Esprit de Corps - New Document · Esprit de Corps Swensen, Shanafelt ... once you get a taste of...

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.

Six Actions

Esprit de Corps

Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June 2017 43(6) 308

2 Measures

Negativity Positivity

Human Needs

Business Case

2 Measures Esprit

de Corps Leader Index

Quadruple Aim

Unit Specific

• Engagement

• Teamwork

• Satisfaction

• Resilience

• Burnout


• Appreciation

• Ideas

• Transparency

• Career

• Inclusion

Human

Needs

Baard, Deci, Ryan. Intrinsic Need Satisfaction. J Applied Social Psych, 2004. 34(10): 2045

Swensen, Kabcenell, Shanafelt. J Healthcare Management.61:2;105-127 2016

Camaraderie

Esprit de corps

Resilience Passion

Trusted

Esprit de

corps Human Needs

Swensen, Shanafelt. Organizational Framework to Reduce Professional Burnout. Joint Commission Journal on Quality and Patient Safety June 2017 43(6) 308 Swensen Gorringe Caviness Peters . Leadership by Design. Journal of Mgmt Development Vol. 35 (4) 2016

Leaders

Design

Commensality

Pebbles

Second

Victims

Resilience

Esprit de Corps ↓ Burnout

Patient Experience Outcomes

Safety

QI

The Business Case…a virtuous cycle

$

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


Five Leader Index Behaviors

• Appreciation:

• Express gratitude in a meaningful way to colleagues

• Transparency:

• Share what you know with the team

• Ideas:

• Consistently solicit input of coworkers

• Career:

• Support professional aspirations of staff

• Inclusion:

• Nurture a culture where all are welcome and psychologically safe

• Professionalism 5 6

• Medical errors 1-3 11 12 13 15

• Patient Satisfaction 7 14

• Productivity Turnover 9

• Suicidal Ideation 9 10

1JAMA 296:1071 2JAMA 304:1173 3JAMA 302:1294 4Annals IM 136:358 5Annals Surg 251:995 6JAMA 306:952 7Health Psych 12:93 8JACS 212:42 9Annals IM 149:334 10 Arch Surg 146:54 11Fahrenkoph 2008 12Shanafelt 2010 13West 2006 14 Beach 2013 15 Halbesleben 2008

• Professionalism 5 6

• Medical errors 1-3 11 12 13 15

• Motor Vehicle Accidents 16

• Patient Satisfaction 7 14

• Productivity Turnover 9

• Suicidal Ideation 9 10

1JAMA 296:1071 2JAMA 304:1173 3JAMA 302:1294 4Annals IM 136:358 5Annals Surg 251:995 6JAMA 306:952 7Health Psych 12:93 8JACS 212:42 9Annals IM 149:334 10 Arch Surg 146:54 11Fahrenkoph 2008 12Shanafelt 2010 13West 2006 14 Beach 2013 15 Halbesleben 2008 16 Shanafel 2012 MCP

©2013 MFMER | 3239472-11

Shanafelt Noseworthy Executive Leadership

Physician Well-being. Mayo Clin Proc. 2016

Categorize ‘Pebbles’

Swensen, Kabcenell, Shanafelt. J Healthcare Management.61:2;105-127 2016

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)

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; 2013. Available: www.ihi.org.

Human Error (lapse, slip, mistake)

Risky (choice increases risk where risk is

unrecognized or mistakenly believed to be justified)

Reckless (choice to consciously disregard a substantial and unjustifiable risk)

Console Learn

Coach Learn

Corrective

Action

Fair

and

Just

Culture

Leonard, Frankel. Patient Education and Counseling. 80 (2010) 288-292 Reason J. Human error: models and management. BMJ. 2000 Mar 18; 320:768-770.

Marx D. (2001) Patient Safety and the “Just Culture”: A Primer for Health Care Executives. Columbia University, New York, NY.

Faulty design or lack of system?

Accountability not determined

by outcome

Fix System

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

Accountability is

not determined by

the outcome

Near misses or undesirable

outcomes reviewed and responded

to in a consistent manner

Fair and Just Culture What can we learn

from this to prevent

future harm?


Reason J. Human error: models and management. BMJ. 2000 Mar 18; 320:768-770.

Leonard, Frankel. Patient Education and Counseling. 80 (2010) 288-292

Individual Behavioral Choices •Human Error •Risky (Drift) •Reckless

Human Error = inadvertent action (lapse, slip, mistake)

Risky (Drift) = behavioral choice that increases risk where risk is unrecognized or mistakenly believed to be justified

Reckless = behavioral choice to consciously disregard a substantial and unjustifiable risk

Console/ Learn

Coach/ Learn

Corrective Action

Management Response

Fair and Just Culture


Reason J. Human error: models and management. BMJ. 2000 Mar 18; 320:768-770.

Leonard, Frankel. Patient Education and Counseling. 80 (2010) 288-292

Value Creation System

Value Creation System

MeasurementManaged

DiffusionDiscoveryAlignment

Swensen, Dilling, Harper, Noseworthy, The Mayo Clinic Value Creation System. Sept 2011. AJMQ

Leadership Index

Shanafelt, Menaker, Buskirk, Gorringe, Swensen. 12 Leadership Dimensions. Mayo Clinic Proceedings. April 2015: 90(4); 432-440

(P<0.001)

(P<0.001)

Mission

Strategy

Vision

Mission

Strategy

Vision

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

Patient-Designed Culture

Us

Them

I We

Cooperation

Competition

Mistrust

Social

Capital

Swensen Gorringe Caviness Peters . Leadership by Design. Journal of Mgmt Development Vol. 35 (4) 2016

Value

Execution

Infrastructure Culture

Engineering

Patient Centered

Value Creation

Swensen , Dilling , Milliner, Zimmerman, Maples, Lindsay, Bartley. Quality: the Mayo Clinic Approach. Am J Med Qual 2009;24:428-440

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.

