October 2017

Preventing Stress, Avoiding Burnout
By Lindsey Getz
For The Record
Vol. 29 No. 10 P. 10

The coding profession can be pressure packed, but there are steps managers can take to alleviate the strain.

What is the most stressful job in America? Police officer? Heart surgeon? Firefighter? Some might say that HIM, coding, and clinical documentation improvement positions fall into the high-stress category. These professionals must maintain a high-quality standard of work despite the fact that they're expected to operate quickly and keep abreast of ever-changing rules and regulations.

It's a lot to handle, making it no surprise that many coders and other HIM professionals feel overwhelmed in the workplace.

Having seen many coders wind up in his office for psychotherapy, psychiatrist H. Steven Moffic, MD, has a special interest in the coding profession. He says the pressure associated with coding can take a toll and if individuals reach the "burnout phase," then it can lead to full-blown psychiatric disorders.

"My concern with the stresses associated with coding originated from seeing so many coders from within our own medical system come in for treatment," Moffic says. "I was starting to feel as though I was seeing more coders than other professions."

Noting that burnout in any environment is caused mainly by a "loss of empowerment," Moffic says workplace structure can make coders more prone to the condition. Because coders are typically in disempowered positions, they tend to be more likely to reach that stage than those in other professions.

"It's difficult because coders generally do not have much power in their organizations despite the vital role they play in it," Moffic says. "That feeling can contribute to the likelihood that they'll reach the burnout stage."

According to the Mayo Clinic, job burnout is a "special type of job stress," a state of physical, emotional, or mental exhaustion combined with doubts about one's competency and value in the workplace. Rather than experiencing occasional stress, it's a state of chronic stress—and it can take a toll on your health.

Burnout is a serious issue, but there are ways to prevent it. However, before delving into how burnout can be prevented, let's discuss the roots of the dysfunction.

At the Root of the Problem
There are many ways in which workplace drama can rear its ugly head and set a lot of problems into motion. According to New York Times best-selling author David Maxfield, PhD, cofounder of VitalSmarts, an innovator of corporate training and leadership development, workplace drama occurs when minor disagreements are allowed to grow into long-term, hurtful divisiveness.

"People take offense at something a colleague has said or done, but instead of discussing their concerns, they give them the cold shoulder, talk behind their back, or take sides and form cliques," Maxfield says. "We studied this kind of drama by collecting more than 2,500 examples from health care professionals and then surveying another 1,200."

Maxfield says the examples were often as simple as a peer making a comment about a coding error. Maybe the peer intended to be helpful—maybe not—but either way the comment came across as sarcastic, cutting, or rude. The peer who was insulted fumed, but instead of talking it out, he acted out.

"He told others about her 'bad behavior' and left the breakroom whenever she entered," Maxfield says. "This kind of immature and ugly behavior continued for months."

Typically derived from an overly competitive environment, peer comments are a common workplace problem, Moffic says. Unfortunately, the coding field is ripe for this type of scenario. Moffic says people who feel unduly criticized can react in two potentially negative ways—assuming they choose not to take the high road or decide to "talk it out." The offended party may go into a shell and begin to feel worthless or devalued or, as Maxfield suggests, he or she may react in anger and lash out. These situations, when allowed to carry on, can spread the negativity to colleagues.

Wanda Cranford, CCS, corporate coding manager for Revenue Cycle Services, part of Novant Health, says workplace drama can create a rumor mill with the potential to spread rapidly throughout the organization. Should that occur, the ramifications can have long-lasting effects.

"The consequences of workplace drama in a dysfunctional HIM/coding department include diminished morale, a decrease in production and/or accuracy, higher turnover, lack of teamwork, and erroneous communication, aka, the rumor mill," she says. "For example, say a consulting firm is hired to assist with reviewing processes and making recommendations for increased efficiencies. Team members feel insecure that someone is looking over their shoulders and are concerned that negative recommendations, including eliminating positions, may occur."

Cranford says such a scenario can trigger the rumor mill as employees project the worst possible outcomes from the consulting firm's findings. Team members wind up angry, afraid, and disappointed, and the entire department falls into turmoil. This can lead to team members performing poorly, becoming stressed, or resigning.

Moffic agrees that the sense of being "watched over" can contribute to increased stress, noting that it's another way to make employees feel disempowered and promotes paranoia. The presence of an outside consultant can exacerbate the situation, he says.

"Consultants don't really have anything to lose—they have no skin in the game," Moffic says. "They can make recommendations, but there's really no risk to them, as they're not invested in the company in any way. There is increased opportunity for coders to feel stressed as they're put under the microscope by an outside consulting firm analyzing their work."

