to disclose Leaders Igniting Joy in Work and Creating Safetyapp.ihi.org/.../Document-12628/Presentation_SL9_Joy_in_Work_Balik.pdf · Leaders Igniting Joy in Work and Creating Safety

Leaders Igniting Joy in Work and Creating SafetyBarbara Balik, Jennifer Lenoci-Edwards, Kristine White

SL 9 29th Annual National

Forum on Quality

Improvement in Health Care

The presenters have nothing

to disclose

Sunday, December 10, 2017

Objectives

Translate learnings from IHI/NPSF to address

your organizational needs to ignite joy in work and

create safety

Interpret and apply practical methods in physical

and psychological safety plus steps to joy in work

Construct an initial journey map that sets the path

to a safer, more joyous workplace

Get to Know Each Other

What are Your Sources of Joy?

Our intent

Create psychological safety within this time we have

together

4 attributes of an environment of psychological safety:

Anyone can…

…ask questions without looking stupid

…ask for feedback without looking incompetent

…be respectfully critical without appearing negative

…suggest innovative ideas without being perceived as disruptive

What will it take? How can we create this here today?

Start with Why!

What Matters to You?

Purpose

Begin here; do not proceed without clarity

What is your purpose for choosing this session, and how

does that translate back into your work environment?

Why is the time exactly right to focus on creating and

sustaining Joy in Work as a strategic imperative, with a

clear link to Safety and other key organizational

objectives?

What is Joy in Work?

▪ “By joy, we refer to the feeling of success and fulfillment that results from meaningful work… without joy and meaning in work, the workforce cannot perform at its potential. Joy and meaning are generative and allow the best to be contributed by each individual, and the teams they comprise, towards the work of the Triple Aim every day.”

▪ Intellectual, behavioral and emotional commitment to meaningful and satisfying work.

▪ Employee engagement is about how connected an employee is to the culture, mission and values of your organization and the degree to which they are enabled and inspired to participate in furthering them.

Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24:608-610.

Sirota D, Klein D. The Enthusiastic Employee: How Companies Profit by Giving Workers What They Want (2nd edition).

Pearson FT Press; 2013

Dimensions of Joy in Work

Joy in Work

Workload & Job Demands

Meaning in Work

Social Support & Community

at Work

Control & Flexibility

Work – Life Integration

Organizational Culture &

Values

Efficiency & Resources

Shanafelt T, Noseworthy J, Executive Leadership and Physician Well-being. Mayo Clinic Proceedings, Volume

92, Issue 1, Pages 129-146 (January 2017) DOI: 10.1016/j.mayocp.2016.10.004

What Joy in Work is Not

▪ Something you announce

▪ Flavor of the month – a project

▪ Superficial one-time actions

▪ Pizza parties

▪ Tokens not linked to purpose, e.g. thank you notes

▪ Solely individual resilience

▪ Only a means to an end

▪ Something done ‘to’ or ‘for’ team members not ‘with’

What is and isn’t Joy in Work?

It isn’t “happy” people

It isn’t the absence of burnout

It isn’t high staff engagement scores…alone

It is identifying and addressing the gaps to the above, and

enabling each and every person to clearly understand

their connection to meaning and purpose in their/the work.

For Dr. Deming, pride in work = joy

What is Your Experience?

Think of a time –When you routinely experienced joy in work

What did it look like?

What did it feel like?

Use 1 word to describe

Why Was it Joyful?

Do a mini- root cause analysis and share

with colleagues at the table

– Ask why 5 X

Joy in Work + Safety

Is it possible?

Not only is it possible, it is absolutely necessary!

Safety – Joy in WorkBelieve Safety Joy in Work

Others will respond positively when I ask a question or

voice a concern

Others will respond positively when I admit a mistake

Raising a dissenting view is expected

Error reporting is welcomed

No one will be humiliated or punished for speaking up

All team members are treated equally

Respectful interactions expected by everyone

Disrespectful behavior is rapidly and consistently

addressed – no matter who

Failures are learning opportunity

May the force of Florence be with us

“I attribute my success to this…

I never gave or took an excuse.”

