Joey Wahler (Host): It's a major issue right now, so we're discussing burnout and elevating workforce health. Our guests, Tim Fischer, President of Jackson & Coker Locum Tenens, one of the nation's largest physician and advanced practice locum tenens staffing firms. Jackson Healthcare is one of ACHE's premier corporate partners. Our premier corporate partners support ACHE's vision and mission to advance healthcare leadership excellence. For more information on Jackson Healthcare, please visit the corporate partners page at ache.org. We're also joined by Corey Feist. He's CEO and co-founder of the Dr. Lorna Breen Foundation. This is the "Healthcare Executive" podcast from the American College of Healthcare Executives. For more information, please visit ache.org. Thanks for joining us. I'm Joey Wahler. Hi there, gentlemen. Welcome.

Tim Fischer: Hey, Joey.

Corey Feist: Great to see you, Joey.

Host: Same here. We appreciate the time, of course. So first, you've each spent years working directly with health systems on workforce health issues. And so to get us started in a nutshell here, what does your work actually look like on a daily basis, and why has this particular issue become such a focus for you? How about you, Tim?

Tim Fischer: Well, there's a lot going on under the healthcare industry in the United States right now. And I think there always has been, but there's a lot going on right now. So from a locum tenens standpoint, we basically are moving physicians and advanced practitioners around the United States from areas that have plenty of them to areas that need help. So, that's kind of what we're doing on a day-to-day from Jackson and Coker perspective. But the bigger issue is there's a lot of people working in healthcare right now who are struggling. And I'm looking forward to the discussion today. And obviously, Corey and his team are doing a lot of amazing things to combat what's going on with burnout and wellbeing of people who are working so hard to take care of us. So at a high level, we're partnering with Corey and his team to try to help solve that problem.

Host: And how about you, Corey?

Corey Feist: Well, I'm glad we have an hour and a half for this podcast, Joey, because I think your first question is a critically important one and it bears some thought and real depth of discussion. But at a high level, we have 21 million health workers in the United states. And just a couple years ago, the occupational safety arm of the CDC, an agency called NIOSH, did a comparison of the mental health of health workers in the United States compared to all other job sectors. And it identified that health workers in the United States have the worst mental health of all job sectors. That was a huge surprise to me as somebody who had worked a career in healthcare, because many of the issues around the mental health and the need and the access to mental healthcare by our health workforce are hidden in plain sight from the leadership and certainly the patients.

But, you know, when NIOSH published that report, it identified that almost half of health workers in the United States were burnt out. Almost half of those health workers were looking at new jobs. Violence and threats were all up against health workers, as were their poor mental health days, their days off because of their poor mental health.

And so, we have a crisis in the United States because without a thriving and sustainable health workforce, we have no healthcare delivery system. And the well-intended response by the healthcare industry to the workforce's challenges the last few years have really been very important to what I would refer to as hold pressure on a bleeding wound, and that wound being burnout. But we have not accelerated our maturity in this work to one where you're getting to the root cause of the problem, and I hope to get into that a little bit more with you all today.

Host: Well, certainly, Corey, some very eye-opening numbers there to say the least and concerning as well. So, an important discussion indeed. Before we go any further, Corey, I know that the Dr. Lorna Breen Foundation recently switched its name. It used to include the word heroes. Of course, you and yours are heroes, but why the switch?

Corey Feist: Thank you for asking that question. We were created in the summer of 2020 when the nation of health workers and their families and friends responded to our family after my sister-in-law, Dr. Lorna Breen, died by suicide. And in that moment, in the summer of 2020, if I take you back there to when the country was really celebrating our health workers as heroes, banging pots and pans, hanging signs up across our healthcare delivery system, celebrating the heroes, there was a connotation there that the efforts that health workers were making was really and truly heroic.

Over time, that sentiment has evolved, and frankly, we need to think first about our healthcare workers as humans before we gave them that accolade heroes. And so, I think this is really encapsulated in a letter that a nurse wrote to her employer before she took her life just a couple years ago. This nurse's name was Tristin Smith, and she said, "When we think we are going to receive the love and support that we deserve, we get pizza parties and pens for the healthcare heroes." And in that sentence that she left in that letter, it has really stuck with me and our organization, and really, I think represents the larger sentiment here. And so, we've removed that word from our name and really just trying to recognize that these are truly humans, and we need to take care of them just as they take care of us.

