Fluent Essays

please see attached A. Create a computer-generated mind map that identifies a main idea that contributes to or impedes joy in work and includes the following factors: •   three individual factors •   three team or department factors •   three organizational factors Note: This assessment requires you to submit an original computer-generated diagram. You may use the software program of your choice. Save and submit your mind map as a PDF or Word document (i.e., DOC or DOCX). Using another file type may cause the file to be too large to submit. Note: A “main idea” could be a concept, a strategy, or an idea.   B. Using the attached “Force Field Analysis Template,” complete a force field analysis that includes the following components: •   one recommendation of a social communication strategy or technology strategy for implementing the “Institute for Healthcare Improvement (IHI) Framework for Improving Joy in Work” (see Supporting Documents) in the workplace •   five facilitating forces for implementing the recommendation •   five restraining forces against implementing the recommendation •   one score for each of the ten identified forces •   one “Facilitating Forces Total Score” •   one “Restraining Forces Total Score” •   one “Force Field Analysis Total Score” Note: This assessment requires you to complete the force field analysis using the “Force Field Analysis Template” in the Supporting Documents section. Save and submit your force field analysis as a PDF or Word document (i.e., DOC or DOCX). Using another file type may cause the file to be too large to submit.   C. Write a reflection paper (suggested length of 4-6 pages) discussing how to use social and emotional intelligence power skills to handle difficult workplace situations and implement joy in the workplace by doing the following: 1.  Describe, using scholarly sources, how advanced professional nurses can manage difficult workplace situations by using each of the following social and emotional intelligence power skills: •   self-awareness •   self-management •   interpersonal communication •   executive function •   social awareness 2.  Describe how you, as an advanced professional nurse, would use two of the social and emotional intelligence power skills in the workplace to achieve each of the following results: •   a professional presence •   enhanced mindfulness in healthcare •   a positive social presence to promote a sense of caring and belonging •   a culture of joy to solve the problem of incivility in the workplace and initiate organizational change 3.  Discuss how you, as an advanced professional nurse leader, would implement the four steps from the “IHI Framework for Improving Joy in Work” (see Supporting Documents) in the workplace, including one strategy for each of the four steps. 4.  Include three or more scholarly sources in your reflection paper. JOY IN THE WORKPLACE FORCE FIELD ANALYSIS Force Field Analysis Template In the table below, list your recommendation of a social communication strategy or technology strategy for implementing the “Institute for Healthcare Improvement (IHI) Framework for Improving Joy in Work” in the workplace. Then, list five facilitating forces and five restraining forces for and against implementing this recommendation. Using the following scale, score each of your facilitating and restraining forces from 1 to 5 according to the degree of influence each force would have on your recommendation: 1 = very weak 2 = slightly weak 3 = neither weak nor strong 4 = slightly strong 5 = very strong To calculate the “Facilitating Forces Total Score”, add your five scores for the facilitating forces and enter this number in the last row of the chart. To calculate the “Restraining Forces Total Score”, add your five scores for the restraining forces and enter this number in the last row of the chart. To calculate the “Force Field Analysis Total Score”, substract the “Restraining Forces Total Score” from the “Facilitating Forces Total Score” and enter this number in the middle column of the last row of the chart. If the difference is positive, move forward with implementing the recommendation. If the difference is negative, reconsider implementing the recommendation. Score (1-5) Facilitating Forces for Recommendation Recommendation Restraining Forces against Recommendation Score (1-5) Facilitating Forces Total Score: Force Field Analysis Total Score: Restraining Forces Total Score: IHI Framework for Improving Joy in Work AN IH I RES OUR CE 20 University Road, Cambridge, MA 02138 • ihi.org How to Cite This Paper: 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) WHITE P APER AUTHORS: Jessica Perlo, MPH: Network Director, IHI Open School Barbara Balik, RN, EdD: Senior Faculty, IHI, and Co-founder, Aefina Partners Stephen Swensen, MD: Medical Director for Professionalism and Peer Support, Intermountain Healthcare, and Senior Fellow, IHI Andrea Kabcenell, RN: Vice President of Innovation, IHI Julie Landsman: Project Coordinator, IHI Derek Feeley: President and CEO, IHI Acknowledgments: IHI would like to thank the following organizations for their contribution to the IHI Framework for Improving Joy in Work: American Medical Association; Barry–Wehmiller; Baylor