout, stress, and workload control, exploratory analyses examined significant changes in answers between the two years. Characteristics of participants in both years are shown in Table 2. Response rate was 100% in 2016 (29/29) and 92% (23/25) in 2017. Both the burnout and workload control questions had possible answers in the form of a Likert Scale from 1 to 5 Similarly, stress had possible answers in the form of a Likert Scale from 1 to 5 such that 1 is an indication for strong disagreement of feeling a great deal of stress because of job while 5 is an indication for strong agreement. The results for the modified Mini-Z instrument are displayed in Tables 3 and Table 4. Table 3 tabulates the difference in proportions between 20016 and 2017 for the dichotomized outcomes and drivers of the Mini-Z instrument, while Table 4 tabulates the difference in means between 2016 and 2017 for the numerical outcomes and drivers of the Mini-Z instrument. The dichotomization of the outcomes and drivers of the Mini-Z instrument in Table 3 was well justified given that the power loss was not considerable and effect sizes were maintained when comparing proportions relative to  Table 2. Burnout substantially decreased (48% to 25%) over the year of this project showing a medium effect size (Cohen's h ¼ 0.490) while being on the boundary of significance (p ¼ 0.097). In fact, the mean burnout score decreased from 2.52 to 2.08 over one year (Cohen's d¼0.535 with p ¼ 0.064). Family Medicine faculty sense of control over workload also improved significantly (p ¼ 0.011) from 10% to 42% over one year exhibiting a large effect size (Cohen's h ¼ 0.751). The t-test showed a difference on the boundary of significance in mean answers of workload control between the two years (pvalue 0.105) with roughly medium effect size (Cohen's d¼0.364).
Our data indicate that the decrease in burnout was significantly associated and coupled with an increase in faculty sense of control over workload (Person's r¼ -0.485, p ¼ 0.0002) as shown in Figure 3. In fact, we have observed that a one unit increase in faculty sense of control over workload is associated with -0.4 units decrease in burnout. Further, we have examined how the change in burnout from 2016 to 2017 is mediated by sense of control over workload. We found out that the proportion of the total effect that is mediated is about 0.39 which is a respectable amount. The ratio of the indirect effect to the direct effect is about 0.65 or almost 2/3 the size of the direct effect. And finally, the total effect is about 1.65 times the direct effect.
While statistically insignificant (p ¼ 0.154), jobrelated stress was reduced from 72% to 50% demonstrating clinical significance (Cohen's h ¼ 0.465). This effect was more pronounced when comparing the mean stress between the two years using the t-test. Specifically, the mean stress score decreased from 3.76 to 3.25 over one year (Cohen's d¼0.451 with p ¼ 0.068). There was evidence from this study to argue a clinically significant improvement in workload control and reduction in burnout and stress because of job from 2016 to 2017, although this is also limited by sample size.
The closed loop feedback improvement process was an acceptable way for faculty to anonymously share concerns with leadership and for leadership to hear what was specific to one or two faculty vs. the larger group. It provided an approach to highlighting problems and facilitated working towards a commonly acceptable solution, giving insight into impacts on burnout and professional well-being of faculty. The faculty survey identified thematic concerns, which resulted in constructive solutions and systemic changes. FM   faculty/providers initially communicated themes related to: long clinic hours of operation and lack of scheduling flexibility; desire to improve work efficiency/clinic flow; recognition of academic work; lack of sense of control; and poor mission alignment. See Table 5 for representative examples of thematic issues with quotes and resulting solutions.
Leadership addressed concerns at division meetings and through policy changes, including shortened clinic hours of operation and reducing the number of faculty clinic sessions canceled due to space constraints, which improved work flexibility. Procedures for facilitating time away requests supported schedule flexibility. Clinic flow and efficiency improvements are ongoing with steady changes. An academic relative value unit (RVU) strategy was reviewed to recognize academic  Table 5. Action Plans Implemented in the Division to Improve Provider Well-Being.

Issues Identified Quotes Changes Taken Category
Long hours of operation; inconsistent workload "Close the clinics at 7 pm. It is rare to find a provider or a patient who would rather see or be seen after 7.
We are only open then out of convenience for scheduling and room access. Find another way. This is huge for morale." Condensed hours of clinic operation and allowed providers more schedule flexibility as long as all hours covered; Templated schedule to reduce variation Workload; work-life integration Faculty frequently bumped out of clinic to accommodate resident clinic requirements "If you want providers that are going to be here for a long time and continue doing a quality job, there needs to be better scheduling practices. They need to be consistent, they need to support healthy work-life balance, and they need to be what each individual provider wants/needs. I know this is a work in progress, and I hope things will improve." Schedule faculty first and residents second, in order to reduce faculty bumps out of clinic work. Salary is now more accurately tied to amount of time spent supervising residents.

Discussion
The implementation of a closed-loop survey process facilitated communication between a team of division faculty/providers and leadership allowed a deeper understanding of the challenges of a group along with a roadmap for action. This process allowed division leadership to identify factors contributing to provider burnout and target appropriate organizational changes. Support by leadership of this project was essential to its success as they were responsible for implementation of suggested changes. Over one year, FM faculty/providers at the University of Utah experienced a substantial decrease in burnout and an improved sense of control. Correlation between control and burnout is an ongoing area of interest in the literature and worthy of further investigation. Randomized studies have demonstrated that improving communication and targeting interventions to address clinicians' concerns may be an effective means of improving burnout among healthcare providers. 11 The survey process represents a cost-effective, time-efficient means of allowing faculty/providers to share ideas and concerns with leadership in a safe and reliable manner. This process is intended to give faculty/ providers an opportunity to impact change, which may reduce burnout through an improved sense of control. Faculty/provider wellness has institutional reverberations by impacting recruitment and retention of faculty and clinicians, 12 and the potential to impact the learning environment of all trainees. 13 Attention to improving faculty/provider wellness is a worthwhile investment in the many academic missions of medical institutions. A ground up approach, such as in this Wellness Champions model, is an important complement to system wide strategy, which at the University of Utah is led by the University of Utah Health Resiliency Center. These results on burnout and sense of control must be interpreted with caution, given the limitations of a relatively small sample within a single division at one institution. It is also difficult to disentangle whether the effects are due to improved communication by completing and discussing a survey or due to the structural changes that followed. In future efforts, the ability to pair survey answers on the same individual would help to clarify changes in responses by reducing potential confounding factors. Longer follow-up with more varied populations is needed to better understand the mechanisms underlying improvements in burnout and control. To better understand a true impact vs. regression to the mean, longer studies that look at groups in a variety of levels of distress will be helpful. Consideration of sustainability is also important.

Conclusion
A closed-loop anonymous survey may help improve well-being in a variety of health care professions by facilitating discussion about issues that contribute to professional fulfillment ultimately leading to organizational change.

Authors Note
This project was reviewed and deemed exempt by the University of Utah Institutional Review Board.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.