Host: Appreciate the interesting background there. So next up also for each of you, if we don't invest in the workforce, the system starts to fracture, as we've already touched on. So for a health system leader, what does that fracture look like in day-to-day operations, Tim?

Tim Fischer: Well, I think the system does not fail just instantly. So, let me start by saying I think CEOs of hospitals in America, executives of hospitals are under tremendous pressure right now. And I think most of them are very mission-driven, they want to take care of the communities that they're in, and they're very focused on helping people. And so, I'll say that. But it's a very difficult environment right now, because they're under a lot of financial pressure, and it's easy to forget about the people and the importance and how that kind of translates the financials.

So when the system fails, it rarely shows up all at once. It usually shows up as friction in the system. And then, it's inconsistency, and then it's instability. You know, schedules become harder to fill. The best people start carrying the weakest parts of the system. Burnout begins to look like a performance problem where before people now are getting less patient. They're less collaborative, less willing to go the extra mile, the workforce. Turnover accelerates, patient throughput deteriorates, quality becomes more hit-and-miss, physicians become less productive, middle management gets crushed. It's a slow burn. It doesn't just happen. And eventually, the patient feels it. So, we have to focus on people first. And the financial challenges that we all have in this current environment, they are a challenge. But we have to make sure that we're working with the workforce and caring about the workforce and asking questions and building an environment where they know they're surrounded by people who care about them, and that will keep all those things that I talked about from happening.

But we work with hospitals in all 50 states, and I see varying levels of everything that I just mentioned. And it doesn't just happen like that. It's a slow burn. And there's a lot of hospitals that once they start to see friction in the system, instability, they're not sure what to do. And again, that's where I think Corey and his team can really provide a lot of value. So, that's how I see it.

Host: All right. Certainly a lot of different things you listed there, Tim, to think about. Corey, what do you want to add to that?

Corey Feist: I think Tim did a great job. Recruitment, retention, quality of patient care, access to patient care, patient satisfaction, all of these are what I would refer to as lagging indicators of burnout. We have to remember that burnout is an occupational syndrome. It is a workplace-created syndrome, and it manifests in the individual.

And so, the symptoms that we see, those things that I just mentioned, all are really manifestations of this problem that we need to address at the root. Boards of directors, leaders will see these numbers start to tick up in terms of their turnover, difficulty in retaining, what would often have been thought of as professionalism issues between colleagues; as Tim was saying, shortness between colleagues in terms of communication. All of these things are really symptoms of this problem, which is why we think it's critical to address it at the root.

Host: And so Tim, having said all of the above so far, why do you think CEOs and boards should be thinking about workforce burnout as a core business risk and not just an HR issue?

Tim Fischer: Well, again, I want to emphasize that I think CEOs and boards of hospitals are under tremendous pressure right now, I get that. And I think they're under more pressure now than they've ever been. So, there's a lot of things that are out of their control that they're waiting to find out, you know, the Medicare reimbursements and Medicaid changes and the Big, Beautiful Bill and all the different things.

There's so much going on in healthcare right now, that being an administrator in a hospital or healthcare system has never been more challenging. So, I think at the C level and the executive level, they're struggling with burnout, too. And I think they're struggling with their wellbeing. And I think a lot of leaders feel the burden that they have of leading a hospital or healthcare system in their community, and that burden is heavy. I think a lot of the people that you mentioned, the CEOs, are struggling with this themselves. So, it's really trying to figure out a way to put people first.

And I think the numbers back up that if you don't take care of the people that you have in your workforce and they leave, it just makes it worse. So fundamentally, you have to take care of the people that you have that are obviously very good at what they do. And by doing that, it will best position you to deal with some of the other challenges that you're dealing with as a CEO.

Host: And Tim, when leaders start to see burnout as a business risk, it changes how they think about solutions. But you push back on the idea that burnout is a resilience problem. So, where do you see organizations putting that burden on individuals instead of fixing the system?