Florence Nightingale

Leaders Make a Difference

Working against ourselves

PATIENTS / FAMILIES

SATISFACTION

Who comes first?

It’s Both/And

Leaders MUST be able to draw the

connections and pull the common

threads together

Maslow’s Hierarchy of Needs

Maslow Experienced

© Spectrum Health

Critical leadership dimensions/precursors

Compelling vision, purpose, clear why, and ability to

engage others

Build trust, respect and inclusion

Commitment to continuous learning, a robust learning

system including leadership development

Clear behavioral expectations

Aligned values and skills; and the ability to make

changes

Must act as owners

The proverbial “buck” stops with the executives

Why?

– True change isn’t about just trying harder, although motivation is

clearly a requirement

– True and sustainable change also requires the systems,

infrastructure and skills to achieve this change.

Starts at the top with a commitment in words AND

actions

– Individually

– As a team

– With proper systems, skills and infrastructure

What if leaders aren’t “there”?

Assume good intentions

Get a plan

Four Powerful ComponentsOur Focus

2. Identify unique impediments to Joy in Work in the

local context

3. Commit to making Joy in Work a shared

responsibility at all levels

1. Ask staff “what matters to you?”

Outcome:↑ Patient experience

↑ Organizational performance

↓ Staff burnout

4. Use improvement science to test

approaches to improving joy in your

organization

Steps Leaders Take

Perlo, J, Balik, B, Swensen, S, Kabcenell, A, Feeley, D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2017.http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx

http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx

Critical Components for Ensuring a Joyful, Engaged WorkforceInterlocking responsibilities at all levels

Wellness & Resilience

Physical & Psychological

Safety

Daily Improvement

Meaning & Purpose

Recognition& Rewards

Autonomy& Control

Participative Management

Happy

Healthy

Productive

People

Camaraderie

& Teamwork

Real Time

Measurement

Perlo, J, Balik, B, Swensen, S, Kabcenell, A, Feeley, D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2017.http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx


Critical Components for Ensuring a Joyful, Engaged WorkforceInterlocking responsibilities at all levels

Wellness & Resilience

Physical & Psychological

Safety

Daily Improvement

Meaning & Purpose

Recognition& Rewards

Autonomy& Control

Participative Management

Happy

Healthy

Productive

People

Camaraderie

& Teamwork

Real Time

Measurement

Physical & Psychological Safety:

Equitable environment, free from harm, Just Culture that

is safe and respectful, support for the 2nd Victim

Meaning & PurposeDaily work is connected to what called individuals to

practice, line of site to mission/goals of the

organization, constancy of purpose

Autonomy & Control:Environment supports

choice and flexibility in daily lives and work, thoughtful

EHR implementation

Recognition & Rewards:Leaders understand daily work, recognizing what

team members are doing, and celebrating outcomes

Participative Management:Co-production of Joy, leaders

create space to hear, listen, and involve before acting. Clear

communication and consensus building as a part of decision

making

Real Time Measurement:Contributing to regular feedback

systems, radical candor in assessments

Wellness & Resilience: Health and wellness self-care,

cultivating resilience and stress management, role modeling

values, system appreciation for whole person and family,

understanding and appreciation for work life balance, mental

health (depression and anxiety) support

Daily Improvement:Employing knowledge of

improvement science and critical eye to recognize

opportunities to improve, regular, proactive learning from defects and successes

Camaraderie & Teamwork:

Commensality, social cohesion, productive teams,

shared understanding , trusting relationships

Flow of Time Together

Diagnostic Tool – complete

4 Powerful Components

– We briefly review definitions & examples linking Joy + Safety

– At table: Use diagnostic tool to discuss how you will address

each component through lens of impact on:

– Colleagues

– Patients/Families

– Business case

– Self

What are you worried about?