Scott & White Health; Bellin Health Systems; Beth Israel Deaconess Medical Center; Brigham and Women’s Hospital; Gaylord Hotels; Google; Healthcare Transformation Project at ILR School of Cornell University; Hospitality Quotient; Hospital Quality Institute; Iora Health; Mayo Clinic; Menlo Innovations; Samueli Institute; Service Employees International Union; Starbucks; Veterans Health Administration; and Zappos. We would also like to thank the following organizations that participated in prototype testing of the framework: American Association of Critical Care Nurses; Charleston Area Medical Center; Glen Cove Hospital, Northwell Health; iMatter NHS Scotland; Imperial College Healthcare NHS Trust; Kaiser Permanente Erwin Street Medical Offices; Mount Auburn Hospital Labor and Delivery; Nemours/Alfred I. DuPont Hospital for Children Pediatric Intensive Care Unit; NHS Highland; Penn State Altoona Nursing Department; University of Michigan Cardiac Intensive Care Unit; and University of Virginia School of Nursing. The authors are grateful for the thought leadership provided by IHI Leadership Alliance members who participated in the Joy in Work Workgroup and helped to frame the basic concepts as they apply to health care. We also thank Jane Roessner, Val Weber, and Don Goldmann of IHI for their support in developing and editing this white paper. The authors assume full responsibility for any errors or misrepresentations. The Institute for Healthcare Improvement (IHI) is a leading innovator in health and health care improvement worldwide. For more than 25 years, we have partnered with a growing community of visionaries, leaders, and frontline practitioners around the globe to spark bold, inventive ways to improve the health of individuals and populations. Together, we build the will for change, seek out innovative models of care, and spread proven best practices. To advance our mission, IHI is dedicated to optimizing health care delivery systems, driving the Triple Aim for populations, realizing person- and family- centered care, and building improvement capability. We have developed IHI’s white papers as one means for advancing our mission. The ideas and findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and early results where they exist. Copyright © 2017 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. Institute for Healthcare Improvement • ihi.org 3 Contents Foreword 4 Executive Summary 5 Introduction 5 Four Steps for Leaders 8 IHI Framework for Improving Joy in Work 16 Measuring Joy in Work 21 Conclusion 22 Appendix A: “What Matters to You?” Conversation Guide 23 Appendix B: Change Ideas for Improving Joy in Work 27 Appendix C: Assessment Tools for Improving Joy in Work 33 References 38 WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 4 Foreword Okay, I admit it. “Joy in work” sounds flaky. That was the reaction a friend of mine had when I suggested a couple of years ago that she add that to the strategic goals she was exploring with her team on a day-long management retreat. She did try, and her report back to me was this: “They hated it. They said, ‘Get real! That’s not possible.’” Sad to say, I suspect that may still be the response of all too many workgroups and leaders, both inside and outside health care. “Hunkering down,” “getting through the day,” “riding out the storm” — these are much more familiar attitudes in inevitably stressed work environments, as truly good people try hard to cope with systems that don’t serve them well, facing demands they can, at best, barely meet. The closest most organizations come to “joy” is “TGIF” parties — “Thank goodness it’s Friday. I made it through another week.” It has long seemed a paradox to me that such depletion of joy in work can pervade as noble and meaningful an enterprise as health care. What we in the healing professions and its support roles get to do every day touches the highest aspirations of a compassionate civilization. We have chosen a calling that invites people who are worried and suffering to share their stories and allow us to help. If any work ought to give spiritual satisfaction to the workers, this is it. “Joy,” not “burnout,” ought to rule the day. In our work in health care, joy is not just humane; it’s instrumental. As my colleague Maureen Bisognano has reminded us, “You cannot give what you do not have.” The gifts of hope, confidence, and safety that health care should offer patients and families can only come from a workforce that feels hopeful, confident, and safe. Joy in work is an essential resource for the enterprise of healing. Good news! Joy is possible. We know it is possible, not only from intuition, but also from science. This IHI White Paper summarizes a surprisingly large literature on theory and evidence about factors, such as management behaviors, system designs, communication patterns, operating values, and technical supports, that seem associated with better or worse morale, burnout, and satisfaction in work. It also cites a growing number of health care organizations that are innovating in pursuit of joy in work, and often getting significant, measurable results. (One of those organizations is IHI, itself, whose local projects are worth studying.) Since joy