Tim Fischer: I don't know many people in life that would respond well when they're struggling with their wellbeing or they're burned out, which are two different things, by the way. I don't know many people that say, "Hey, thank you for telling me I need to be more resilient" as the solve to my problem. That's the issue. You need to be more mentally tough, or you need to be more resilient. I think people who are struggling and really care about what they're doing, and they're driven by mission and purpose, they almost consider that offensive, I think.

So, it's not about the system or the people being more resilient, that's going to fix the system. I don't think that's the solve. I think it's a much more complex issue than that. And I hear people talk about resiliency and, you know, that's the answer. I don't think that's the answer. And there's so much more to that, which I know we're going to talk about, but that's my take. When people are struggling, they don't want to hear, "Be more resilient."

Host: And so, Corey, when you layer in the aging population and projected shortages, what changes if this issue isn't addressed right now?

Corey Feist: We don't have enough health workers to take care of the aging population. Hard stop. I recently testified before the Senate Committee on Aging, and in that testimony identified this phenomenon, which is called the silver tsunami, which is a 46% increase in aging Americans between the ages of 60 and 90.

And when you think about the demands that that population is going to create on the workforce, there simply will not be enough healthcare delivery to take care of those aging individuals. And the good news in all of this story, though, is there are solutions, and I know we're going to get to it, that will allow organizations at a very, very low investment to address these issues.

Again, at the root of the problem, as Tim was alluding to, you know, the word resiliency has become a four-letter word to healthcare workers. And so, we look forward to engaging in that part of this conversation because while there are big red flags out there and big downstream impacts associated with the aging population, and this corresponding rise in burnout across all of our healthcare workers and leaders, as Tim has said, there is hope on the horizon, and that hope is in addressing the solutions at the root.

Host: And again, Corey, some definitely attention-getting numbers that you just provided there. So regarding the day-to-day experience of clinicians, how, Corey, should leaders think about administrative burden, not as an inconvenience, but as something directly impacting retention and that care delivery?

Corey Feist: Administrative burden is the root of much of the burnout in the United States. And so, what's really important for healthcare leaders to understand as they attempt to address the burnout challenges is that this shows up in different places, in different spots in your organization at different times of day.

And so, the most important thing that organizational leaders can do is to start by asking the workforce what is it that gets between them and their patients, because administrative burden will show up in different ways. Nonetheless, when you realize that about 40% of the time that a physician spends is away from the bedside in administrative burden. And about half the time that a nurse spends is away from the bedside working on administrative tasks, you then quickly start to do math and say, "Hold on a minute. For every percentage that I can decrease or eliminate the administrative time that the clinicians are taking, that can increase the amount of time that they have to spend with patients." And so, being laser-focused on eliminating first administrative burden is going to benefit all of your populations across the workplace.

And so, we are really advocating for a shift from this conversation around resiliency to one of let's look at the cause of this issue, heavily focused on administrative burden, and let's circle that on everyone's page, make it part of our organizational priorities and goals, and we will see all of the other KPIs that we report to our boards of directors go in the direction that we want.

Host: And Corey, the loss of autonomy can also contribute to burnout. So, what would you say that actually looks like, and why does that push people to leave?

Corey Feist: There's an organization called Medscape that surveys physicians every year about their burnout. And when you look back to which physicians in the United States are most burnt out, those with the least amount of autonomy are the most burnt out. And so, the concept of autonomy can be a threatening one to those in leadership positions. I just want to say that. And yet we need to embrace the fact that when someone doesn't have control over their schedule, are required to fit complex patient care into incredibly tight bands that don't necessarily reflect the complexity of the care, that their compensation is exclusively driven on productivity metrics as opposed to other types of metrics. These all create in the individual clinician a feeling like they are just a cog in the wheel. And when you do that, it contributes to the burnout of the workforce. And so, when you look at actually that data from Medscape over the years, the top two drivers of burnout are administrative burden and loss of autonomy.

And so again, when you realize that these are the drivers, it's not that these individuals are less resilient than others, that they're just being difficult, that they're frankly focused exclusively on the dollar signs, that's not it at all. They've lost any ability to take care of patients.

And I want to just introduce a concept here, which came from the military, which is called moral injury. And moral injury is a condition that's experienced by our clinicians in the United States when something outside of their sphere of influence and control is dictating to them how they take care of patients.