Self-Care activity

Journey Map – from Diagnostic Tool

Current State of Your Organization:Diagnostic Journey Map

JIW Diagnostic Journey

This tool is about learning

NOT judgement

Read the descriptions

within levels 1-5 for each

domain

Circle the ones that sound

like your organization

Its okay to pick descriptors

from the different levels

You have 10 minutes

Talk at your Tables

• Quick reflections?

• Are you more developed in

one domain over the others?

• Are there some quick wins

you can make in your

organization?

• What are some areas that you

identified that you have no

idea how to improve?

Debrief

Physical Safety

Aim

Where patients and those who care for them are free from

harm in systems of safety across the continuum of care

41

Impact

Healthcare worker Musculoskeletal Disorders incident

rates:

More than 7x the average of all industries

– Healthcare: 249 per 10,000 workers

– All workers: 34/10,000

– Construction: 85/10,000

– Laborers & freight, stock and material movers: 155/10,000

Direct and indirect costs associated with only back

injuries in the healthcare industry estimated to be $20

billion annually.*

2010 OSHA data https://www.osha.gov/SLTC/healthcarefacilities/safepatienthandling.html

Workplace Violence

Any act or threat of physical violence, harassment,

intimidation, or other threatening disruptive behavior

that occurs at the work site - OSHA

Healthcare Workers:

– Healthcare: highest rate of workplace violence

– 45-52% of all incidents

Patients: most common perpetrators of health care

violence

Kick & punch: most common mechanism of non-fatal

injuries

Break

Psychological Safety


What is it?

Psychological safety is a shared belief that the team

is safe for interpersonal risk taking. It can be defined as

"being able to show and employ one's self without fear of

negative consequences of self-image, status or career"

(Kahn 1990, p. 708).

Psychological safety

People believe that no one will be:

– Humiliated or punished for speaking up

– Punished for human errors in unsafe systems;

consistent with a just culture.

Is a:

– Team characteristic not an attribute of individuals

– Consistent with exemplar safety environments

– Critical input to an effective learning system

Schein E. Organizational Culture and Leadership. San Francisco, CA: Jossey-Bass; 1985.

Edmondson A. Teaming: how organizations learn, innovate, and compete in the knowledge economy. San Francisco: Jossey-Bass; 2012.

Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work.

IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org)

http://www.ihi.org/

What does it mean in real world?

These are value added encounters that occur without

judgement or retribution

Scrub tech in the OR stop the line because the team has

not performed the surgical checklist

In a team meeting, a leader encouraging all voices to

share their insights

Nurse questioning a physician’s medication order

Patient stopping a nurse to wash her hands

Most Important Thing in Effective Teams

Transparency

Leadership


Negotiation

Teamwork & Communication

Accountability

ReliabilityImprovement

&

Measurement

Continuous Learning

Engagement of Patients & Family

Framework for Safe, Reliable and

Effective Care

Facilitating and mentoring teamwork, improvement,

respect and psychological safety.

Creating an environment where people feel comfortable and have

opportunities to raise concerns or ask questions.

Being held to act in a safe and respectful manner given the

training and support to do so.

Developing a shared understanding, anticipation of needs and problems, agreed methods to manage these as

well as conflict situations

Gaining genuine agreement on matters of importance to team members, patients and families.

Regularly collecting and learning from defects and successes.

Improving work processes and patient outcomes using standard improvement tools

including measurements over time.

Applying best evidence and minimizing non-patient specific variation with the goal of failure

free operation over time.

Openly sharing data and other information concerning safe, respectful and reliable care with staff and partners

and families.

The Path to Get there

Know thyself

Seek out the comments/questions/feedback from lesser

powered team members for their insight

Encourage differing viewpoints and listen

Model it at every level

Let people know it is part of their job – See Something,

Say Something

Call it out as a desirable value at your organization

Organizational policy and accountability to bullying,

disrespect and disruptive staff and patients

Meaning and Purpose

Quick reflection of current state

Back to why

Back to purpose

Think about yourself, and your colleagues, and your

executives

Meaning and Purpose

I am proud to be part of this organization

I have a good understanding of how my job contributes

to achieving our mission, vision and strategic plan

I would recommend our organization to others as a good

place to work

I personally contribute to our organization’s success

54

Meaning and Purpose

Personal Why – The First Step

Personal Why/Purpose – Be very clear on:

What joy in work means to you?