in work is a consequence of systems, quality improvement methods and tools have a role in its pursuit. That is to say: organizations and leaders that want to improve joy can do so using the same methods of aim setting, tests of change, and measurement that they use in the more familiar terrain of clinical and operational process improvement. So, listen up! “Joy in work” is not flaky, I promise you. Improving joy in work is possible, important, and effective in pursuit of the Triple Aim. This IHI White Paper will help you get started. And you might well find that the joy it helps uncover is, in large part, your own. Donald M. Berwick, MD President Emeritus and Senior Fellow Institute for Healthcare Improvement WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 5 Executive Summary With increasing demands on time, resources, and energy, in addition to poorly designed systems of daily work, it’s not surprising health care professionals are experiencing burnout at increasingly higher rates, with staff turnover rates also on the rise. Yet, joy in work is more than just the absence of burnout or an issue of individual wellness; it is a system property. It is generated (or not) by the system and occurs (or not) organization-wide. Joy in work — or lack thereof — not only impacts individual staff engagement and satisfaction, but also patient experience, quality of care, patient safety, and organizational performance. This white paper is intended to serve as a guide for health care organizations to engage in a participative process where leaders ask colleagues at all levels of the organization, “What matters to you?” — enabling them to better understand the barriers to joy in work, and co-create meaningful, high-leverage strategies to address these issues. The white paper describes the following: x The importance of joy in work (the “why”); x Four steps leaders can take to improve joy in work (the “how”); x The IHI Framework for Improving Joy in Work: nine critical components of a system for ensuring a joyful, engaged workforce (the “what”); x Key change ideas for improving joy in work, along with examples from organizations that helped test them; and x Measurement and assessment tools for gauging efforts to improve joy in work. Introduction If burnout in health care were described in clinical or public health terms, it might well be called an epidemic. The numbers are alarming. A 2015 study found over 50 percent of physicians report symptoms of burnout.1 Thirty-three percent of new registered nurses seek another job within a year, according to another 2013 report.2 Turnover is up, and morale is down. Burnout affects all aspects of the pursuit of better health and health care. It leads to lower levels of staff engagement, which correlate with lower customer (patient) experience, lower productivity, and an increased risk of workplace accidents. These all significantly affect the financial vitality of an organization. The impact on patient care is even more worrying. Lower levels of staff engagement are linked with lower-quality patient care, including safety, and burnout limits providers’ empathy — a crucial component of effective and person-centered care. So, what can leaders do to counteract this epidemic? The Institute for Healthcare Improvement (IHI) believes an important part of the solution is to focus on restoring joy to the health care workforce. With this in mind, IHI developed four steps leaders can take to improve joy in work (the “how”); and the IHI Framework for Improving Joy in Work — critical components of a system for ensuring a joyful, engaged workforce (the “what”). Together, they serve as a guide for health care organizations, teams, and individuals to improve joy in work of all colleagues. WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 6 To inform this work, IHI led three 90-day Innovation Projects on Joy in Work in 2015–2016, with the goal of designing and testing a framework for health systems to improve joy in work. The Innovation Projects comprised scans of the current published literature on engagement, satisfaction, and burnout; more than 30 expert interviews based on the literature scan, including interviews with patients and exemplar organizations both within and outside of health care; site visits; and, finally, learning from 11 health and health care systems working to improve joy in work as they participated in a two-month prototype program testing steps, refining the framework, and identifying ideas for improvement. In addition to presenting the four steps and the framework, this white paper describes specific changes to test, discusses practical issues in measuring joy in work, presents examples from organizations involved in testing and implementation, and includes self-assessment tools for health care organizations looking to understand their current state. Why Use the Term “Joy in Work”? Why “joy in work”? And why now? Some may think focusing on joy in health care — a physically, intellectually, and emotionally demanding profession — is a distant goal. But focusing on joy is important for three fundamental reasons. First, focusing on joy, as opposed to focusing only on burnout or low levels of staff engagement, accords with