3 part assignment
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 patient care better. Through this process, leaders can begin to identify assets and bright spots on which to build, as well as defects in the system that might be improved. By cultivating leaders’ ability to work collaboratively, facilitate change, build relationships, and employ a participative management style, the organization will be in a better position to tackle complex challenges.25
During the Innovation Projects, IHI interviewed a few organizations outside of health care that have done this well. Howard Behar, former president of Starbucks Coffee Company, shared that listening and ensuring people feel heard has been the cornerstone of their work. “Leaders can’t always do something to improve the problem, but they can listen and try,” Behar said. “The tension
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 11
goes away as soon as people feel like their feedback is valued.” One way Starbucks did this was through “Mission Review” cards. Every employee was given a postcard-sized card and encouraged to report any decision that did not, in their opinion, support the company’s mission statement to a “Mission Review” team. Employees received a response from leadership within two weeks.
Step 2. Identify unique impediments to joy in work in the local context Steps 1 and 2 usually happen in the same conversation and continue over time. Having conversations about what really matters to each person builds the trust needed to identify frustrations they experience during the work day. Everyone must feel like their ideas, opinions, and comments will be listened to before they can be open and honest.
Just as answers to the question, “What matters to you?” will vary depending on the individual, the system-level impediments to joy in work will also vary depending on the organization, department, program, clinic, or team. Responses to this question, in combination with other real-time data collection and surveys (explained in the measurement section), enable leaders to build a comprehensive understanding of what contributes to joy in work in the organization, as well as what doesn’t.
In Step 2, identifying unique local impediments to joy in work is how leaders can begin to address the psychological needs of humans. By building on the “What matters?” conversations, leaders work with colleagues to identify impediments that exist in daily work — the “pebbles in their shoes” — and then set priorities and address them together. This offers everyone a chance to give input on which impediments to address, build camaraderie by working together to remove impediments, and practice equity in respecting all voices.
IHI’s work with the organizations involved in prototype testing offers the following examples of identifying local impediments:
x The University of Michigan Cardiac Intensive Care Unit aimed to engage members of their community in a discussion around joy in work, discover what matters to their team, and identify two to three areas in which to test small changes. To do this, they asked staff about what matters to them and what gets in the way of experiencing joy in work. They then asked small groups of nursing staff, cardiology fellows, and “scribes” to use check marks to indicate “echoed” comments to identify top priorities. This process provided everyone a chance to see the issues identified and to weigh in on what to tackle first.
x Many organizations involved in the prototype testing created regular huddles, workgroups, or team meetings as forums for members to share “bright spots” and identify impediments to joy in work. Huddles were used to ask colleagues to share what a good day at work looks like for them; what makes for a bad day; and what they appreciate or are grateful for. One site described this as a pause for a “joyful moment.”
x All organizations had some mechanism for making the identified impediments visible, such as a “What Matters to You?” or other type of communication board. For example, many sites posted sticky notes that resulted from conversations in meetings or huddles on a display in a team area, with an opportunity to contribute additional impediments or improvement ideas to the list. Making the impediments and associated ideas for improvement visible adds to the collective sense that “we are in this together.”
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 12
One area that prototype sites identified as a challenge in Step 2 is how to respectfully handle the negative team members — those who complain, but don’t participate in identifying solutions. Most leaders were pleased to discover that by initiating the “What matters?” conversation with colleagues first, spending time truly listening — rather than defending or saying why something will not work, clarifying what they heard, and adding the impediments identified to the suggestions list or notes — led to positive engagement. Emphasizing a focus on what staff can do together to address the impediments using improvement science methods and tools was vital for these teams. This led to previously negative members joining in as they developed hope that irritants in daily life would be addressed.
Step 3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organization Making a workplace joyful is the job of leaders. Nevertheless, everyone from senior executive leaders to clinical and administrative staff has a role to play. From creating effective systems to building teams to bolstering one’s own resilience and supporting a positive culture, each person contributes. According to most sites engaged in the IHI prototype testing, it is critical for leaders at all levels to dedicate time, attention, skill development, and necessary resources to improving joy in work. Leaders from the American Association of Critical Care Nurses shared that it is vital to have a constant champion dedicated to joy in work to ensure momentum and sustainability.
Improving joy in work is directly linked to the skills of leaders at all levels. Organizations cannot just delegate responsibility for joy in work to the Human Resources department; it is everyone’s job. In Step 3, it is most important to note that although there is a shared responsibility, not everyone does everything. The IHI Framework for Improving Joy in Work (see Figure 2) shows nine core components that contribute to a happy, healthy, productive workforce. (Each of these components is discussed in detail later in the paper.) In addition, the three outer rings of the framework show who is responsible for these components: senior leaders are responsible for all nine components; managers and core leaders are responsible for five components; and individuals, for three components. The responsibilities depicted in Figure 2 are meant to help leaders assess and plan for ongoing development of behaviors and systems at all levels to improve and sustain joy in work.
Certain barriers to joy need to be addressed before others and it’s critical to recognize some basic psychological preconditions for joy in work. With Maslow’s hierarchy of needs in mind, we identified that five fundamental human needs must be met to improve joy in work.26 These five needs play a central role in the IHI Framework for Improving Joy in Work (see Figure 2): physical and psychological safety; meaning and purpose; choice and autonomy; camaraderie and teamwork; and fairness and equity. The first four fundamental needs are discussed in more detail below. Fairness and equity were previously addressed at the beginning of the paper and contribute to each of the core components. While all five of these human needs will not be resolved before addressing local impediments to joy in work, actions and a commitment to addressing all five will ensure lasting results.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 13
Figure 2. IHI Framework for Improving Joy in Work
Step 4. Use improvement science to test approaches to improving joy in work in your organization There are many ways to take a systems approach to improving joy in work. The aim is to make the change process rewarding and effective. Using principles of improvement science, organizations can determine if the changes they test are leading to improvement; if they are effective in different programs, departments, and clinics; and if they are sustainable. In IHI’s prototype initiative, teams used the Model for Improvement27 or another improvement method that was standard in their organization. In all cases, the teams set an aim for their work, decided on measures that would tell them if they were making progress, and selected components of the Framework for Improving Joy in Work as areas in which to test changes.