Why it is personally important?

How does joy in work connect to safety?

20 foot Conversation – practice your personal why

1 min in silent reflection – draft personal why

Pair with a partner– Practice sharing, walking 20’ and sharing ‘Why’

– Listener offers feedback

– Switch roles and repeat

Choice and AutonomyTo – For – WithTeam Members

SL9 29th Annual

National Forum on

Quality Improvement in

Health Care

Presenter has

nothing to disclose

Sunday December 10, 2017

#IHIFORUM

This? Or This?

You Know You are Doing To –

When Leaders –Say and team members do

Plan and design the systems team work in without them

Judge – not justice

– Unsafe to speak up; psychological safety missing

Listen to people who look/sound like them

Dislike disagreement

Blame team if patients/families complain

Are not sure what happens in daily work – but assume they do

Offer no line of sight between mission and what team members

do

Assume doing your job is enough; limited recognition and

celebration

You Know You are Doing For –

When Leaders –Design systems with team in mind – without the team

“My team” – parental– Take disagreements personally

“Random acts of goodness” – e.g. a new lounge will improve engagement

Death by 1000 measures

One way communication - share lots of information

Some dialogue with some sense of every voice counts

”Atta girl/Atta boy” recognition – token or superficial recognition

Some sense of just and fair but variable– Psychological safety is growing but not pervasive

You Know You are Doing With

When Leaders –Treat all team members with dignity and respect

Nothing About Me Without Me: Shared decision making

Co-design: At the table on all topics that affect team

Inspire each to do their best

Are committed to team member well-being and development

Assure trust abounds – psychological safety is evident

Have conversations – keeps team updated on changes; asks team opinions

Assure Purpose– Line of sight between team daily work and mission

Offer meaningful, frequent recognition and celebration

Activity: To-For-With Assessment Team Members

Doing To – Team Members

Doing For – Team Members

Doing With – Team Members

1. Individually – Complete 1-2 examples in each category2. Review with 1-2 colleagues3. What do your lists tell you? What gets in the way of doing with?

Barbara Balik [email protected]

Teamwork

What makes a Functioning Team?

Most Important Thing in Effective Teams

Attributes of a Strong Team

Plan forward

– Outline next steps, potential risks, agree on the path to address

safety and efficiency, e.g. checklist review

Reflect back

– Debriefs – what went well & didn’t

– Did everyone know the plan?

Communicate early

– Structured communication – SBAR; read back/call back

Manage risk

– Signal word or phrase – stop & assess

– “I need clarity”

Frankel, A, Haraden, C, Federico, F, Lenoci-Edwards, J. A Framework for Safe, Reliable, and Effective Care. White Paper.

Cambrideege, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx


Behaviors for Teaming Success

Speaking up

– Honest, direct conversation

– Asking questions, seeking feedback, talking about errors

Collaboration

– Working together; all are valued

Experimentation – small tests of change

– Always testing, always learning

Reflection

– Consistent observation, questions, and talking about how the

process went; how it could go better

Edmondson A. Teaming: how organizations learn, innovate, and compete in the knowledge economy. San Francisco: Jossey-Bass; 2012.

Twitter - @Helen Beven, NHS

Trust Arrives on a Tortoise and Leaves on a Horse

What are You Worried About?

Care of Self

Three Good Things

©2014 MidMichigan Health; J. Bryan Sexton, PhD




©2014 MidMichigan Health

Where to From Here?

Your Roadmap

Upcoming Program81

Begins March 1,

2018

12 week virtual

training with video

content, group

calls, and options

for added coaching

Learn more and enroll:

www.ihi.org/joyinwork

http://www.ihi.org/joyinwork

Resources

Resources Perlo, J, Balik, B, Swensen, S, Kabcenell, A, Feeley, D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2017.