an approach applied to solving many intractable problems in heath and health care. It’s tempting to analyze a problem by only paying attention to deficits or gaps. But to get to solutions, it is essential to identify, understand, and leverage all the assets that can be brought to bear, and joy is one of health care’s greatest assets. Health care is one of the few professions that regularly provides the opportunity for its workforce to profoundly improve lives. Caring and healing should be naturally joyful activities. The compassion and dedication of health care staff are key assets that, if nurtured and not impeded, can lead to joy as well as to effective and empathetic care. This assets-based approach to improvement enables people to look at issues from different perspectives, which often leads to designing more innovative solutions. The sociologist Aaron Antonovksy taught us to think of health as more than merely the absence of disease. Health is about coherence, he said — a sense that life is comprehensible, manageable, and meaningful.3 Following Antonovsky’s lead, the second reason to focus on joy in work is because joy is about more than the absence of burnout. Joy, like Antonovsky’s conception of health, is about connections to meaning and purpose. By focusing on joy through this lens, health care leaders can reduce burnout while simultaneously building the resilience health care workers rely on each day. Again, the goal is to design innovative solutions by looking at issues from a different perspective. The third reason for focusing on joy takes us back to W. Edwards Deming. His 14 Points for Management, first presented in his book Out of the Crisis, address joy, but use different terms. Consider, for example, Point 11, “Remove barriers that rob the hourly worker of his right to pride of workmanship,” and Point 12, “Remove barriers that rob people in management and in engineering of their right to pride of workmanship.” For Deming, “pride of workmanship” and “joy” were highly related, if not interchangeable.4 Later in life, Deming increasingly emphasized the importance of joy in work. In his final lectures, he routinely stated that “Management’s overall aim should be to create a system in which everybody may take joy in [their] work.” Ensuring joy is a crucial component of the “psychology of change,” one of the cornerstones of Deming’s scientific approach to improvement. In addition to being a core part of his theory of improvement, joy in work, to Deming, was also a fundamental right. It is up to leaders, he argued, to ensure that workers can enjoy that right. WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 7 Fairness and Equity as Contributors to Joy in Work Individuals who experience unfairness and inequity at work, or even outside of work, feel disempowered and will likely disengage, regardless of the basis for the inequity. Links have been made between race and ethnicity and wellbeing, showing various racial and ethnic groups experiencing less joy in work. The National Health Service in England went about measuring this within their environment and found significant disparities between the experience of white employees and that of black, minority, and ethnic employees. They went further to show that the sites with the highest rates of discrimination against minorities had the lowest patient experience scores. Besides indicating toxic environments for individuals and teams, addressing racism and inequity in the workplace becomes a quality-of-care imperative.5 Focusing on equity can also lead to improving joy in work. For example, Henry Ford Health System’s emphasis on health care equity has been a driver of employee engagement. They administered a Gallup Employee Engagement survey and found that employees involved in health care equity work were seven times more engaged than other employees. The IHI White Paper, Achieving Health Equity: A Guide for Health Care Organizations, offers a framework for health care organizations to improve health equity for their staff and the communities they serve.6 Regardless of the approach taken, health care organizations need the full engagement of all staff members in the mission. If individuals disengage, group output becomes less diverse, opinions are marginalized, decisions and performance suffer, and consequently, patients suffer.7 When everyone is engaged in an equitable and diverse environment, they feel as though they can listen to what matters to patients and colleagues; comfortably ask questions, request help, or challenge what’s happening; and use teamwork to successfully solve challenges. All of these contribute to a positive work experience and enable the entire team to experience joy in work. The Case for Improving Joy in Work Perhaps the best case for improving joy is that it incorporates the most essential aspects of positive daily work life. A focus on joy is a step toward creating safe, humane places for people to find meaning and purpose in their work. There is also a strong business case for improving joy in work. Recognizing that joy does not yet have a single validated measure, which we’ll discuss more in the measurement section, the business case draws on outcomes of the work