And it often manifests in them having additional burnout, and it can contribute to depression and other mental health conditions because simply the system isn't allowing them to do what they trained to do. And so whether it be the administrative burden or the lack of autonomy, these issues are creating this toxic cocktail, which is, again, leading to increases in turnover, increases in mental health needs, and really this crisis that we have as the United States healthcare delivery system right now.

Host: Tim, back to you. When health systems lose people, of course, they come to you. So, what does that tell us about what's breaking? And what does the growth of locums work reveal about what clinicians are seeking, including the price tag on turnover?

Tim Fischer: We here at Jackson and Coker have an interesting perspective on our healthcare system in America. So, I mean, let's talk about price tag on turnover that you mentioned first, and then I'll talk a little bit about locums. The MGMA, the AHA, AMA, their numbers that they have published on this say that anytime a physician, I'm talking physician specifically, a physician leaves and you have to replace that physician, it's anywhere from 500,000 to a million-dollar financial hit. It's a big number. So when somebody leaves, it's a big number. There's a cost, the revenue that they were generating for the system by providing quality care to their patients when they leave, the ecosystem that they have that goes through them. There's so many variables as far as financial, in addition to just finding a new quality physician, which there's all kinds of cost, and then you have signing incentives, and you have relocation.

So, the number when a quality physician leaves is a massive number. And again, I've already said a lot of executives in the hospitals are under tremendous financial pressure right now. So, there is a financial incentive to make sure that people are happy and that they're getting joy from the profession that they signed up for as opposed to the alternative.

From a locums perspective, this sounds bad, but we would prefer that there be no need for locums, that all the physicians in the United States were so happy in their profession working where they are that they never left and went somewhere else. There aren't enough physicians and there aren't enough healthcare workers in the country, but we're trying to be more than just transactional locum tenens firm.

In other words, "Oh, you need a surgeon in Indiana?" Okay. We can find a surgeon for you that can cover for the next three months. But we're trying to take it a step further and say, "Why do you consistently need a surgeon? Why do you need three urologists in this area?" And then, digging into the heart of the problem. And many times when we do that, it comes down to people leaving because they don't feel like anyone was listening to them. So, they're trying to find a leadership and culture environment where they can thrive, to Corey's point. They feel like a cog in the system. They're asking themselves, "Is it better somewhere else?"

And then, they're moving around from job to job trying to find a leader in a culture where they don't suffer from a wellbeing standpoint, and that they feel like they get joy from what they wanted to do. So, there's an economic factor, absolutely. But by taking care of the people who work in the system and truly getting to know them in a way where you know where they are and they feel comfortable, they feel the psychological safety to talk to people around them, that's the type of environment that people want to work in. And when you do that, the financials take care of themselves.

Host: Well, Corey, you mentioned your testimony earlier. And in your testimony before the Senate Special Committee on Aging, you called out prior authorization. So, what's the executive case for treating that as a workforce and patient experience issue, not just a process issue?

Corey Feist: When you think about that Medscape survey that I just referenced and drivers of burnout, when you look at the administrative burden bucket, there are two big categories there. Administrative burden created by the electronic health record and the inefficiencies there, the direct patient messages that are on the rise, the secure chat messaging between clinicians, the inefficiencies in documenting care, and then there is prior authorization.

And prior authorization was included in my Senate Special Committee on Aging testimony for two reasons. One is because it is a big driver of burnout, and the second is that there was a piece of legislation that is before Congress, and was at that time called the Improving Seniors' Timely Access to Care Act of 2025, which was focused on making and streamlining prior authorization for Medicare Advantage patients.

But all of these issues, as we start to uncover them, give us a roadmap for action. And so, for leaders in the organization to be able to identify that what these drivers of administrative burden are gives them that roadmap to then address it, eliminate it in their sphere of influence and control, because there is a lot more that you can do with it at the state and local level than even at the federal level.

But we need to recognize that there's a direct relationship between the burnout of our healthcare workers and the quality of our patient care, as well as clearly the access to our patient care. So, this issue, which might to some seem like just another paperwork issue, really has a downstream impact on those who we are all in this business of serving our patients.

