El Rio Health in Tucson, Arizona, renowned for its commitment to community health, has become the first federally qualified health center (FQHC) to receive gold-level recognition from the AMA Joy in Medicine™ Health System Recognition Program.
This underscores El Rio Health’s dedication to enhancing well-being and combating burnout, setting an example for other federally qualified health centers. Through innovative initiatives and a deep commitment to fostering a supportive work environment, El Rio Health—which includes 14 locations and 1,900 employees—is working to ensure that physicians and other health professionals can thrive, improving the quality of care for the diverse communities they serve.
“We first got involved with the Joy in Medicine program in 2022 through a collaboration between the AMA and the Arizona Alliance for Community Health Centers, AACHC,” which is the nonprofit primary care association for Arizona that represents community health centers, said Mark Schildt, MD, a family physician and chief wellness officer of El Rio Health in Tucson, Arizona. “Through that collaboration, we started doing the AMA’s Organizational Biopsy® survey in 2020 and have continued with this every year.”
After completing the Organizational Biopsy in 2024, 36.7% of El Rio Health physicians reported feeling some level of burnout, which is a drop from 45.8% in 2023 and 43.7% in 2022. This is far below the Organizational Biopsy’s physician burnout rate of 48.2%.
With the survey data in hand, “we were starting to look and say: OK, we have all this data, now what do we do with it? How do we make it meaningful and not just an exercise in collecting data?” Dr. Schildt added. “The Joy in Medicine framework gave us a good road map for how to get started when you’re brand new to the work and you don’t know where to begin, what to focus on.”
“It was really helpful in giving us a set of criteria and an easy, understandable road map to follow,” he said. “It also helped to get buy-in among some of the senior leadership in our organization to be able to say: Here’s why we’re doing this. This is from the AMA. There’s recognition that comes with it.”
“We wouldn’t be where we’re at without the collaboration with the AMA and AACHC because just getting started is half the battle,” Dr. Schildt said. “Having the support of these partners to get the survey up and running and then getting the data reports back and access to the data through the AMA data lab, that was key in getting us started.”
“Starting to survey and measure things is the most important first step because it’s hard to know what to work on until you figure out where you’re at and what are the pain points and the areas for opportunity,” he said. “That was a crucial first step for us and collaborating with the AMA and AACHC removed many of the barriers to getting started.”
Part of El Rio Health’s success was due to simple—yet often overlooked—interventions to remove administrative burdens for physicians and other health professionals.
Identifying pain points
Some examples at El Rio Health have been including electronic signatures on patient letters and setting up a system to deal with faxed documents electronically, rather than on paper.
“It’s easy to overlook—or not be aware of—those little things in the day to day that are just taking an extra minute or two but really add up over the course of the day,” Dr. Schildt explained. “For us, the most important thing is having a way to hear about those and identify those because, in the case of the faxed documents, we already had an organizational workflow in place for this.
“But through one of our listening sessions with clinic teams, it came to light that this one particular clinic site for whatever reason wasn’t using that workflow. They were printing everything,” he added. “It gave us an opportunity then to say: Let’s get you up to speed and train you on this workflow.”
Minimizing logins
“Other interventions have been identified through getting feedback from our clinicians who are speaking up,” Dr. Schildt said. “One burden in particular that we were hearing a lot about was having to type in your password every time you switched from the exam room computer back to your office workstation.”
By “collaborating with our IT team, we were able to implement the tap-in badge login. We had that in the exam rooms, but we didn’t have it out at the workstations,” he said. “We had the partial solution, but it wasn’t optimized yet. So, that was a matter of advocating and collaborating with our IT team to install this on every computer that our clinicians touch during the day. That was a big win and a very popular intervention among our clinicians.”
“When we were able to do this, it coincided with the time when our IT department was implementing more robust password requirements,” Dr. Schildt said. “So, it was good timing because everybody had just been forced to pick a more complicated, lengthy password than they were using before.”
Transitioning to a new EHR
About three years ago, El Rio Health transitioned from their legacy system to Epic. The switch “was a game changer as far as allowing us to measure clinician efficiency and optimize the EHR workflows to help reduce some of that EHR burden that we wouldn’t have had the technical ability to do with our legacy system,” Dr. Schildt said.
“There are certain things that are much harder to do at smaller FQHCs. But one of the potential resources that we have as FQHCs is the federal support that we get,” he said. “We’ve been able to make use of some federal grants to help support some of the work with the EHR.”
Additionally, “here in Arizona, we’ve been able to collaborate and partner with some of our sister FQHCs through our common connection to the AACHC,” Dr. Schildt said. “In that way, we’ve been able to share best practices with each other and advance the work more broadly.”