environment, including engagement, satisfaction, patient experience, burnout, and turnover rates. Engagement is an imprecise but often-used proxy measure for joy. An engaged workforce is one that holds a positive attitude toward the organization and its values, and is foundational to creating high-performing organizations.8 When researchers studied human capital management drivers, they found that traditional Human Resources metrics (e.g., average time to fill open positions and total hours of training provided) do not predict organizational performance. Rather, a score of human capital drivers including employee engagement, among other factors, was more relevant.9 A UK study also demonstrated the relationship of performance and profitability with employee engagement.10 These and other studies confirm the intuitive: improving engagement contributes to improved performance.11 It enables greater professional productivity with lower turnover rates. Joy in work, in turn, improves patient experience, outcomes, and safety, resulting in substantially lower costs.12 WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 8 Many have documented this correlation between greater employee satisfaction and safer, more efficient patient care.13 There is ample evidence that management practices to produce a joyful, engaged workforce are associated with fewer medical errors and better patient experience;14 less waste; higher employee productivity;15 and more discretionary effort on the part of staff and reduced turnover, leading to better financial performance.16 Studies have also shown a link between job dissatisfaction and plans for leaving a job. By considering employee turnover as a factor that’s associated with joy in work, it is possible to make an explicit financial case as well. One study showed that lost revenue for replacing one full-time equivalent (FTE) physician is $990,034, plus recruitment costs of $61,200 and annual start-up costs of $211,063. That means replacing one departing physician and on-boarding a new physician will cost the organization more than $1 million ($1,262,297).17 Finally, measuring joy and sharing the measurement results externally helps attract and retain top performers to an organization.18 Four Steps for Leaders As IHI engaged with partners in thinking about how to restore, foster, and nurture joy in the health care workforce, it became evident that leaders often find it challenging to see a way to move from the current state to “joy in work.” Here are four steps leaders can take to find a path forward. Figure 1. Four Steps for Leaders Figure 1 depicts the steps as stairs, to illustrate that each step serves as the foundation for the steps that follow. First, leaders engage colleagues to identify what matters to them in their work (Step 1). Next, leaders identify the processes, issues, or circumstances that are impediments to what matters — the “pebbles in their shoes” that get in the way of meeting professional, social, and psychological needs (Step 2).19 Then, in partnership, multidisciplinary teams come together and share responsibility for removing these impediments (focusing on nine critical components), and for improving and sustaining joy (Step 3). Leaders and staff use improvement science together to accelerate improvement and create a more joyful and productive place to work (Step 4). The four steps do not ignore the larger organizational issues, or “boulders,” that exist, such as the impact of electronic health record functionality on clinicians’ daily work, or workload and staffing issues. Rather, the steps empower local teams to identify and address impediments they can WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 9 change, while larger system-wide issues that affect joy in work are also being prioritized and addressed by senior leaders. This process converts the conversation from “If only they would…” to “What can we do today?” It helps everyone see the organization as “us” and not “them.” Creating joy and engagement in the workplace is a key role of effective leaders. IHI’s High-Impact Leadership Framework describes leaders’ actions that make them effective, from being an authentic presence at the front line to staying focused on mission and what matters, and identifies attention to joy in work as a major component of the leadership role.20 These leadership actions also give meaning to work, promote camaraderie, and are essential to improving joy. Similarly, everything we know about improving safety in health care relies on ensuring a fair and just culture, effective teams, and daily improvement — those things that also contribute to joy in work.21 Safety, effective leadership, and a joyful workforce are inextricably linked. Get Ready Before launching into Step 1, three “Get Ready” actions will establish a foundation for success. To embark on the steps without making these preparations risks derailing well-intentioned plans. x Prepare for the “What matters to you?” conversations: These are rich, learning conversations — not intended to communicate information, but rather to listen and learn. Leaders are often ill equipped to have effective conversations with colleagues, and many put off these important dialogues because of two