February 2021

OBGYN

P2P NETWORK: SCALING PEER SUPPORT FROM PILOT PROJECT TO HOSPITAL-WIDE SERVICE

Featuring: Angela Chaudhari, MD
What Was the Problem?
Physician burnout is an epidemic in the US health care system with 44% of physicians reporting signs of burnout such as emotional exhaustion and depersonalization at least once per week.1 Individual strategies to increase resilience such as yoga, meditation, and resilience training are often considered mainstays of combating burnout; however, literature suggests that resilience amongst physicians is already high.2 Instead, approaches that create engagement and address drivers of organizational burnout may make more of a difference in reducing physician burnout.

The Scholars of Wellness (SOW) program was created at Northwestern Medicine in 2017 to develop physician champions into well-being experts capable of channeling their unique insight and personal experience into developing, launching, and leading wellness programming for their colleagues. Ten physician Scholars of Wellness across several departments were chosen for the first cohort. Wellness projects ranged from ergonomics in workspaces to improving electronic charting to peer support.

​Developing the Intervention
Angela Chaudhari, MD, a practicing obstetrician-gynecologist and one of the Scholars in the original cohort, recognized the need to combat distress and burnout related to adverse events experienced by colleagues in her department. As her SOW project, she created a peer support program for the OB-GYN department at Northwestern.

Dr. Chaudhari's project followed 3 steps (Figure 1).
Assess the underlying problems
First, the problem was defined and measured via a survey of departmental physicians regarding adverse events and complications. The survey found that >50% of physicians had experienced an adverse event in the previous 6 months, and most of these physicians stated they would utilize support if available. When queried whether they had ever used the hospital-wide Employee Assistance Program (EAP), only 7% of physicians reported ever using this resource. This left a disconnect between use of current resources and desire to utilize these resources.

Survey respondents indicated they did not use the EAP because “I didn't think they would understand because they haven't had experience with something like this,” “It didn't seem like my stress was bad enough to use EAP,” and because “I didn't have time.”

The survey was supplemented by an exploration into current processes to understand how complications were reported in the department: morbidity/mortality conferences, peer review triggers, and risk management. These assessments established the need for a peer support program.

Recruit volunteer peer supporters
Volunteer peer supporters were actively recruited by email and during department-wide presentations at Grand Rounds and faculty meetings. Peer supporters were chosen from a list of volunteers from across subspecialties. Peer supporters were then formally trained in techniques including utilizing nonjudgment, active listening, normalizing, and reframing. Training materials were developed in-house and supplemented by teachings from peer support programs at other institutions, such as the Center for Professionalism & Peer Support at Brigham & Women's Hospital/Harvard Medical School.3,4

Establish contact and referral processes
A department-specific confidential email for peer support referrals was created and advertised to the department for self and peer referrals. In addition, partnerships with Risk Management were created to best identify adverse events in the department that could benefit from peer support given the low utilization of the Employee Assistance Program. For these Risk Management referrals, a standard method was established so that contact occurred within 72 hours of a reported event, and follow-up contact was made 1 week after the initial reach-out. All program referrals were routed through Dr. Chaudhari and were then distributed to volunteer physician peer supporters to maintain confidentiality.

Barriers
Barriers to this pilot intervention were minimal, as both the chairman and department administrators of Obstetrics and Gynecology were heavily invested and supportive of innovative engagement and wellness programming.

Results
In the first 6 months of implementation of the departmental program, 26 OB-GYN physicians were referred for peer support. No formal records were collected after the support meeting to keep all information confidential.

Individual responses included: “getting an email after... made me feel seen by my colleagues” and “having someone from the program reach out really helped me cope with my stress after....”
—Anonymous physician participants in the OB-GYN peer support pilot program

Scaling Up
Given the pilot success, Gaurava Agarwal, MD, Director of Physician Well Being chose to scale this Scholars of Wellness peer support pilot across the hospital for all attending physicians. Due to her work on the pilot, Dr Chaudhari was recruited to scale the physician-to-physician peer support program for the entire region and ultimately to lead what became known as the P2P Network. The primary goal of the P2P Network was to provide confidential peer support for distress and support after adverse events to physicians regardless of rank, department, and specialty.

New challenges emerged as the pilot was scaled from a departmental service to a regional service.