Implement order defaults
El Rio Health also created a team that regularly monitors EHR order defaults to identify ones that are requiring excessive “clicks” and used data to inform this project from the outset to fruition.
“This has been an ongoing effort benefiting from the robust efficiency data that Epic is able to provide to us,” Dr. Schildt said. “Once a month they provide us with an order friction report, and it tells us a list of the top orders with the most friction—additional clicks that are needed before you can sign the order from the time that you bring it up.”
For example, “it could be something as simple as you’re going to order a medication, and the quantity isn’t filled in for you,” he added. “You have to pick each time what quantity you want to prescribe, where for a lot of medications we want to prescribe a 90-day supply every time we order it. So, we can just default that in and then save a click every time you order it.”
“This project has been a wonderful example of the power of collaboration between our clinical informatics team, and our IT and pharmacist partners to create a multidisciplinary group that once a month looks through this list, identifies orders that we can fix or improve upon and then make those changes and track our progress,” Dr. Schildt said. “We can tell we’ve been successful because now when we meet and review the report, we can’t find much to do because of all the issues we’ve previously identified and fixed.”
“Through this process we’ve been able to demonstrate a steady decrease in the number of clicks required per order across the organization,” he said, noting “that over the last couple of years this initiative has saved clinicians at our organization over 2 million clicks during that time.”
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Create a culture of support
At El Rio Health, 86.8% of physicians reported feeling satisfied with their job, which rose from 77.1% in 2023 and 81% in 2022.
There are a lot of factors that feed into and affect physician job satisfaction at El Rio Health, said Dr. Schildt. “But, at the end of the day, clinicians want to come to work, be able to see their patients and feel like they are able to make a meaningful difference in people’s lives and have a minimum number of barriers that get in the way of that.”
“What it boils down to is how do we as an organization create a culture where people feel connected to the work that they’re doing and feel a high sense of meaning and that they’re making a difference,” he said, adding it’s all about “how we as an organization address and remove things that get in the way of that, whether it’s efforts to reduce EHR documentation time, providing schedule flexibility, or optimizing support staff workflows to enhance team-based care.”
Establishing a sense of value
There are high feelings of value across El Rio Health, which can be attributed to the federally qualified health center’s mission and values. According to its Organizational Biopsy, 73.7% of physicians reported feeling valued by their organization, which is up from 69.2% in 2023 and higher than the AMA’s national comparison of 50.4%.
“I attribute much of this to each clinician’s immediate clinical leader. That’s the most important place where that sense of value is established,” said Dr. Schildt. “While we certainly try and send that message from the very top of our organization, what makes the biggest impact with clinicians is their relationship with their direct clinical leader.
“If that leader is providing them with the support that they need to do their job well,” he added, “and demonstrating that they care about them as a person, supporting their professional development, communicating transparently with them and giving them recognition and feedback, that all contributes to that sense of value.”
And it shows in the survey results—77.7% of respondents said leadership “supports me in my work” and 70.5% said their leader supports their career development. Meanwhile, 69% reported that their leader “solicits and follows up on my ideas and perspectives” and “shares organizational information openly with me.”
“One of the real strengths of our organization is that we have strong clinical leaders and that really sets the tone for our organization and our clinicians,” Dr. Schildt emphasized.
Stay true to the mission
“Last fall we went through a strategic planning process with our clinician well-being council and brought in an outside facilitator,” Dr. Schildt said. “As a group we came up with our mission and vision statements for our well-being program.”
“Our mission is to advance the organizational culture and systems to cultivate a workplace in which our clinicians can thrive, both professionally and personally,” he said. “And we have a vision to be a national model of an innovative, evidence-based and sustainable well-being program that makes El Rio the place where everybody wants to work.”
“As an FQHC, our organizational mission is central to everything that we do. Many of our clinicians have specifically chosen to work at an FQHC because of that mission to care for the underserved and to meet the needs of the historically marginalized people in our communities,” Dr. Schildt said. “That creates a higher baseline coming in of people’s commitment to the mission and support for that mission.
“There are some challenges with that too,” he added. “We’re caring for a population that is often significantly under resourced and so our clinicians are more likely to face scenarios where there are structural or systemic challenges to having the patient get the most appropriate care they need and it’s not always possible depending on the circumstances which can create moral distress at times for clinicians.”
“However, as an organization, we do a lot to eliminate those barriers and provide additional resources to address social drivers of health,” Dr. Schildt said. “In addition, we provide a variety of resources to our clinicians for peer support and building personal resilience such as clinician dinner and discussion groups, professional mentoring and coaching in collaboration with MAVEN Project, and compassion-based mindfulness trainings in collaboration with Compassion Institute and Capacitar International.”