For example, one IHI prototype initiative team’s inpatient unit had the aim to improve staff engagement scores by 50 percent overall. By noting concerns in several units regarding safety and poorly coordinated care, and reviewing the components in the Framework for Improving Joy in Work, the team decided to focus on improving teamwork as a good way to raise staff engagement. Daily huddles had been successful in critical care areas, so the manager and some of the staff decided to test change-of-shift huddles as a standard practice on the inpatient unit as a way to improve teamwork and engagement. The team’s tests of changes included the following:
x Aim: Increase staff engagement scores on the inpatient unit by 50 percent by December.
x Measures:
o Percent of shifts for which all teams had a daily huddle
o Percent of staff that report they feel like a productive member of a team
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 14
x Changes: The changes included finding a time that worked for daily huddles for each shift, building a standard agenda that could be completed in 10 minutes, and specifying who on the unit could lead the huddles.
x Testing Changes: At this site, the team ran multiple tests on one unit the first week:
1. Have one 15-minute huddle, with one team on the day shift, focusing on all patients.
In response to what the team learned from this first test, the staff on the unit ran multiple subsequent tests:
- Change the huddle agenda to focus only on high-risk patients.
- The charge nurse runs the huddle.
- Have the huddle immediately after bedside report.
- Huddle at a different time for the evening shift.
By tracking the percent of shifts with a huddle and percent of staff that report feeling like a productive member of the team, the leaders had a sense of whether or not daily huddles were contributing to improved teamwork and engagement. The team changed the measure from focusing on “feeling like a productive member of a team” to percent of staff responding “Agree” or “Strongly Agree” to the statement, “I have the tools and resources I need to do my job.”
2. Once this first team had a process that worked for both the day and evening shifts, the charge nurse established tests for the three other teams on the unit. Each team created their own tests to refine the daily huddle for their needs, including the timing that would allow staff to cover all patients. By the end of four months, 90 percent of teams on the unit were conducting daily huddles. The evening shift was an outlier, so the teams decided to keep working on shift huddles over time. Engagement scores rose by 30 percent as a result.
3. At this point, the leaders were ready to spread daily shift huddles to other units. Each unit had its own structures and routines, so the shift huddles had to be adapted in each unit location, again using a methodology to test changes and measure the results. Leaders also noted that feeling a part of a team and having the tools needed to do the work were not sufficient for raising engagement by 50 percent, and so began working on other changes related to the framework components for camaraderie and daily improvement.
This example highlights key elements of improvement science:
x Make sure the aim is clear and numerical (how much, by when).
x Start small and use data to refine successive tests.
x Make sure the change idea works before getting more people involved or spreading the change. With confidence that the change works, then try it in many different situations.
x Track results of every test, using process measures first and then ultimately outcome measures; share results openly and help team members understand and use the data.
x Improvement is participative and involves everyone, from senior leaders who set the organization’s strategic aim and support improvement, to core leaders who drive improvement every day, to the individuals who identify problems, seek and test solutions, and track the results.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 15
Appendix B provides examples of suggested changes for organizations to test for each of the nine critical components of the Framework for Improving Joy in Work. Of the nine components, prototype organizations frequently cited camaraderie and teamwork as the most critical to their progress in the initial stages of their work. The following are a few highlights from the IHI prototype testing that can serve as a model for Step 4.
x The University of Virginia School of Nursing team found that using concepts from the IHI Framework for Improving Joy in Work was more effective than the standard committee- driven process. In previous surveys, employees identified a strong desire for time off, unencumbered by the expectation of responding to email. With a small group of staff, the team tested a small change: stop sending email to staff during their time off. The benefits were immediately evident, so they expanded the change to all School of Nursing employees with great success. In a follow-up survey after the change was implemented, 80 percent of respondents reported improvement in respect for their personal time off. Building on this success, the team is using the IHI framework to address other longstanding problems that affect staff joy in work.
x The Mount Auburn Hospital team used small tests of change to restructure their approach to engaging colleagues in efforts to improve joy in work and address issues identified by staff. They focused on re-establishing trust among staff to ensure them that concerns they raised would be addressed. Following each “What matters?” conversation, local core leaders posted the issues identified during these discussions on a board where they were visible to all staff. Then, as each concern was addressed with small tests of change, core leaders documented what was being done along with the resolution, including issues that had to be escalated to a higher level of leadership. Making small, visible changes on local issues, and being transparent about the work, alleviated staff concerns that their voices weren’t being heard and made the work environment more positive.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 16
IHI Framework for Improving Joy in Work While the four steps (see Figure 1) are designed to provide leaders with a pathway for “how to get from here to there,” the IHI Framework for Improving Joy in Work (Figure 3) shows the critical components of a system for ensuring a joyful, engaged workforce.
Figure 3. IHI Framework for Improving Joy in Work
As mentioned, four of the nine critical components for improving joy in work — physical and psychological safety, meaning and purpose, choice and autonomy, and camaraderie and teamwork — are fundamental human needs that require the greatest attention, perhaps first. For this reason, these four components, particularly physical and psychological safety, are elaborated on in more detail than the other components in this section. Fairness and equity, discussed earlier as the fifth fundamental human need, contributes to achieving success in all critical components.
Physical and Psychological Safety
x Physical Safety – People feel free from physical harm during daily work.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 17
x Psychological Safety – People feel secure and capable of changing;28 there are respectful interactions among all; people feel able to question, seek feedback, admit mistakes, and propose ideas; and the organization provides full support for the staff involved in an adverse event (often referred to as the second victim).29
We define “physical safety” as feeling free from physical harm at work. Health care workers, particularly nurses, have very high rates of acute and chronic musculoskeletal injuries, high exposures to blood-borne pathogens and other infections, and across the US there are increased incidences of violence in health care settings.30 Care facilities may be located in settings that pose risks (e.g., having to walk to dark parking lots or working in communities with potential safety issues). To be fully present at work, colleagues need to feel that adequate precautions have been taken to protect them.
We define “psychological safety” as people feeling secure and capable of changing; they are free to focus on collective goals and problem prevention rather than on self-protection; and they believe that no one will be humiliated or punished for speaking up. They know that staff will not be punished for human errors in unsafe systems, consistent with a just culture. Psychological safety is a team characteristic rather than an attribute of individuals. It is a climate in which people feel free to express relevant thoughts and feelings or speak up about unsafe conditions without retribution.
Psychological safety is founded on respectful interactions by everyone, and disrespectful behavior is rapidly and consistently addressed. People feel confident that others will respond positively when they ask a question, seek feedback, admit a mistake, or propose an idea. Consistent with exemplar safety environments, psychological safety fosters a climate in which raising a dissenting view is expected and respected, error reporting is welcomed, and people are willing to offer ideas, questions, and concerns.31 This allows for productive discussion and early detection of problems.
It’s imperative to put a focus on equity when addressing psychological safety. Every member of the team must feel respected and comfortable speaking up — not just some. A shared sense of psychological safety is a critical input to an effective learning system that leaders must develop.