– http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx

Frankel, A, Haraden, C, Federico, F, Lenoci-Edwards, J. A Framework for Safe, Reliable, & Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

– http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx

Leading a Culture of Safety: A Blueprint for Success– http://www.npsf.org/?page=cultureofsafety

Through the Eyes of the Workforce: LLI Report– http://www.npsf.org/?page=throughtheeyes

Shanafelt, T., Goh, J. Sinsky, C. The Business Case for Investing in Physician Well-being. JAMA Internal Medicine, Sept 25, 2017

Linzer, M. et al. 10 Bold Steps to Prevent Burnout in General Internal Medicine. J. Gen Inten Med 29 (1): 8-20. Sept 4, 2013

Salyers, M., et al. The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. J. Gen Intern Med 32 (4): 475-82. Oct 26, 2016

83



http://www.npsf.org/?page=cultureofsafety

http://www.npsf.org/?page=throughtheeyes

Four Steps - #1: “What Matters to You?

▪ Understand and identify (through eyes of team)

opportunities to improve (participative management)

▫ Leaders show genuine interest in wellbeing

▫ Understand what brings joy and what impedes

▫ Identify unique local and organizational opportunities

▫ A place to start to improve both work life and patient care

84

Perlo, J, Balik, B, Swensen, S, Kabcenell, A, Feeley, D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2017.



Four Steps - #2: Identify Impediments

▪ Identify impediments that sap joy

▫ Together: See the impediments, analyze, devise solutions

▫ Builds a sense of mastery

▪ First meet five social and psychological needs required

for people to flourish

▫ Physical and psychological safety

▫ Physical = free from harm

▫ Psychological = feel secure and capable of changing

▫ Meaning and purpose in their work

▫ Some choice and control over their time

▫ Camaraderie with others at work

▫ Work life is fair and equitable

85




Four Steps - #3: Share Responsibility

▪ Organizational, leader, work unit, and individual level

▪ Participative management + collaborative process

improvement = meet fundamental human needs

▪ Impediments addressed team engagement improves

and burnout recedes

▪ Individual shared responsibility:

▫ Cultivate own resiliency and engagement – civility,

physical fitness, stress reduction, personal

development, mindfulness

86




Four Steps - #4: Test Approaches

▪ Use improvement science to test approaches that

address impediments

▪ A brief list – not limited to:

▫ Leader development in proven approaches that improve a sense

of joy, meaning, and purpose; e.g. coaching

▫ Measure engagement regularly

▫ Gauge effectiveness of unit leaders; support them in using best

practices

▫ Assure team members feel part of something important, clarity

about roles, tools to do their job

▫ Safety, hiring, orientation, development, compassionate support

practices

87




Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations,

and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

IHI High-Impact Leadership FrameworkWhere Leaders Focus Efforts

Resiliency

Stress Management and Resiliency Training (SMART) Program among Department of Radiology Faculty: A Pilot Randomized Clinical Trial. Sood A, Sharma V, Schroeder DR, Gorman B. Explore (NY). 2014 Nov-Dec;10(6):358-63. doi: 10.1016/j.explore.2014.08.002. Epub 2014 Aug 21.

References – Physical Safety

Casteel C, Peekasa C, Nocera, M, et al. Hospital Employee Assault Rates Before and After Enactment of the California hospital safety and security act. Annals of Epidemiology. 2009;19(2): 125-133.

Meloy JR. Empirical basis and forensic application of affective and predatory violence. Australian and New Zealand Journal of Psychiatry. 2006; 40: 539-547.

Peek-Asa C, Casteel C, et al. Workplace violence prevention programs in psychiatric units and facilities. Archives of Psychiatric Nursing. 2009; 49 (7) 756-763.

Phillips JP. Workplace violence against healthcare workers in the United States. N Engl J Med. 2016; (374)1: 1661-1669.

Speroni KG, Fitch T, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing. 2014;40(3): 218-228.

Documents

to disclose Leaders Igniting Joy in Work and Creating Safetyapp.ihi.org/.../Document-12628/Presentation_SL9_Joy_in_Work_Balik.pdf · Leaders Igniting Joy in Work and Creating Safety