Esprit de Corps. (taking care of each other for our patients) the case for eradicating burnout

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1 Esprit de Corps (taking care of each other for our patients) the case for eradicating burnout Stephen Swensen, MD, MMM, FACR Senior Fellow Institute for Healthcare Improvement Professor Emeritus, Mayo Clinic College of Medicine Medical Director of Professionalism, Intermountain Healthcare Nothing to disclose.

2 Esprit de Corps Human Needs Positivity Negativity Six Actions 2 Measures Business Case Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June (6) 308

3 2 Measures Esprit de Corps Engagement Teamwork Satisfaction Resilience Burnout Unit Specific Quadruple Aim Leader Index Appreciation Ideas Transparency Career Inclusion Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June (6) 308

4 Baard, Deci, Ryan. Intrinsic Need Satisfaction. J Applied Social Psych, (10): 2045 Swensen, Kabcenell, Shanafelt. J Healthcare Management.61:2; Esprit de corps Camaraderie Human Needs Trusted Passion Resilience

5 Leaders Pebbles Design Esprit de corps Second Victims Human Needs Commensality Resilience Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June (6) 308 Swensen Gorringe Caviness Peters. Leadership by Design. Journal of Mgmt Development Vol. 35 (4) 2016

6 The Business Case a virtuous cycle Esprit de Corps QI Burnout $ Patient Experience Outcomes Safety

7 Six Actions DESIGN: Design Organizational Systems to Address Human Needs LEADERS: Develop Leaders with Participative Management Competency PEBBLES: Remove Sources of Frustration and Inefficiency SECOND VICTIMS: Reduce Preventable Harm and Support Second Victims COMMENSALITY: Build Community and Camaraderie RESILIENCE: Bolster Individual Wellness Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June (6) 308

8 Five Leader Index Behaviors Appreciation: Express gratitude in a meaningful way to colleagues Transparency: Share what you know with the team Ideas: Career: Inclusion: Consistently solicit input of coworkers Support professional aspirations of staff Nurture a culture where all are welcome and psychologically safe

9 Professionalism 5 6 Medical errors Patient Satisfaction 7 14 Productivity Turnover 9 Suicidal Ideation JAMA 296: JAMA 304: JAMA 302: Annals IM 136:358 5 Annals Surg 251:995 6 JAMA 306:952 7 Health Psych 12:93 8 JACS 212:42 9 Annals IM 149: Arch Surg 146:54 11 Fahrenkoph Shanafelt West Beach Halbesleben 2008

10 Professionalism 5 6 Medical errors Motor Vehicle Accidents 16 Patient Satisfaction 7 14 Productivity Turnover 9 Suicidal Ideation JAMA 296: JAMA 304: JAMA 302: Annals IM 136:358 5 Annals Surg 251:995 6 JAMA 306:952 7 Health Psych 12:93 8 JACS 212:42 9 Annals IM 149: Arch Surg 146:54 11 Fahrenkoph Shanafelt West Beach Halbesleben Shanafel 2012 MCP

11 Shanafelt Noseworthy Executive Leadership Physician Well-being. Mayo Clin Proc MFMER

12 Categorize Pebbles Swensen, Kabcenell, Shanafelt. J Healthcare Management.61:2;

13 Categorize each Pebble Individual Ownership (Individual takes lead on their development with support) Local work unit team ownership (Prioritize and act together) Local work unit leader ownership (Individual takes lead on their development with support) Reporting entity ownership (Communicate to reporting entity) Organization ownership (Communicate to Organization Leadership) Profession ownership (Communicate to Professional Societies)

14 High-Impact Leadership Framework Where leaders need to focus efforts Swensen, Pugh, McMullan, Kabcenell. High-Impact Leadership: Improve Care, Improve the Health of Populations & Reduce Costs. Institute for Healthcare Improvement; Available:

15 Fair Faulty design or lack of system? Fix System and Human Error (lapse, slip, mistake) Console Learn Just Culture Risky (choice increases risk where risk is unrecognized or mistakenly believed to be justified) Coach Learn Accountability not determined by outcome Reckless (choice to consciously disregard a substantial and unjustifiable risk) Corrective Action Leonard, Frankel. Patient Education and Counseling. 80 (2010) Reason J. Human error: models and management. BMJ Mar 18; 320: Marx D. (2001) Patient Safety and the Just Culture : A Primer for Health Care Executives. Columbia University, New York, NY.