Leaders build psychological safety through the following actions:
x Be accessible and approachable;
x Acknowledge the limits of current knowledge, frame the work accurately as complex, and show humility and fallibility;
x Invite participation;
x View failures as learning opportunities;
x Use direct, clear language;
x Set boundaries about what is acceptable behavior and hold others accountable for boundary violation;32 and
x Develop and sustain a just culture.33
Meaning and Purpose
Do people find meaning in their work? Do they feel connected to a purpose that is larger than themselves in service to the community? Do they feel that the work they do makes a difference? Daily work is connected to what calls individuals to the health care profession. There is a line of
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 18
sight for each person from daily work to the mission and goals of the organization, and constancy of purpose is evident in the words and actions of leaders.
Outside of the health care industry, organizations like Menlo Innovations and Hospitality Quotient put an emphasis on the customer — those served by the organization’s work. Other organizations, such as Barry–Wehmiller, take a more iterative approach to living their mission, behavior, and values with a recurring mission review. Within the health care industry, finding meaning and purpose may be easier as these are inherent in saving lives and keeping patients healthy and happy. Leaders who frequently talk about the purpose of collective work and encourage conversations about the individual and collective purpose in the organization tap into the meaning that each person brings to their work.
Choice and Autonomy
The environment supports choice and flexibility in daily lives and work. Do people feel like they have some choice in how they execute their daily responsibilities? Do they have voice in the way things are done in daily work? Are they a part of decisions on processes, changes, and improvements that affect them? Do they have information to make informed contributions to choices in their work? Do team members have the performance improvement skills and support to improve daily work?
Participative management and shared governance are two longstanding approaches that offer choice. For example, Starbucks teaches that leaders and managers should listen to staff and include them in solutions. Zappos call center employees do not work from a script and are encouraged to use their imagination to work with customers. Not needing to ask permission enables these sales representatives to succeed.34 Empowered support staff members at Bellin Health can request the resources they need without having to go through leaders. In other health care settings, this means staff are empowered to make improvements and suggest innovations to the use of the electronic health record (EHR) to reduce the administrative burden and tasks which unnecessarily question physician or clinician judgment. This is frequently identified as a “boulder” in experiencing joy in work. From these examples, we learn that colleagues need the freedom and trust to make choices in their daily lives and careers, while following clearly identified necessary rules and guidelines.
Recognition and Rewards
Effective leaders understand daily work, regularly provide meaningful recognition of colleagues’ contribution to purpose, and celebrate outcomes. Some of the most meaningful rewards are rarely monetary.35,36 Organizations that are more successful in their efforts to improve joy in work begin to move away from traditional approaches that often have limited effectiveness. For example, while important for building camaraderie, parties and social gatherings alone are not sufficient to bring joy in work. It is the recognition, camaraderie, and celebration of team accomplishments that are validating, not the party itself.
Participative Management
Joy in work entails leaders creating space to listen, understand, and involve colleagues in providing input into decisions as an essential step in co-creation and participative management. Decision making involves clear communication and consensus building.
Participative leaders do three things:
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 19
x Engage before acting: They involve others in the beginning stages of an initiative to explain why the work is needed and gain commitment before implementing changes.
x Inform: They keep individuals informed of future changes that may impact them.
x Listen: They encourage colleagues to share, and listen to individuals at all levels in the organization. They consistently listen to everyone — not only when things are going well.
Camaraderie and Teamwork
Social cohesion is generated through productive teams, shared understanding, and trusting relationships. Do people feel like they have mutual support and companionship? Do they feel that they are a part of a team, working together toward something meaningful? Do they have a friend or someone who cares about them at work whom they can regularly ask for advice? Do they trust the organization’s leadership? Do leaders regularly practice transparent communication? Do team members regularly express appreciation for each other’s work?
Daily Improvement
The organization uses improvement science to identify, test, and implement improvements to the system or processes. Teams and the wider organization undertake regular proactive learning from defects and successes. Improvement in processes is part of daily practice.
Wellness and Resilience
The organization demonstrates that it values health and wellness of all employees. This goes beyond workplace safety to cultivating personal resilience (i.e., the ability to bounce back quickly from setbacks) and stress management; utilizing practices to amplify feelings of gratitude; understanding and appreciation for work/life balance and the whole person and their family; and providing mental health (depression and anxiety) support. Taking care of oneself is part of a larger systems approach to joy in work, not a standalone solution.37
Real-Time Measurement
Measurement systems enable regular feedback about system performance to facilitate improvement. Daily, weekly, or monthly feedback is the norm to ensure effective data for ongoing improvement.
Responsibilities by Role There is a strong relationship between the qualities of leadership at all levels and engagement and performance. When researchers studied nursing staff experience, the variable contributing the most to retention was management style.38 Other studies evaluating burnout and leadership quality of supervisors showed that positive leadership qualities of physician supervisors influence the wellbeing and engagement of individual physicians.24
This is not to say that leaders are solely responsible for improving joy in work. Everyone in the organization has an essential part to play. Yet, leaders do have an important role in modeling the expected behaviors and in creating a culture that supports improving joy in work. For this reason, the change ideas that prototype organizations tested (see Appendix B) were guided by leadership behaviors set forth in the IHI High-Impact Leadership Framework.39 It is also important to note the concordance between these critical components for a healthy, happy, and productive workforce
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 20
and the Framework for Safe, Reliable, and Effective Care, which also focuses on many of these elements as well as the prominent role of leadership.40
Senior Leaders
Senior leaders are accountable for developing a culture that encourages and fosters trust, improvement, and joy in work. They ensure that improving joy in work is a responsibility at all levels of the organization, beginning with healthy, effective teams and systems.
While senior leaders ultimately bear the responsibility for each of the nine components (Figure 3), some components are most under their locus of control. After ensuring physical and psychological safety, they then set the vision and model the way for the transformation that joy in work requires. Senior leaders are responsible for articulating the organization’s purpose, providing a clear line of sight from the work of each person to the mission of the organization, and ensuring meaning and purpose in work. They also ensure fair, equitable systems that embody the fundamental human needs that drive joy in work. By understanding daily work, leaders can recognize the context in which colleagues work, ensure the effectiveness of systems, and identify opportunities to make improvements and celebrate outcomes.
Managers and Core Leaders (leaders at the program, department, and clinic level)
Primary responsibilities of core leaders are utilizing participative management; developing camaraderie and teamwork; leading and encouraging daily improvement, including real-time measurement; and promoting wellness and resiliency through attention to daily practices.
Core leaders have the pivotal role of improving joy in work every day at the point of service. They work with their teams through the process of identifying what matters, addressing impediments through performance improvement in daily work, analyzing what is and is not working well, developing strategies, co-creating solutions with team members, advancing system-wide issues to senior executive champions, and working across departments or sites for joint solutions. This practice of participative management combined with collaborative process improvement makes it possible to meet fundamental human needs.41 As impediments are addressed, staff engagement improves and burnout recedes. Participative management results in greater individual and team productivity, while process improvement increases efficiency.42
One key to the manager’s role is balancing the benefit and burden of improvement. Research by Chris Hayes at St. Joseph’s Health Care in Hamilton, Ontario, shows that improvement efforts, however well-meaning, can raise the workload and stress on the staff.43 For example, installing health information technology has been reported as a cause of burnout, despite its value for safety and efficiency, because the workload in using it falls heavily on busy people, increasing their fatigue and stress. Wise managers select the improvements with high perceived value that ultimately lower the workload when they can. During any improvement effort, they monitor the staff for stress and take steps to lessen and smooth the additional work.