Making Positive Changes
While there are plenty of avenues for problems to emerge in the workplace, there are also viable solutions to counteract the potential for disarray. One key is to make coders feel heard, valued, and empowered. "The HIM/coding manager needs to be responsible for listening to the needs of the team members and taking action on those needs," Cranford says, adding that this is particularly important during times of change, a common condition in the HIM/coding universe.

"The manager can be a positive change agent by promoting the advantages of the changes and assisting team members in understanding the reasons for the changes, communicating frequently and transparently, involving team members in planning and projects, and assisting team members in professional growth," she says. "While this is more challenging in a remote environment, it can and must be done for the betterment of the team and the organization. The leader must reassure team members about changes he or she knows are not happening—such as a common fear of outsourcing—but must be completely honest and transparent with whatever information can be shared."

Maxfield agrees that transparency is key, noting that "dialogue is the antidote to drama." He says that when people speak up about their concerns in a way that is frank, honest, and respectful, then disagreements can be contained before they develop into full-blown drama.

"Managers can help by making it safe to talk about mistakes, errors, and misunderstandings," Maxfield says. "These are normal parts of being human and working with other humans. Managers can also encourage team members to discuss their concerns with each other instead of behind each other's backs. Often, team members need some coaching or even training on how to talk to a colleague about these kinds of concerns, and managers can help here as well."

Moffic says managers can take steps to help prevent a competitive environment, including encouraging peers to support one another, a key to employee success and department harmony. He says a workplace where everyone feels as though they are competing for a promotion does more harm than good and should be avoided.

To curtail the feeling that employees are constantly being monitored, Moffic suggests coders be involved in the review process. While he personally is not a fan of outside consultants—he believes it's better for someone internal to perform the audits—should that be the only option, managers and executives can make coders feel a part of the process by involving them in the hiring. Be transparent about who is being brought in to conduct reviews and value the opinions of coding staff members. These efforts can help eliminate workplace stress and drama.

"Making coders part of that process gives them some responsibility and, in turn, empowers them," Moffic says. "This is a lot more effective than causing them to feel watched over or devalued by keeping them totally out of the loop."

Preventing Burnout
All of these efforts are components of an overall strategy to prevent workplace stress and burnout. According to Maxfield, burnout includes three elements: emotional exhaustion, professional efficacy, and depersonalization.

"Exhaustion, by itself, is very different from burnout," Maxfield says. "We all feel physically and emotionally exhausted after a long, tough day, week, or month. But burnout occurs when we come to believe that we can't make a difference. Then we begin to withdraw from relationships and turn negative, cynical, and callous."

Exhaustion may be a somewhat inevitable part of a health care professional's work life, he says, but leaders can take steps to alleviate the other factors. First, give team members as much control as possible over how they do their work.

"Ask them to identify the obstacles they face and get their ideas for improving the quality and productivity of their team," Maxfield says. "Then implement the best of their ideas. Show them that they have an impact on your thinking."

Second, he suggests leaders take steps to remind team members of the positive impact their work has on people's lives. Maxfield says to use "mission moments" to reinstill purpose and passion into their tasks. This will help connect team members to the result of their work.

Cranford recommends leaders empower team members by taking the following steps:

• Encourage wellness breaks.

• Implement an open-door policy for issues and concerns.

• Create opportunities for socializing and networking.

• Ensure timely and effective education.

• Welcome feedback and ideas.

• Promote a work/life balance.

• Adopt a positive outlook and inclusive structure in which all team members are valued and appreciated (this should include rewards and recognition).

Leaders must communicate often and effectively and be willing to answer any questions from staff, Cranford says. Transparency and creating an environment where rumors aren't allowed to fester are key, she notes, adding that when leaders are open, honest, and clear, gossiping is limited.

Because loss of power is associated with burnout, empowerment is essential, Moffic says. Many of his coder clients operate more under fear than confidence, a circumstance that makes it difficult to work at a high level. He says managers and executives must open the lines of communication so coders feel comfortable asking for help when it's needed.

When problems arise, they should be dealt with swiftly. Problems allowed to fester can grow and spread rapidly throughout a department, leading to stress and ultimately burnout for some staff members.

Naturally, some employees are more prone to burnout than others, Moffic says, noting that everyone has a "different vulnerability level to burnout. However, empowering employees will help promote a positive workplace environment for all—regardless of burnout risk.

"Empower coders by continually asking for their feedback and listening to their ideas," Moffic says. "It's very likely that there are some great ideas at the level of the person doing the job, and they deserve to have their voices heard. When you feel as though your feedback and your opinion is heard, it decreases stress and the risk for burnout. That's the key to a more productive and healthy work environment for everyone."

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.