Leader Competencies System

Competency Behavioral

Competency

Eliminate Preventable

Harm

Value

Standardization and Diffusion of Best Practices

• Standard practice guidelines

• Single practice

• Knowledge management

• Value creation system

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. 2011 AJMQ

Sen

ior

Lead

er P

ersp

ecti

ve →

Leader Heat Map

Swensen, et al. Leadership by Design. Journal of Management Development. Vol. 35 No. 4, 2016 pp.1-26

Staff Perspective→

Consultants (Care Team Leaders)

Residencies

Medical School

BOG (12)

Mentor-Coaches

Executive Deans

(3)

Shield /Institutional Committee Leaders

(56)

EOT’s MCHS MT

(41)

Site CEO’s

(3)

Non-Shield Leaders

(26)

Center/Office/IMP Chairs (28)

Dept/Div Executive Committee Leaders

(90)

President (1)

SAC’s Officers &

Counselors (18)

Dept/Div Chairs (233)

The Leadership Pipeline

Swensen, Kabcenell, Shanafelt. Journal of Healthcare Management. 61:2 105-127 March/April 2016

©2013 MFMER | 3239472-28

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

& Reduce Costs. Institute for Healthcare Improvement; 2013. Available: www.ihi.org.

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

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, 2013. 9(1): p. 44-52.

Mayo Clinic Diffusion Model Leadership

Culture

Sponsoring Body

Value Creation Team

Best Practice

Standardized Mayo Care Process Model D

iffu

sio

n

Team

Best Practice Owner

Order sets

Rules/ Alerts

Patient education

Staff education

Workflow changes

Operational Work Unit

Implementation

EMR/Dept systems

Brochures PAG, GPS

Ask Mayo Expert

Outcome measures

IT Liason and Infrastructure Support

Dilling , Swensen… Mayo Clinic Model of Diffusion. Jt Comm J Qual Patient Saf. 2013;39:167.

Value Equation

Value-Based Health Care. Cortese, Landman, Smoldt. September 2012 September 7, 2012. Accessed august 11, 2014:

http://iom.edu/~/media/Files/Perspectives-Files/2012/Commentaries/VSRT-First-Step.pdf

Appropriateness x (Outcomes + Service)

Cost over Time

Swensen, Dilling, Harper, Noseworthy. The Mayo Clinic Value Creation System. 2011 AJMQ

4. Use improvement science to

test approaches to improving joy.

Joyful Engaged Workforce

2. Identify unique impediments to

Joy in Work in the local context.

3. Commit to making Joy in Work

shared responsibility at all levels.

1. Ask staff “what matters to you?”

Critical Components for Ensuring a Joyful, Engaged Workforce Interlocking 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 & 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

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

“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.”

“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

“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

“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

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, 2013. 11(3): p. 272-278.

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, 2016. 61(2): p. 105-127.

Johnson, J.V., et al., Long-term psychosocial work environment and cardiovascular mortality among Swedish men. American Journal of Public Health, 1996. 86(3): p. 324-331.

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, 2004. 34(10): p. 2045-2068.

Swensen, S., et al., Leadership by design: intentional organization development of physician leaders. Journal of Management Development, 2016. 35(4): p. 549-570.

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:10.3389/fpsyg.2016.00763.

Riess, H., et al., Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum. Journal of general internal medicine, 2012. 27(10): p. 1280-1286.

Krasner, M.S., et al., Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Jama, 2009. 302(12): p. 1284-1293. 16 | P a g e

References

Taris, T.W., Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work & Stress, 2006. 20(4): p. 316-334.

Swensen, S.J., et al., The Mayo Clinic Value Creation System. Am J Med Qual, 2012. 27(1): p. 58-65.

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, 2012. 87(6): p. 815-9.

Kniffin, K.M., et al., Eating Together at the Firehouse: How Workplace Commensality Relates to the Performance of Firefighters. Human Performance, 2015. 28(4): p. 281-306.

West, C.P., et al., Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med, 2014. 174(4): p. 527-33.

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, 2015. 30(8): p. 1105-1111.

Sinsky, C., et al., Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Annals of Internal Medicine, 2016. 165(11): p. 753-760.

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, 2015. 28(3): p. 371-81.

Wu, A.W., Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000 Mar 18;320(7237):726-7.

Scott, S.D., et al., Caring for our own: deploying a systemwide second victim rapid response team. Communication of Critical Test Results, 2010.

References

West, C.P., et al., Association of resident fatigue and distress with perceived medical errors. Jama, 2009. 302(12): p. 1294-1300. 17 | P a g e

Williams, E.S., et al., The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health care management review, 2007. 32(3): p. 203-212.

Swensen, S.J., et al., The business case for health-care quality improvement. J Patient Saf, 2013. 9(1): p. 44-52.

Ruotsalainen, J.H., et al., Preventing occupational stress in healthcare workers. The Cochrane Library, 2015.

Laskowski, E.R. Walking Throughout Your Day Keeps Depression (and a Host of Other Health Problems) Away. in Mayo Clinic Proceedings. 2016. Elsevier.

Epstein, R.M. and M.S. Krasner, Physician resilience: what it means, why it matters, and how to promote it. Acad Med, 2013. 88(3): p. 301-3.

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, 2014. 10(6): p. 358-363.

Panagioti, M., et al., Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Internal Medicine, 2016.

West, C.P., et al., Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet. 388(10057): p. 2272-2281.

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. 422-431.

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