  1. Awareness and marketing became more difficult. Adaptation was required to reach the many departments and physicians in the region. Individual, personalized engagement with divisions, departments, and private medical groups was performed via presentations at faculty meetings, Grand Rounds, and lunches. These forums promoted the program. Verbal feedback was encouraged at these meetings to tailor programs to the needs of the many different physicians and departments.
  2. Concerns about confidentiality as top priority came to light. To alleviate these concerns, a partnership was created between the Medical Staff Office and the Department of Physician Well-Being, which helps to protect these conversations under the Illinois Patient Safety and Quality Improvement Act.
  3. The referral process became more complicated. To streamline this process the Department of Physician Well-Being set up and managed a hospital-wide email address for referrals. Risk managers across departments also held many meetings throughout the first 6 months of implementation to better script and directly refer physicians for support. Proactive outreach after an adverse event is currently thought to be the best practice for establishing peer support. Therefore, all adverse events reported to Risk Management were referred to the P2P Network, who then contacted the physicians involved. Physicians were able to opt out of peer support at any time. Champions of peer support on the risk management team helped promote the program. New sources of referrals, such as those from the patient liaison team, were also uncovered throughout implementation.
  4. Recruitment of peer supporters became more complex. Where the volunteer system was effective in a single department, this could not be replicated across multiple departments. Finding physicians that were interested, empathic, and had the ability to commit time to the program was not simple. Instead, peer supporters for the first hospital-wide peer support team were individually chosen by senior members of the hospital staff familiar with individuals who already often supported colleagues. Peer supporters were chosen across specialties, age, gender, and experience to have a wide breadth of supporters on the team. Importantly, all identified peer supporters were contacted by Dr Chaudhari and not directly told that they had been recommended by senior leadership. By changing this recruitment method, Dr Chaudhari was able to engage empathic physicians who already performed some level of support then train them in more formal peer support techniques. Knowing that some physicians are best supported from within the department while others may benefit from being supported by physicians outside of their specialty, supporters were recruited from both medical and surgical subspecialties. Supporters were surveyed on what scenarios they did and did not feel comfortable providing support. Certain scenarios, such as an unexpected maternal death or a child's death, may be trigger personal negative feelings for individual supporters due to prior experience, and the program recognized the importance of the emotional well-being of the support team in addition to their physician colleagues.


Scale-up Results
Six months after implementation, the P2P network has gotten more than 50 referrals spanning 16 different divisions and departments. Of these, 23 referrals originated from Risk management, 22 from peers, 7 self-referrals, and 1 from corporate health. These individuals were contacted by email, phone, or in-person support. Many physicians choose to interact through email, others by phone, video conference, or in-person. Follow-up emails are sent at 1 week after their initial peer support session. This follow-up sometimes leads to additional conversations or referrals for other resources. No record is made of the conversation, and all conversations are confidential. The service has been well received and more awareness of the support programming around the hospital is reported. Plans are in process for system-wide expansion as the Physician Well-Being Program has seen the service as a foundational component to creating a culture of caring. Through this process Northwestern learned that the P2P infrastructure can be expanded to create specialized support teams. These may include specially trained supporters for compassion fatigue, diversity ambassadors, and physicians facing stress from peer review or legal issues.

Conclusions
No single person, not even a Chief Wellness Officer or the Chief Executive Officer, is capable of transforming an organization's culture. However, by educating just 1 member of the initial wellness cohort and empowering her to create a departmental peer support program, the Scholars of Wellness Program's initial investment will return huge dividends. Dr. Chaudhari's participation in the Scholars program turned her into a well-being leader who is now funded in her role as the P2P Director; she also serves as a core member of the overall Physician Well-Being team. In addition, pilot programs provide a cost-effective opportunity to create learning mechanisms for organizations and well-being programs. Testing out ideas that may be useful could build momentum to accelerate change. Scaling the P2P pilot from OB-GYN to an entire region means that it will reach nearly 2000 physicians who will have a service available in their time of need.

About the Organization
Northwestern Medicine comprises over 200 sites with 10 hospitals spanning the Chicagoland area. The medical staff numbers over 4000 with 1000 residents and fellows and more than 1500 employed physicians. Its flagship campus, Northwestern Memorial Hospital, and the location of our regional program, is comprised of 894 inpatient beds and spans 3 million square feet of medical buildings in downtown Chicago. It has over 1900 employed and affiliated attending physicians. The Department of Obstetrics and Gynecology at Northwestern Memorial Hospital has 185 attending physicians, both employed and affiliated, and over 60 resident and fellow trainees.
This article was originally published in the STEPS Forward section of the AMA Ed Hub on    February 11, 2021. ​
Angela Chaudhari, MD, vice chair of faculty development and associate professor of Minimally Invasive Gynecologic Surgery.​

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