Host: And Corey, beyond process, there's also work environment. You've talked about safety, especially for nurses. So, what's non-negotiable would you say if organizations want people to stay and feel supported?

Corey Feist: I'm glad you raised safety, because violence and threats against our healthcare workforce, and I would say of all types of healthcare workers, has been on the rise. And so, I think one of the non-negotiables here for healthcare leaders and really the industry is to check in with our workforce first and foremost to see what it is that is driving them to leave. And in some cases, that's going to be a drive in administrative burden and just all of the other things that are not patient related. In some cases, it will be the rise in threats and violence and not feeling supported.

But your question really reminds me of a survey that I saw early in the pandemic that came out of the American Medical Association, and that survey was a Coping with COVID-19 survey, and it surveyed all health workers. I'm a lawyer, like even the lawyers got questioned. But it identified something that was really striking, which was that less than half of the workforce in the United States felt valued and supported by their organization. And what the AMA was able to then do was to say, "Okay, where workers feel valued and supported, their retention increases, their patient quality increases, again, all the KPIs increase."

But for me, I have a different answer to the question of what makes me feel valued and supported than Tim does. And so, what our leaders need to really recognize and understand, irrespective of where they sit in an organization, in the C-suite or on the front lines, is that the first and most important thing they need to do is check in with their workforce and just simply ask that question as a starting point. What is it that makes you feel valued and supported? What is it that is getting between you and your patients? And using those answers as our guide to address the problem moving forward.

Host: Tim, back to you. And if a leadership team member is listening right now and the message from the two of you has gotten through, and hopefully, of course, it has, if they're thinking, "We need to act," what's the first step to move from awareness to real change?

Tim Fischer: Well, I want to take a little different approach to this because, a month or two ago, I was at an ACHE cluster in Boston and I was in a room for two days with a group of executives, a lot of CEOs of hospital systems. And it was kind of eye-opening for me because Corey and I have had many conversations through the last few years on this around healthcare workers.

What surprised me was I was sitting there with CEOs and CNOs and people with very big titles and a lot of responsibility, and they were pretty vulnerable themselves. So, the audience of ACHE, we have a lot of leaders of these systems who are struggling with the same issues themself, and they don't want to raise their hand and ask for help because, say, they're a CEO of a hospital in a rural community, and they're on Rotary Club with this group of people, and they go to the football game on Friday night. They're the CEO. They feel like they should have all the answers. But in their reality, they know that they're struggling to keep the hospital open, and there's so many challenges that they're dealing with on a daily basis that people don't understand. So, the first thing that leadership can do is take care of themselves.

Self-care will then lead to a better culture for everyone else to work for if the top starts with themself. So, you have to take care of yourself first. And then, I think just by doing that and understanding the importance of that and being intentional with that, then you will foster a culture where people do feel value, as Corey just talked about, and they feel the support. And when people feel value and they feel the support, the financials will improve, the KPIs will improve, the patient care will improve. And I think sometimes because of the financial constraints in the system right now, the healthcare workforce turns into a spreadsheet. When it turns into a spreadsheet, that's not good. And the financials actually deteriorate rather than improve. So, I think it all comes back to taking care of themself as a hospital leader and then fostering a culture where people do feel valued and supported.

Host: All right. A few other questions for the two of you. Corey, which organizations that are doing this work we're discussing have gotten it right? What would you say they did first? What was the cost? And what fundamentally would you say changed as a result of all that?

Corey Feist: The approach to this problem is more than the resilience conversation that Tim noted at the beginning. And so, the very first thing that those organizational leaders recognized is that this is multifactorial, and this is not about exclusively asking our healthcare workers to be stronger healthcare workers.

To use a phrase that we've heard, we're not asking the canaries to be stronger canaries. We are working to redesign the coal mine. So, the very first thing they did is recognize that this problem is not, as you just suggested in earlier questions, an HR problem to solve, because HR is not responsible for the operations of the organization. So, that's the first thing that they did.

Then, they did something which is critically important, which is they used some of the national resources, whether those are from the Lorna Breen Foundation, whether those are from the National Academy of Medicine, whether those are from NIOSH, which is again that occupational safety arm of CDC. But they then took that approach down to the level of the workforce and simply asked the question, again, in an assessment of, "What is burning you out?" This is not, by the way, an engagement survey. This is a different type of a survey, and there are a tremendous number of burnout surveys and assessments that are available online.

