Thank you so much, Sasha, and thank you for the invitation to come here today and give both my personal research and perspective on this issue, but in addition to give what we at CMS are thinking about. I have my standard disclaimer that no financial conflicts of interest, and in many ways, I do not make any representations about this. But as we think about it, and it's already been mentioned, about the National Academy Report on Clinician Well-Being, and just for a framing of how CMS and the federal government has been thinking about this, and we are involved, and in fact, one of my medical officers is a member of this task force at the NAM. Now, a number of years ago, and during the previous administration, the administrator had really talked about focusing patients over paperwork. And as part of that, they redirected one of our offices to do a journey map of the complexity of hospital burden and some of the things that we at CMS and as regulators really put additional burden on all of us as clinicians. And you can see here that caring for patients, which is our goal between the accreditation, certification, the quality reporting, the utilization, and case management, which I know critical care physicians know a lot about, the case reporting, the coding, as well as the individual provider enrollment is quite complex. It's quite burdensome. So when you finally get down to doing what we think is most important, which is caring for those patients, that it really represents another reason that I think all of medicine is really having significant burnout. So in fact, during the previous administration, these were the strategic priorities in 2020 when I came in, that as you see, it really puts patients at the center, that part of the goal is unleashing innovation. And I just heard a lot of talk just an hour earlier on the ICU liberation bundles and how we can actually improve the lives of our patients and patient-reported outcomes. We want to empower patients, and we want to focus on results. So we've continued with that focus on patients at the center, but our current strategic pillars, which are identified by the Administrator Chakrita Brooks-Ashour, is around advancing equity. And as you know, the entire administration is focused on that, trying to close the gaps that we see throughout this country, expanding access, engaging our partners, driving innovation, directing programs, and fostering excellence. So within that framework, the Center for Clinical Standard and Quality, which I lead, developed the CMS National Quality Strategic Goals. And I'm going to go into some detail in some of these areas and how we think that really affects the way that we hopefully both burn out, but more importantly, how our patients receive care. We've actually changed and refocused on embedding quality across the entire care journey, from birth to death. And we know how important sort of the end-of-life decisions are, and I personally know that from many of my critical care faculty when I was the chair. We're very much oriented around whole-person care, which again gets to your ICU liberation. We have seen, and I'll talk more about that, to have deteriorated during the public health emergency with a lot of good reason. One of the key goals that I've really been talking a lot about is embracing the digital age, and how do we get to a future in which we're not checking bubbles and not sending data individually to CMS, but really pulling it through fast interoperability healthcare resources, FHIR standards, pulling it from the cloud directly, and reducing the burden of individuals from reporting. I'll talk more about strengthening resiliency and setting innovation. And what we're trying to do a lot is working to align the quality measures across all the different payers, so that you don't have to worry about looking at what does CMS want versus Aetna versus Blue Cross Blue Shield. So I am a clinician. I still remember very vividly March 2020, and I continue to practice, which has helped me inform some of the policies we developed at CMS. But as was mentioned, a lot of this depends around psychological safety and how that safety influences burnout, and I believe there's a strong, and I'll show you some work we did at the beginning of the pandemic. But that a colleague of mine, Amy Edmondson, talks about this idea that in a psychologically dangerous situation, we've got fear of making mistakes, blaming others, less likely to share ideas, as opposed to where there's comfort in admitting mistakes. There's learning from failure. There's everyone openly sharing ideas, and that gets to better innovation. I think that's the key to unlocking the directions we're going. In fact, we started to do work, and this is truly important, in debriefing after critical events that happened either in the OR and the ICU. And we did some mixed methods and worked with some anthropologists, and what we started to see is that the next generation, our residents, had a lot of problems with the debriefing process that almost half of them, if not more, tried to avoid meeting with the attending before they went home. And part of that is this idea that critical events are continuously reconstructed in their mind, that we actually develop mechanisms to cope with some of the stressors that we see, that, in fact, debriefing is just one stage of the event reconstruction, and that each stage, what we saw when we interviewed these residents was that they renegotiated how they felt about blame, culpability, and appropriate of the emotional response. And if you think about it, that that stressors that we put upon ourselves and our learners can