Individuals
Everyone plays an important role in nurturing joy in the workplace by committing to doing their best, having respectful interactions, identifying opportunities to improve, being part of the solution, speaking up, and cultivating their own wellness and resilience. Each team member has a responsibility to be a good colleague, in addition to role modeling the core values of transparency, civility, and respect.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 21
Measuring Joy in Work How can one measure “joy”? At present, there is no single validated measure of joy in work. Until there is, leaders need to draw on other indicators that are known to contribute to, or signal trouble for, joy in work.
Measuring joy in work calls for both system-level and local-level measures:
x Two or three system-level measures (such as satisfaction, engagement, burnout, turnover, retention, employee wellbeing, workplace injuries, or absenteeism) that can be reviewed at least annually to identify areas for improvement and to track progress over time; and
x Local-level measures or assessments that occur more frequently that local leaders can use for improvement on a daily or weekly basis. Daily or weekly assessments of joy in work are initiated and tracked by the staff themselves, along with the core leader of the unit, clinic, or department. The timing of these local assessments matters. Assessments can occur after an event, such as an adverse event; after an interval, such as a day or a week; or at random.44
It’s particularly helpful if data can be stratified by unit, department, discipline, and other demographic factors such as race and ethnicity. By drilling down into different units or groups of staff, organizations can identify areas in which to focus their improvement efforts first. More frequent and tailored data collection, and transparent sharing of results with each work unit and its leaders, allows for more real-time improvement and a better way to track the impact of changes over time.
Appendix C includes examples of existing measurement and assessment tools for improving joy in work that organizations may adopt or adapt. In IHI prototype testing, no single measurement system was used across sites. The most practical approach is to leverage existing measurement data (e.g., satisfaction, engagement, burnout, turnover, retention, absenteeism) and measure more frequently over time, if possible. Certain measures will be better indicators of the effectiveness of changes that are tested, and certain tools will work better at some organizations than at others based on a variety of factors (e.g., the type of work in which colleagues are regularly engaged, the capacity of individuals to dedicate time to filling out an assessment). Rather than starting from scratch, many organizations choose to incorporate a few questions from other assessments into their existing assessment tool.
Regardless of what is measured, leaders need to track data regularly, make the results transparent, and address issues that are identified as a priority. It’s important for joy in work to be a key organizational metric, on the same level as other organizational priorities and measures. This sends an important message to staff about the culture and values of the organization. Measuring joy in work can also help secure an organizational sense of “we’re in this together for our mission” when such measurement is used to demonstrate the link between joy in work and the patient experience, and to its impact on costs (e.g., staff turnover, recruitment and retention).45
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 22
Conclusion Improving joy in work is an underused and high-leverage opportunity for creating environments where people find meaning and purpose while improving patient experience, outcomes, and safety, as well as organizational effectiveness and productivity. The leadership and management practices designed to improve joy in work are some of the most high-leverage changes an organization can undertake since a focus on joy in work simultaneously impacts so many goals embedded within the Triple Aim.
Health care is in the beginning stages of recognizing the strategic significance of improving joy in work. The four steps for leaders and the IHI Framework for Improving Joy in Work provide an approach for organizations to begin that important journey. The opportunities to learn together how to build cultures that thrive through nurturing joy in daily work are immense. Let us begin and learn together.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 23
Appendix A: “What Matters to You?” Conversation Guide This resource is intended to help leaders guide conversations with colleagues about “What matters to you?” — Step 1 of the Four Steps for Leaders (see Figure 1). The content is derived from the “Listen to Understand” material.46
Purpose
To increase joy in work, senior and core leaders engage in effective, meaningful conversations with colleagues to understand:
x What matters to you in daily work?
x How to build on assets: What helps make a good day? When we are at our best, what does that look like?
x What gets in the way of a good day?
Principles
x Ask the question, listen to the first response, and then allow for deeper reflection about initial comments. Be comfortable with silence; practice curiosity and inquiry to listen — not just to hear, but also to understand.
x You do not have to fix everything now — the intention of the conversation is listening to understand what matters, then working together using improvement science tools to address the things that get in the way of what matters.
x Ensure that this work is done with colleagues and team members — not to or for them.
Step 1. Ask staff, “What matters to you?” — The purpose of the conversation
Do Don’t Steps to Try
• Consider asking a colleague who is a skilled facilitator to co-lead the conversations in team meetings
• Talk about the purpose of the conversation — why you are interested in what matters to staff
• Share a story about what matters to you and what makes a good day for you
• Assume you know what others are thinking or experiencing
• Promise to fix everything • Do this as a one-time activity • Talk to just those who are positive
and avoid the negative voices
• Purpose = Be able to articulate why you are talking about joy in work
• Talk about your commitment to working together to make daily life better for everyone
• Emphasize that this is about ongoing improvement, not a one-time or quick fix
• Use brief huddles in the work area to have conversations with as many people as possible; this builds inclusiveness
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 24
Step 1. Ask staff, “What matters to you?” — Build on assets and “bright spots”
Do Don’t Steps to Try
Ask staff members to share: • Why I decided to work in health care • What makes me proud to work here • What matters to me in my work is… • What is the most meaningful or best
part of my work • I know I make a difference when… • When we are at our best, it looks and
feels like… • What makes a good day is…
• Assume all team members will understand what you’re talking about immediately; they are often not used to being asked “What matters?”
• Assume all will feel safe talking initially
• Assume all have the same view • Mandate participation — instead,
welcome and invite • Speak for others
• Choose one question to get started, then listen and invite others to comment
• Ask follow-up questions to clarify statements
• Point out when bright spots are similar; identify the themes you hear
• Capture what you are hearing so it is visible (e.g., on a whiteboard) and post the feedback in a location that’s visible to all staff
Step 2. Identify unique impediments to joy in work — The “pebbles in their shoes”
Do Don’t Steps to Try
Ask members to share: • What gets in the way of what matters
(the “pebbles in their shoes”) is… • What gets in the way of a good day
is… • What frustrates me in my day is…
• Stay with general or broad comments (“never,” “always,” etc.)