But they then took that approach. They then took the approach of doing this work in an interprofessional way, because what we've recognized and what we need to continue to reinforce in this heavily siloed industry that is our healthcare delivery system, that there is a tremendous amount of overlap between all of our professions. Leaders, frontline workers, frontline leaders, every clinician in the place. There's about a 90%, I would say, overlap in the issues. And so, we need to attack this problem recognizing that and doing it in an interprofessional way. So, that's the next thing that they did.

The next thing after that that they did was they tied this to their quality and performance improvement initiatives that they already had underway. The infrastructure that they had already built to focus on the quality of patient care. They then incorporated this work into those teams, into those who are specifically trained in process improvement to simply shift their view 10 degrees to say, "I'm not just going to look at this process on its impact on patient care, but also on the impact of the work on the workforce." So, those have been some of the key steps that those organizations have taken.

Another key element of it is that they've elevated these conversations to their board of directors, and not just simply by reporting lagging indicators of key performance indicators like retention or turnover rather. But taking to them in real time what they're hearing from their workforce and what they are doing to address it systems wide, and how that then ties to the other key performance indicators in the organization. What these organizations who've taken this approach have seen is an increase in retention, improvements in quality and performance, reductions in cost. And so, all of the KPIs that they kind of cared about, if you will, were moved through this approach.

Host: In summary here, for both of you, if you could ask one thing of health system executives in the next 90 days to protect the retention we've been discussing, what would it be? Tim, let's start with you.

Tim Fischer: I don't know if I would frame it as protecting retention, but I think it's dealing with all the issues that we have just talked about. And I think it's really three things. First is take care of yourself. You know, a lot of times, it's like the starving baker analogy. The baker that made great bread, unbelievable bread for the whole community, but never ate themself and they died of starvation, but they were the best baker there was. Like, you have to be careful because some of the best CEOs around America that I've talked to about this issue, who are very intentional and are educated on the issue, they are so focused on other people in their system that they're responsible for, that they're not taking care of themselves. You have to be very careful not to do that. So, take care of yourself.

Second one is educate yourself on the issues that Corey and his team are focused on. And be very intentional on setting up a program that works. Just because you hire a chief wellness officer does not mean that you're responsible for feel valued and supported. That's not a check the box and it's done. There's so much more to that. It's such a complex issue.

And then, the last one is a lot of times I'll talk to people. And when I travel around the country, I'll have hospital administrators say, "Hey, I know we're struggling with this. We want to do right by our people. We want a system where they feel valued and supported. I just don't know how to do it." And what I tell every one of them, and I have told every one of them and will continue doing so, is call the Dr. Lorna Breen Foundation and just tell them, "I want to solve this problem, and I don't know how." Just ask for help. The foundation is made up of incredible people who care, and they will work with you to come up with a program that works.

Corey Feist: Thank you, Tim, for that incredible endorsement. We do have a wonderful team at the Dr. Lorna Breen Foundation, and thank you so much for that. If organizations are looking for resources right now, and I would say the very first thing that I would do if I was in a leader position, I would familiarize yourself with a guide that is called the Impact Wellbeing Guide. It is on the CDC website. We co-created that with NIOSH. And it is a step-by-step leader guide to how to comprehensively address these issues using as many existing resources as possible.

So, that'd be the only addition that I would have is take a look at the Impact Guide. All of our work at the foundation is really grounded in that guide. And so, the next thing you can do is give us a call or reach out to us through our website at drlornabreen.org.

Host: Well, we trust you're now more familiar with burnout and elevating workforce health. Tim, Corey, keep up all your valuable work. We appreciate the time and the discussion, and thanks so much again.

Tim Fischer: Thank you.

Corey Feist: Thanks for having us.

Host: And a reminder, Jackson Healthcare is one of ACHE's premier corporate partners. Our premier corporate partners support ACHE's vision and mission to advance healthcare leadership excellence.

For more information on Jackson Healthcare, please visit the corporate partners page at ache.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of the Healthcare Executive podcast from the American College of Healthcare Executives.