16 Fair and Just Culture What can we learn from this to prevent future harm? Error, Event or Near Miss Was it the system? Faulty design or lack of system? Was it the behavior? Human error Risky behavior Reckless behavior Near misses or undesirable outcomes reviewed and responded to in a consistent manner Accountability is not determined by the outcome Marx D. (2001) Patient Safety and the Just Culture : A Primer for Health Care Executives. Columbia University, New York, NY. Reason J. Human error: models and management. BMJ Mar 18; 320: Leonard, Frankel. Patient Education and Counseling. 80 (2010)

17 Fair and Just Culture Human Error = inadvertent action (lapse, slip, mistake) Management Response Console/ Learn Individual Behavioral Choices Human Error Risky (Drift) Reckless Risky (Drift) = behavioral choice that increases risk where risk is unrecognized or mistakenly believed to be justified Coach/ Learn Reckless = behavioral choice to consciously disregard a substantial and unjustifiable risk Corrective Action Marx D. (2001) Patient Safety and the Just Culture : A Primer for Health Care Executives. Columbia University, New York, NY. Reason J. Human error: models and management. BMJ Mar 18; 320: Leonard, Frankel. Patient Education and Counseling. 80 (2010)

18 Value Creation System Alignment Discovery Managed Diffusion Measurement Swensen, Dilling, Harper, Noseworthy, The Mayo Clinic Value Creation System. Sept AJMQ

19 Leadership Index (P<0.001) (P<0.001) Shanafelt, Menaker, Buskirk, Gorringe, Swensen. 12 Leadership Dimensions. Mayo Clinic Proceedings. April 2015: 90(4);

20 Mission Mission Vision Vision Strategy Strategy Swensen, et al. Cottage Industry to Postindustrial Care. N Engl J Med 2010; 362

21 Patient-Designed Culture Us Competition Cooperation Social Capital Them Mistrust I We Swensen Gorringe Caviness Peters. Leadership by Design. Journal of Mgmt Development Vol. 35 (4) 2016

22 Patient-Designed Culture Us Competition Cooperation Social Capital Them Mistrust I We Swensen Gorringe Caviness Peters. Leadership by Design. Journal of Mgmt Development Vol. 35 (4) 2016

23 Swensen, Dilling, Milliner, Zimmerman, Maples, Lindsay, Bartley. Quality: the Mayo Clinic Approach. Am J Med Qual 2009;24: Patient Centered Value Creation Execution Value Infrastructure Culture Engineering

24 Personal Goals Leading Self: I commit to for myself. Leading Team: I commit to for my team. Leading Organization: I commit to for my organization.

25 Leader Competencies System Competency Standardization and Diffusion of Best Practices Standard practice guidelines Single practice Knowledge management Value creation system Value Eliminate Preventable Harm Behavioral Competency Commitment to Safety in a Fair and Just Culture Clearly defined behaviors Pay attention to detail Communicate clearly Have a questioning and receptive attitude Handoff effectively Support each other Accountability for behavior Swensen, Dilling, Harper, Noseworthy. The Mayo Clinic Value Creation System AJMQ

26 Senior Leader Perspective Leader Heat Map Staff Perspective Swensen, et al. Leadership by Design. Journal of Management Development. Vol. 35 No. 4, 2016 pp.1-26

27 The Leadership Pipeline EOT s MCHS MT (41) President (1) Center/Office/IMP Chairs (28) Non-Shield Leaders (26) Site CEO s (3) BOG (12) SAC s Consultants (Care Team Leaders) Officers & Counselors (18) Mentor-Coaches Dept/Div Executive Committee Leaders (90) Dept/Div Chairs (233) Executive Deans (3) Residencies Medical School Shield /Institutional Committee Leaders (56) Swensen, Kabcenell, Shanafelt. Journal of Healthcare Management. 61: March/April 2016

28 Swensen, Pugh, McMullan, Kabcenell. High-Impact Leadership: Improve Care, Improve the Health of Populations & Reduce Costs. Institute for Healthcare Improvement; Available: MFMER

29 Swensen, Dilling, Mc Carty, Bolton, Harper. The Business Case for Healthcare Quality Improvement. J Patient Saf 2013;9:44.

30 Accounting Hard Dollar Cash flow effect definite Readily quantifiable Near-term timing Transaction-based evidence Soft Dollar Productivity Capacity Future cost avoidance Lower malpractice costs Swensen, Bolton, Dilling. The Business Case for Healthcare Quality Improvement. J Patient Saf, (1): p

31 Diffusion Team Mayo Clinic Diffusion Model Leadership Culture Sponsoring Body Value Creation Team Best Practice Standardized Mayo Care Process Model Operational Work Unit Implementation Order sets Rules/ Alerts Patient education Staff education Workflow changes EMR/Dept systems Brochures PAG, GPS Ask Mayo Expert Outcome measures IT Liason and Infrastructure Support Best Practice Owner Dilling, Swensen Mayo Clinic Model of Diffusion. Jt Comm J Qual Patient Saf. 2013;39:167.

32 Value Equation Appropriateness x (Outcomes + Service) Cost over Time Value-Based Health Care. Cortese, Landman, Smoldt. September 2012 September 7, Accessed august 11, 2014: Swensen, Dilling, Harper, Noseworthy. The Mayo Clinic Value Creation System AJMQ

33 Joyful Engaged Workforce 4. Use improvement science to test approaches to improving joy. 3. Commit to making Joy in Work shared responsibility at all levels. 2. Identify unique impediments to Joy in Work in the local context. 1. Ask staff what matters to you?