• Allow a single person to do all the talking
• Assume people know you have heard them
• Feel you need to immediately solve every issue identified
• Think you need to do this all yourself
• Choose one question to get started, then listen and invite others to comment
• To move from broad comments (“always,” “never”), ask team members to be more specific, to identify some ideas you might test as a starting point: ◦ “Help me understand what that
looks like?” ◦ “What happened yesterday that
would be an example of that?” ◦ Link to assets/bright spots:
“What from our bright spots list would help us?”
• When one person is primarily talking, thank them for their comments and suggest, “Let’s hear from others on the team…”
• Acknowledge what you’re hearing (e.g., “The thing that frustrates you is… did I get that right?”)
• Capture what you are hearing so it is visible (e.g., on a whiteboard) and post the feedback in a location that’s visible to all staff
• Use brainstorming tools to generate ideas for overcoming impediments
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 25
Step 3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organization — Co-design next steps
Do Don’t Steps to Try
• List what the team identifies as bright spots and impediments
• Ask, “What should we tackle first?” • Ask that all individuals participate in
the local improvement work • Be specific about improvement (e.g.,
“We will develop our skills in improving this process starting tomorrow”)
• Take immediate action with team members and ensure ongoing communication and follow-through
• Ensure that patient and family advisors are part of care system changes
• Judge, accept, or deny ideas • Take it all on yourself • Ask, then do nothing • Allow large gaps of time to occur
between the initial conversation and follow-up conversations
• Engage others and support creative thinking through the sharing of ideas
• Use a short list of criteria to choose where to start — the issue…: ◦ Is something we can do in our
area right away, beginning small tests of change within 24 hours
◦ Is an improvement that is a quick win
◦ Is meaningful to several team members
◦ Is one that team members are willing to test
• You or team members provide brief daily updates to the team
• Patient and family advisors can be a source of energy for the team and reinforce why it’s important for team members to act on changes that impact what matters
Step 4. Use improvement science to test approaches to improving joy in work in your organization
Do Don’t Steps to Try
• Build on the previous three steps • Leaders role-model using
improvement science (e.g., Model for Improvement; Lean) — improving with staff — as the organization strives to improve systems
• Celebrate lessons learned — when a test fails, say “look what we learned from this” and keep testing
• Begin to link the changes for joy in work to other improvements (e.g., how one improvement helps increase safety or efficiency)
• View improvement as part of daily work, something that is an essential part of each person’s role
• Put systems in place to monitor changes, to ensure they are sustained or to signal a need for further improvement
• Use change ideas from Appendix B to challenge the team to continue to aim high
• Celebrate small wins
• Try to “fix it” by yourself as a leader • Try changes that are too big or too
complex, or try to change everything at the same time
• Assume you know the solution • View this work as a project • Assume that changes will be
sustained • Move on to the “next thing” • Fail to develop a short-term and long-
term measurement strategy
• Develop a clear aim — have individuals co-create the aim (achieve what, by when) so everyone knows the target/goal you are working toward
• Ask for volunteers, especially those who have a passion for change, to help with improvement
• Go small to go fast — use rapid, short PDSA cycles to test ideas (e.g., test one small change this afternoon, in one location); if you can’t make progress quickly, try breaking the improvement into smaller parts
• Build capacity — teach improvement science to team members as you do tests of change
• Ensure patients and families are part of the improvement
• Measure results — a combination of fast, short-term feedback and long- term feedback that includes process measures first, then outcome measures; share results; keep testing
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 26
• Experiment — understand which changes you test have the most impact and then expand on these
• Measure ongoing results to ensure sustained results
• Ask “What’s next?” and “What can we do even better?”
• Provide regular recognition for the changes implemented and sustained over time
• Remind team members of the progress made
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 27
A ppendix B
: C hange Ideas for Im
proving Joy in W ork
O rgan
ization s p
articip atin
g in th
e IH I p
rototyp e testin
g to im prove joy in
w ork u
sed an
d ad
apted som
e of th e ch
an ge id
eas d escribed
below .
T h
e ch an
ge id eas are organ
ized by th
e n in
e critical com p
on en
ts of th e IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork (see F igu
re 3).
W h
ile th e ch
an ge id
eas ap p
ly to all colleagu es, lead
ers h ave accou
n tability to m
od el th
e w ay w
h ile also exp
ectin g oth
ers to d em
on strate
beh avior con
sisten t w
ith th
eir p osition
an d
skills. A s m
en tion
ed in
th e p
ap er, th
is fram ew
ork d raw
s key con cep
ts from an
d accord
s w ith
IH
I’s H igh
-Im p
act L ead
ersh ip
F ram
ew ork an
d th
e F ram
ew ork for S
afe, R eliable an
d E
ffective C are, sin
ce joy, lead ersh
ip , an
d h
igh levels o
f p
erform an
ce are in extricably lin
ked . 4
7,4 8 A
ll th ree im
p rove togeth
er, an d
con versely all th
ree w ill d
eclin e togeth
er.
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
P hysical and
P sychological S
afety •
D edicate leader tim
e, attention, skill developm ent, and necessary
resources to im proving joy in w
ork •
Leaders role-m odel the behaviors that create and nurture
psychological safety: ◦
B e accessible, visible, and approachable to develop
relationships w ith team
m em
bers ◦
A cknow
ledge the lim its of current know
ledge ◦
S how
fallibility and hum ility —
do not have all the answ ers
◦ Invite participation
◦ V
iew failures as learning opportunities
◦ U
se direct, clear language ◦
S et boundaries about w
hat is acceptable behavior and hold others accountable for boundary violation
◦ S
how respect for all staff, regardless of their role
• C
reate a just and fair culture ◦
H old health care professionals accountable, but do not punish
for hum an m
istakes ◦
E stablish policies and practices used by everyone to address
harm and safety concerns
◦ R
ole-m odel and encourage staff to speak up if there is an
issue that concerns them
◦ O
ffer one-on-one, group, and peer support for second victim s
of adverse events, particularly events involving harm
◦ P
rovide regular training and com petency training to ensure
skills and develop trust to achieve the desired culture
C hief of the A
ustralian A rm
y, Lieutenant G eneral D
avid M orrison, has
said: “T he standard you w
alk past is the standard you accept.” 49 F or
exam ple, if a leader w
alks past people speaking disrespectfully to each other and says nothing, it sends a m
essage that the behavior is acceptable. Identifying and m
odeling behaviors also helps staff know
w hat to expect.
Leaders at H ospital Q
uality Institute regularly visit point-of-care staff to talk about w
hat’s im portant to them
w ith respect to safety, and to thank
people for being open about safety risks and problem s.