actually increase burnout as we go forward. In fact, Amy Edmondson has this great two-by-two graph, which I strongly urge as we teach the next generation as we work towards it, that you need high psychological safety, but only with accountability, that all of us know that if there's, in fact, low accountability and low safety, there's apathy. But if there's low accountability and high safety, that's comfort. That's not the learning that we want, that it's really that mixture of high safety but high accountability. And that's what, at least as a teacher, but also as somebody who works with others, is the sweet area that I was trying to get to. So shortly after the pandemic started, I woke up one morning and my friend, Segal Barced, sent me this article that she had just written for the Harvard Business Review. And we had been doing research in the ICU before this, and what she says is medical and public health are working as hard as they can to control the spread. We need to, of course, listen and heed their advice. And what she's really talking about is stemming negative emotional contagion and making positive emotions more infectious will make us feel more prepared and in control during this frightening period. In fact, one of my favorite lines was from another colleague that I'll talk about at the end, where she said we had enough pizza parties, that at Penn Medicine we had the screaming eagles fly over us. That's not what we needed. We needed to stem this negative emotional contagion. So we actually wrote this up in July of 2020, just as I was entering the agency. And what we found, and this was quite interesting, is that in those who were at baseline anxious, this is about 150 individuals who went through a number of tests, who those were anxious if they had higher anxiety, that in fact the weaker the culture, the effect of the culture of anxiety of the entire department had minimal effect. But if their state anxiety was lower, that in a stronger culture of anxiety, that actually triggered their anxiety. And in trying to put this together and why I started talking about psychological safety, and this was quite interesting, was we said, okay, the stronger their baseline state of anxiety was, their trait anxiety, that affected what they were doing in the ICU. That appreciation from your supervisor, and I think this is really important for the leaders of the ICUs, that appreciation helped decrease the anxiety. Why the CRNA position, we did not know, but what you see here is that culture of anxiety, that idea of how much psychological safety exists, and the transparency, which at the time of COVID was, do we have enough PPE? That that really enhanced the more anxious, the more they led to that anxiety, and in fact, that led to burnout, that it's not burnout that caused anxiety, it's anxiety which caused burnout, which we were actually quite surprised about. So we really think it's important at CMS and where we are that we really need to get to that tipping point, that idea of psychological safety, and get higher on that curve. We know from the Office of Surgeon General, Vivek Murthy, a colleague in the Department of Health and Human Services, that it can have lots of negative consequences. One of the things you've probably heard us say is during the pandemic, most of the quality measures got worse, the HAIs got worse. Now I think there's really good reason for that, I still remember when our intensivists would go into the ICU, they had to be so focused, particularly before there was a vaccine, on their own safety, and the safety of their family when they would go home. Some of them would actually not sleep in the same rooms as their family, that we need to think about that, but that anxiety, that worry, had lots of negative consequences at the beginning of the pandemic, which I think is entirely expected. So I want to go back to some of the things Seagal said and taught me, and she really talked about a positive emotional culture, and one of the things that we're trying to think about from a federal level. And what I mean is really not just pleasant, but really about this idea of what she calls companionate love, and she's done a lot of research, or she did, she unfortunately passed away during the public health emergency, not from COVID, but that in fact, companionate love is the idea of loving what we do, that friendship, that desire to work with our colleagues and the patients we take care of. And she feels it's very important that the top management create that vision and provide the resources, that the managers model the behavior, and that we really have the right people in the ICU, and this is really critical. And Angela Duckworth, who was the one that I said in our quality conference, really talked about the idea of enough with the pizza parties, talks about grit, and we are some of the grittiest people I know. But as I've talked to colleagues, and as I've talked to the people at CMS, what I think has happened is discovering your interests. Nobody says physicians do not have a passion for what they do, deepening with practice. We all practice all the time. We all are continuing to improve both the science and art of what we do for patients. There's no question that we have a purpose, but I think what has happened during the public health emergency is we lost hope, and I think one of the things that we in medicine need to do is restore that hope. I think that will be the biggest impact on where we see what we can see to avoid burnout. So I want to thank you for the opportunity, and I'll stop there.

CMS

clinician well-being

patient care

reducing paperwork

whole-person care