primary concerns: 1) What if colleagues ask for things I can’t do? and 2) How am I going to fix all the things they identify? Leaders rightly fear an avalanche of issues falling on them that they are unable to address effectively. Leaders and colleagues should recognize this is a different approach than the usual “I tell you what isn’t working and you fix it” approach. See Appendix A for a guide to conducting effective “What matters to you?” conversations and resolving issues that arise from such conversations. The guide helps leaders get started quickly and learn as they go. x Ensure leader capacity at all levels of the organization: Leaders at the local level (e.g., program, department, or clinic) — referred to as “core leaders” in this paper — are tasked with guiding the work to improve joy in work in their respective areas. These leaders need the capacity (i.e., time to do the work and improvement science skills) and skill to facilitate the “What matters?” conversations, and to act on the issues that surface. Identifying impediments and then not acting on them intensifies rather than diminishes cynicism. For example, one organization testing these steps asked staff about impediments, but was unable to act at that time. A year later, when leaders returned to colleagues to ask about “What matters?” they were met with frustration — staff were hesitant to participate further because nothing had happened after their previous input. During prototype testing, sites found that they could begin tests of change on some local impediments almost immediately, especially if they broke these down into smaller segments. Sites that made progress on reaching their aims designated skilled and committed core leaders who facilitated improvement immediately, rather than waiting for an external resource team. x Designate a senior leader champion: Optimally, joy in work is an organization-wide strategy, led by senior leaders and involving colleagues and leaders at all levels. Core leaders need to have at least one senior leader as a champion when issues arise that go beyond the scope of their local leadership. The champion also takes on the “boulders” that are too big for a local unit, and begins to address them in the larger organization. WHITE PAPER: IHI Framework for Improving Joy in Work Institute for Healthcare Improvement • ihi.org 10 Step 1. Ask staff, “What matters to you?” This step is about asking the right questions and really listening to the answers to identify what contributes to — or detracts from — joy in work for staff (see Appendix A for a “What Matters to You?” Conversation Guide).22 For many years, IHI has been promoting the transformative provocation to ask patients, “What matters to you?” in addition to “What’s the matter?”23 Health care leaders need to ask the health care workforce the same question. Only by understanding what truly matters to staff will senior management be able to identify and remove barriers to joy. During the IHI prototype testing, some sites found it helpful to start with identifying a senior leader champion who commits to making joy in work a shared responsibility at all levels (Step 3). Highlighting senior leader support enabled staff to feel more comfortable bringing up issues and being honest about what matters to them. At these sites, teams needed assurance that change was an option before they were willing to share. Whether or not a champion is identified at the outset, leaders can support the process and show a genuine interest in the wellbeing of individuals and teams by regularly engaging colleagues in discussions to identify the unique local and organizational opportunities to improve joy in work.24 Discovering what matters relies heavily on trusting relationships and assumes that leaders know how to listen. This is not always the case. Strong leaders use effective listening and communication skills to involve others, build consensus, and influence decisions. Teams have found success with using communication boards, surveys, regular staff meetings or more informal meetings to engage, inform, and listen. Identifying what matters need not take a lot of time. However, what works in one setting may not work in another. It’s up to leaders to find the method that works best for their colleagues and fits into the daily or weekly workflow. By beginning with asking “What matters?” leaders engage in a form of appreciative inquiry that taps into strengths or bright spots, or what’s already working in the organization, that offer energy for change. Conversation questions may include: x What makes for a good day for you? x What makes you proud to work here? x When we are at our best, what does that look like? This then sets the context for asking what gets in the way of a good day or what makes for a bad day. When leaders and team members are frank about what makes for a bad day, whether it is an overload of patients in a clinic or an inability to act on patients’ wishes for care, leaders and colleagues share the problems and ultimately the solutions. This creates a sense of “we are in this together.” While leaders may not take immediate action on all issues, the conversation establishes a place to start to make the work environment and …