B righam
and W om
en’s H ospital invests in supporting its C
enter for P
rofessionalism and P
eer S upport. T
he C enter serves m
any functions, one of w
hich is as a confidential resource for any em ployee to raise
concerns regarding unprofessional behavior by a physician. A
study of the m ost effective team
s and group culture conducted by G
oogle show ed team
s that had em pathy for each other, listened to all
m em
bers of the group, and took turns talking had m ore shared
know ledge and perform
ed m ore efficiently as a team
. 50 B
eth Israel D eaconess M
edical C enter and K
aiser P erm
anente regularly track and address w
ork days lost to injury and share this data w
ith the leadership team and staff (via a new
sletter and their w ebsite).
T he organizations keep a running tally of issues that are addressed
(updated m onthly).
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 28
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
• A
ddress professionalism or disrespectful behavior concerns
through established m echanism
s to hear and address com plaints
◦ H
old professionalism education, including w
orkshops to address disruptive behavior, conflict m
anagem ent, giving
feedback, and team w
ork •
E nsure that fairness is a value acted on every day ◦
E stablish equitable system
s for core organizational practices or equity topics (e.g., salary, skilled supervisors)
◦ Im
prove group culture by encouraging equality in distribution of conversational turn-taking and social sensitivity (perceiving, understanding, and responding to others’ points of view
) ◦
A ddress im
plicit and explicit bias in the organization •
A ttend to physical safety ◦
E nsure that system
s, assistive equipm ent, policies, and
practices that address w orkplace injuries are in use at all
tim es, especially related to physical risks such as lifting,
am bulation of patients
◦ U
se escorts, buddy system s, and other types of support in
high-risk areas (m ental health, em
ergency departm ent,
com m
unity outreach) as needed
M eaning and P
urpose
• P
rovide clear m essages about organizational purpose and a line of
sight, through clear and frequent guidance about the organization’s m
ission and vision, to connect team m
em bers to the m
eaning and purpose of their w
ork ◦
H ighlight the im
portance of w ork in relation to existing goals
◦ M
ake the line of sight to purpose a daily discussion ◦
Leaders at all levels com m
unicate the direct connections betw
een the organization’s goals and everyone’s w ork (e.g.,
w hen infection rates decline, each local leader can point to
the w ork of staff on their unit that contributed —
m edical,
nursing, environm ental services, and other staff)
• F
ocus on w ho is being served by the w
ork and put a hum an face
behind every statistic ◦
R em
ind staff of the “w hy” and find new
w ays to reinforce it
every day
S tarbucks helps staff docum
ent the key elem ents of the desired culture
in the organization through a M ission R
eview program
. S taff are
encouraged to speak up if they feel like the organization is not living up to the m
ission or values. This is escalated up the corporate structure through m
anagers. S taff are also given a culture book that is w
ritten, shared, and reinforced by each em
ployee. B
ringing in veterans to talk about their experiences in health care helped the staff at V
eterans H ealth A
dm inistration connect their daily
tasks back to the w ork.
C onducting purposeful leadership rounds to engage team
m em
bers in conversations about how
they find m eaning and purpose in their w
ork is a highly successful practice.
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 29
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
◦ U
se staff m eetings or huddles as a tim
e w hen staff can talk
about w hy the w
ork is im portant to them
, and w hat m
akes for a good day
◦ E
ngage patient advisors in sharing their stories to reconnect staff to their personal purpose, or incorporate patients as team
m em
bers to regularly link actions to m ission
• E
nlist staff participation in vision setting and critical analysis of the organization’s m
ission and goals
C hoice and A
utonom y
• D
esign system s w
here staff team m
em bers can m
ake choices they see fit, w
henever possible ◦
M ake selections on products and services they use
◦ U
se flexible w ork arrangem
ents ◦
E nsure transparency of inform
ation so that colleagues can m
ake choices based on current inform ation
• M
ake sure that staff have opportunities to voice w hat m
atters to them
, in public (e.g., at m eetings and on feedback boards) and
anonym ously
• E
nable colleagues to identify im pedim
ents in daily w ork through
regular discussions and analysis, and engage them in m
aking im
provem ents to elim
inate the im pedim
ents •
T each team
m em
bers how to do the w
ork and then how to m
ake im
provem ents w
hen they com e across challenges
• D
evelop system s so everyone know
s how they are perform
ing relative to goals and w
hat to do to im prove
M any program
s, departm ents, and clinics have a process by w
hich staff list things that w
aste their tim e. T
he core leader helps identify w hich
item s are high priority and supports a pair of staff m
em bers as they
w ork to rem
ove the w asteful practice. T
he staff ow n and address the
problem s together.
“B reaking the rules” is a concept in w
hich leaders ask their staff, “If you could break or change any rule in service of better care, w
hat w ould it
be?” IH I Leadership A
lliance m em
bers found asking this question enabled their organizations to identify areas w
here they m ight take
direct action to reduce onerous adm inistrative w
aste, in addition to elim
inating habits and rules that appear to be harm ing care w
ithout com
m ensurate benefit. 51
A tlassian, an A
ustralian softw are com
pany, gives their developers one full day every quarter to do w
hatever they w ant. The only requirem
ent is that they share their results at the end of those 24 hours. These days of autonom
y have resulted in softw are fixes that never w
ould have existed otherw
ise. 52 Job sharing and staff-m
anaged w ork assignm
ents are w ell-tested w
ays to ensure clinicians have a choice about w
hat they do and how they do
it. A t B
ellin H ealth, team
s redesigned the office visit to ensure that each team
m em
ber w as involved and w
orking to the top of their degree in the patient interaction. B
aylor S cott &
W hite H
ealth has w orked to restore autonom
y to individual clinics through leadership training for m
edical directors of individual clinics, and by supporting staff through electronic m
edical record changes. T
he lessons learned from the deploym
ent of E pic in
C entral T
exas w ere used to im
plem ent training and w
orkflow in N
orth T
exas, focusing on staff efficiency and team care.
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 30
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
R ecognition and
R ew
ards •
R egularly recognize actions that reflect the m
ission, and celebrate accom
plishm ents or contributions consistent w
ith the organizational purpose
• D
evelop an understanding of the daily w ork lives of team
m em
bers, including shadow
ing team m
em bers on a regular basis to
experience the w ork through their eyes
• P
rovide m eaningful celebrations and rew
ards frequently, em
phasizing im provem
ent, cam araderie, and team
w ork
• U
se financial incentives and prom otions in a fair and transparent
w ay, recognizing that these rarely im
prove perform ance but are
im portant to individuals
S tarbucks em
ployees carry cards to give to co-w orkers w
henever they w
itness a good deed or an action that reflects the m ission.
V eterans H
ealth A dm
inistration and other organizations offer w orkload
credits to staff for participating in initiatives outside of their job description that can be redeem
ed for perks and use of services.