34 Critical Components for Ensuring a Joyful, Engaged Workforce Interlocking responsibilities at all levels Real Time Measurement: Contributing to regular feedback systems, radical candor in assessments Physical & Psychological Safety: Equitable environment, free from harm, Just Culture that is safe and respectful, support for the 2 nd Victim 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 Wellness & Resilience Daily Improvement Camaraderie & Teamwork Real Time Measurement Happy Healthy Productive People Participative Management Physical & Psychological Safety Meaning & Purpose Recognition & Rewards Autonomy & Control Meaning & Purpose Daily 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 Camaraderie & Teamwork: Commensality, social cohesion, productive teams, shared understanding, trusting relationships 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

35 As Medical Staff President, I have witnessed frustrated physicians transform into highly engaged physicians. They became empowered to create change rather than to feel affected by change.

36 The best thing about CI is that once you get a taste of it, it becomes a little addicting. It's extremely satisfying to see improvements that you have been instrumental in affecting, and you start to see opportunities everywhere. Primary Care Doctor

37 And while I still do my fair share of complaining, seeing improvements work has always been much more satisfying than simply pointing out our shortcomings and expecting someone else to fix the problem. Most satisfying has been to see dramatic improvements in patient care while actually relieving burden from physicians. Cardiologist

38 As a physician leader it s been so satisfying to see docs that might be feeling frustrated or questioning their decision to go into medicine completely turn around and become engaged, excited, participants in their physician role. Region Chief Medical Officer

39 References Swensen, Shanafelt. Organizational Framework to Bring Back Joy in Practice. The Joint Commission Journal on Quality and Patient Safety 2017 Sinsky, C.A., et al., In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices. The Annals of Family Medicine, (3): p Swensen, S., A. Kabcenell, and T. Shanafelt, Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. Journal of healthcare management / American College of Healthcare Executives, (2): p Johnson, J.V., et al., Long-term psychosocial work environment and cardiovascular mortality among Swedish men. American Journal of Public Health, (3): p Baard, P.P., E.L. Deci, and R.M. Ryan, Intrinsic Need Satisfaction: A Motivational Basis of Performance and Weil Being in Two Work Settings1. Journal of applied social psychology, (10): p Swensen, S., et al., Leadership by design: intentional organization development of physician leaders. Journal of Management Development, (4): p Thirioux, B., F. Birault, and N. Jaafari, Empathy Is a Protective Factor of Burnout in Physicians: New Neuro- Phenomenological Hypotheses Regarding Empathy and Sympathy in Care Relationship. Front Psychol. 2016;7:763. doi: /fpsyg Riess, H., et al., Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience- Informed Curriculum. Journal of general internal medicine, (10): p Krasner, M.S., et al., Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Jama, (12): p P a g e

40 References Scott, S.D., et al., Caring for our own: deploying a systemwide second victim rapid response team. Communication of Critical Test Results, Taris, T.W., Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work & Stress, (4): p Swensen, S.J., et al., The Mayo Clinic Value Creation System. Am J Med Qual, (1): p Beckman, H.B., et al., The impact of a program in mindful communication on primary care physicians. Academic medicine : journal of the Association of American Medical Colleges, (6): p Kniffin, K.M., et al., Eating Together at the Firehouse: How Workplace Commensality Relates to the Performance of Firefighters. Human Performance, (4): p West, C.P., et al., Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med, (4): p Linzer, M., et al., A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. Journal of general internal medicine, (8): p Sinsky, C., et al., Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Annals of Internal Medicine, (11): p Shultz, C.G. and H.L. Holmstrom, The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med, (3): p Wu, A.W., Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ Mar 18;320(7237):726-7.

41 References Shanafelt, T.D., et al., Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clinic Proceedings. 91(4): p West, C.P., et al., Association of resident fatigue and distress with perceived medical errors. Jama, (12): p P a g e Williams, E.S., et al., The relationship of organizational culture, stress, satisfaction, and burnout with physicianreported error and suboptimal patient care: results from the MEMO study. Health care management review, (3): p Swensen, S.J., et al., The business case for health-care quality improvement. J Patient Saf, (1): p Ruotsalainen, J.H., et al., Preventing occupational stress in healthcare workers. The Cochrane Library, Laskowski, E.R. Walking Throughout Your Day Keeps Depression (and a Host of Other Health Problems) Away. in Mayo Clinic Proceedings Elsevier. Epstein, R.M. and M.S. Krasner, Physician resilience: what it means, why it matters, and how to promote it. Acad Med, (3): p Sood, A., et al., Stress Management and Resiliency Training (SMART) Program among Department of Radiology Faculty: a pilot randomized clinical trial. EXPLORE: The Journal of Science and Healing, (6): p Panagioti, M., et al., Controlled interventions to reduce burnout in physicians: A systematic review and metaanalysis. JAMA Internal Medicine, West, C.P., et al., Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet. 388(10057): p