P articipative
M anagem
ent •
S ystem
s are in place to cultivate capable and talented core leaders, specifically equipping them
w ith skills in building trusting
relationships, participative m anagem
ent, team building, and
im provem
ent m ethods and tools
• B
e visible and connected; ensure executive and core leaders regularly do purposeful rounds in all sites
• U
se “W hat m
atters to you?” conversations (S tep 1) to ensure all
colleagues have a voice in how to im
prove joy in w ork (this can be
done through one-on-one conversations, huddles, or group brainstorm
ing sessions) and include colleagues in co-designing goals, strategies, and actions appropriate for the site or program
•
U se consensus decision m
aking •
E m
ploy shared decision m aking such as an interdisciplinary shared
governance m odel
• A
im to eradicate non-value-adding w
ork using participative m
anagem ent and perform
ance im provem
ent skills •
D em
onstrate real interest in team m
em bers’ career success,
resiliency, and personal w ellness (see Leadership D
im ensions
A ssessm
ent T ool in A
ppendix C )
S eton H
ealthcare noted internal data show ed that structured Leader
R ounding by executives w
ith m anagers and staff had a strong positive
im pact on engagem
ent. IH I Leadership A
lliance m em
ber organizations report that their executives spend tim
e reconnecting to the w ork itself,
for exam ple, through clinical days or spending tim
e greeting patients. T
hese activities show ed others that senior leaders valued their w
ork and m
ade leaders feel connected to the challenges at the point of care. E
xecutives at B arry–W
ehm iller teach listening to their leaders. T
hey offer a training course, w
hich includes storytelling, to help m anagers
value listening to understand.
C am
araderie and Team
w ork
• C
reate clear links betw een the cam
araderie of team -based process
im provem
ent and joy in w ork
• A
ttend to the relationships and cam araderie w
ithin the team /unit
◦ T
ake responsibility for respectful interactions and expect them
of others ◦
Invite participation on all topics
A t IH
I, each new em
ployee is paired w ith an existing em
ployee for their first three m
onths at the organization to help acclim ate them
to the culture and processes, and to m
eet other staff. M
enlo Innovations builds fam iliarity and connections am
ong staff by assigning team
s of tw o. E
very w eek, the team
s sw itch, encouraging
know ledge sharing and capacity building, and ensuring that everyone
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 31
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
◦ O
rganize social events for staff and fam ilies
◦ P
air em ployees and sw
itch pairs frequently to transfer know
ledge, build capacity, and fam iliarize team
m em
bers w
ith each other and w orking styles
◦ E
ncourage com m
ensality (sharing a table) — those w
ho spend tim
e together over food (sharing a table) create a rapport that leads to better team
w ork
• B
uild and support team w
ork ◦
A ssess responsibilities of each discipline and cross-m
atch w
ith licensure lim its and skill sets to m
axim ize perform
ance ◦
R edesign w
orkflow s that are clear, standardized w
here it m
akes sense, and w aste free to ensure everyone is w
orking effectively and at the highest level of their training
◦ R
ole-m odel and train staff in professional and com
m unication
skills ◦
C reate courses, rounds, trainings, groups, program
s, and tim
e for interdisciplinary interaction ◦
H old retreats to have im
portant conversations, highlight linkages betw
een departm ents, focus on problem
s, and begin talking about solutions
◦ U
se team -building exercises to build trust and fam
iliarity
has a chance to w ork together before they w
ork in projects that need larger team
s. W
hen possible, m ake it easy for sm
all groups of staff to take breaks and m
eals together. A
gree on a charity that the unit or clinic w ould like to support together.
H ospital Q
uality Institute builds team w
ork betw een departm
ents by holding m
ini-courses w ith an interdisciplinary group of staff. Leaders
also go on rounds w ith staff to understand experiences at the point of
care.
D aily Im
provem ent
• E
nsure all leaders have the required skills to lead im provem
ent in daily w
ork, are skilled in the identification and elim ination of w
aste, and can coach team
s to participate in im provem
ent activity •
C onstruct a feedback loop system
; keep a running list of “pebbles in their shoes” w
ith the status of each (e.g., escalated in the organization, im
provem ent in progress)
• Im
plem ent changes in real tim
e, if possible; use a fast-paced approach to testing changes to show
progress quickly •
U se visual tracking of successes and failures of interventions
• U
se structured m ethods to reduce w
ork inefficiencies (e.g., “w aste
w alks” are a structured approach to identifying w
aste) •
A sk all team
m em
bers to: ◦
C om
m it to im
proving perform ance and w
ork processes daily ◦
S peak up —
w ith ideas, concerns, questions; help colleagues
to do the sam e
A com
m on list of actions for daily im
provem ent includes:
• S
tandardize w hat m
akes sense •
E veryone at every level of the organization know
s w hat they are
supposed to do and know s how
to get help if they need it •
V isual m
anagem ent practices —
key m easures are tracked and
visible to all •
S tandard use of problem
-solving tools •
P rotocols for escalating problem
s to the right level •
Intentional integration — consideration of the im
pact of im
provem ents across the organization
W H
IT E
P A
P E
R : IH
I F ram
ew ork for Im
p rovin
g Joy in W
ork
Institute for H ealthcare Im
provem ent • ihi.org 32
IH I Fram
ew ork
C om
ponent C
hange Ideas to Test Illustrative E
xam ples
W ellness and R
esilience •
E ncourage w
ellness and resiliency in staff so each team m
em ber
has the tools to better handle stress and turn to healthy coping m
echanism s
◦ Leaders should role-m
odel individual w ellness and resiliency
by attending to their ow n w
ellness and resilience ◦
U se m
obile apps and other tools to prom ote healthy habits
◦ E
ncourage colleagues to be leaders in adopting positive attitudes about w
ork, as w ell as identifying opportunities to
im prove and be part of the solution
◦ E
m ploy m
indfulness techniques ◦
T hree G
ood T hings activity: E
ncourage team m
em bers to
reflect on three good things every day •
S upport staff through personal and organization-w
ide changes •
M ake resources such as E
m ployee A
ssistance P rogram
s, w ellness
apps, and resources visible and accessible •
E nsure core leaders have com
petency in change facilitation to decrease stress during planned w
ork-related changes •
R einforce individual responsibility by em
bodying core values of respect, civility, transparency, and personal responsibility for w
ellness
A t M
ayo C linic, core and senior leaders have incorporated the H
ealthy H
abits into daily practice and they encourage colleagues to also use them
: •
P hysical activity
• F
orgiveness •
P ortion sizes
• P
reventive health care testing •
A dequate sleep
• T
ry som ething new
•
S trength and flexibility
• Laugh
• F
am ily and friends
• A
ddress addictive behaviors •
Q uiet your m
ind •
G ratitude
D artm
outh H ealth C
onnect (Iora H ealth P
rim ary C
are P ractice) fosters
a com m
unity of health by having staff and patients engage in farm er’s
m arket outings and five-m
inute m editation in the m
ornings. D
epartm ents w
ithin the V eterans H
ealth A dm
inistration encourage staff to use a free m
obile app (P rovider R
esiliency) to track personal burnout and w
ellness, as w ell as to provide tips or inform
ation on how to
im prove levels of both.
R eal-Tim
e M easurem
ent
• C
reate m easurem
ent system s that track and display real-tim
e data and ongoing im
provem ent
• Look for existing data in engagem
ent surveys, safety culture surveys, turnover rates, vacancy rates, lost w
orkday injury rates, or burnout scores to be able to track engagem
ent and burnout regularly
• M
ake staff concerns and w hat m
atters to them visible and
transparent, including posters/w hiteboards inviting input on w
hat m
atters •
F oster regular and open discussions about w
hat is w orking and
w hat is not, including regular huddles, w
orkgroups, and team
m eetings to share bright spots and w
hat a good day looks like
IH I uses pulse surveys, adm
inistered m onthly, to track engagem
ent and satisfaction. T
he results are reported to the entire staff each m onth, and
staff are engaged in how to address specific concerns.
B aylor S
cott & W
hite H ealth survey of prim
ary care physicians asks about their five-year plan as a burnout m
arker. T
he V eterans H
ealth A dm
inistration created an app to track resilience in real tim
e through em ployees’ sm
artphones.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 33
Appendix C: Assessment Tools for Improving Joy in Work As health care organizations begin working to improve joy in work, self-assessment tools help guide their efforts and measure progress — identifying specific opportunities for improvement, and determining if the changes they’re testing are leading to improvement. The assessment tools described below are intended to help organizations evaluate current levels of joy in work and assess the impact of their improvement efforts related to the components of the IHI Framework for Improving Joy in Work described in this paper.
System-Level Measures Most health care organizations use standard, proprietary staff satisfaction or engagement surveys. Many vendors exist, including online approaches with templates just for health care. Below are other measurement approaches that our experts and prototype teams have found useful.
Net Promoter Score53
The Net Promoter Score (NPS) was originally devised by Harvard Business Review in 2003 to indicate customer engagement. It is adaptable, however, to measure internal team members’ engagement.
To determine the internal NPS, ask individuals, “On a scale of 0 to 10, how likely are you to recommend this company as a place to work?” A score of 0 (zero) suggests that they would warn people away from applying and a score of 10 suggests that they would tell everyone they know to apply immediately. Scores of 0 to 6 indicate detractors, 7 and 8 passives, and 9 and 10 promoters (though some include 8 in this last group as well). Once responses have been gathered, calculate the internal NPS = (# of promoters – # of detractors) / total # of respondents.
When to use this tool: If your organization is looking for one overall measure of joy in work, this may be a good measure to track as it provides a sense of how colleagues view the organization.
Mayo Clinic Leadership Dimensions Assessment24
The Mayo Clinic has recognized that leadership skill is closely associated with burnout. In surveys that assess the relationship between supervisor leadership qualities and burnout, researchers found that composite leadership scores strongly correlate with the burnout and satisfaction scores of individuals. Tracking leadership capability at the point of service enables senior leaders to identify best practices for spread and to intervene when a leader is struggling.
During prototype testing of the IHI Framework for Improving Joy in Work, IHI created a short assessment tool that highlighted the most important dimensions of leadership (adapted from the Mayo Clinic assessment):
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 34
When to use this tool: The Leadership Dimensions Assessment can be administered to individuals or to groups. Individual data highlights areas where multiple supervisors or areas of leadership need additional training or improvement. Completing this assessment with a group facilitates conversations about bright spots and areas for improvement.
Safety Attitudes Questionnaire54
The Safety Attitudes Questionnaire was developed by Bryan Sexton, Eric Thomas, and Bob Helmreich for organizations to assess their safety culture. This survey elicits health care provider attitudes using six factors: teamwork climate, job satisfaction, management, safety climate, working conditions, and stress recognition. The survey has been validated for use in critical care, operating rooms, pharmacy, ambulatory clinics, labor and delivery, and general inpatient settings.
When to use this tool: Use this survey to assess safety culture, identify areas for improvement, and highlight strengths across the organization. The survey can be used to establish baseline data on the existing culture of an organization, to compare culture internally between specialties, or to compare clinical performance between organizations.
AHRQ Patient Safety Culture Surveys55
The Agency for Healthcare Research and Quality (AHRQ) sponsored the development of patient safety culture surveys, customized by specialization — hospital, medical office, nursing home, community pharmacy, and ambulatory surgery.
When to use this tool: These surveys are used to assess the current safety culture within an organization, raise awareness of patient safety issues, identify areas for improvement, highlight strengths, and provide the ability to view the data over time. This data can be used for internal
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 35
comparisons between specialties or areas of the organization, or external comparison across organizations and the health care industry.
Maslach Burnout Inventory56
The Maslach Burnout Inventory, developed by Christina Maslach and Susan Jackson, has been widely recognized and used to gauge burnout. This tool addresses three scales: emotional exhaustion, depersonalization, and personal accomplishment.
When to use this tool: The Maslach Burnout Inventory measures respondents’ relationship to work; it is typically used to assess a group of staff members in an organization, rather than as an individual diagnostic instrument. The group scores can be correlated with other demographic information and used as baseline data to determine the impact of an intervention.
Mini Z Burnout Survey57
The Mini Z Burnout Survey, developed by AMA StepsForward, is used to determine stress levels in the health care workplace and how they compare with others in the field. The short, 10-item survey measures burnout and the health care practice environment.
When to use this tool: The survey is intended to be distributed annually and completed individually by all providers within a practice. The data can be used as a baseline measure and as a gauge of overall staff wellness over time.
Nine-Item Survey to Measure Physician Engagement in Addressing Health Care Disparities58
This survey was developed by Matt Wynia and colleagues at the American Medical Association. Although the tool was designed for clinicians, Henry Ford Health System modified it with permission to use for all staff. Because equity and fairness are central to a joyful workplace, assessing engagement levels can guide efforts for improvement.
When to use this tool: The nine-item survey is used to measure engagement (physician or staff) in addressing health disparities.
Hackman and Oldham Job Characteristics Model to Job Satisfaction59
The Job Characteristics Model proposed a set of important job qualities, a set of psychological mediators that linked these job characteristics to outcomes, and a set of valued personal and work outcomes. Meaningful work was an important psychological state that mediates between the job characteristics of skill variety, task identity, and task significance and the outcomes of internal (intrinsic) work motivation, work performance, satisfaction with work, and absenteeism and turnover.
When to use this tool: This tool is best used with efforts seeking to improve meaning and purpose in work (e.g., efforts focused on job enrichment and improving the essential nature of the work performed).
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 36
Local-Level Measures Daily Visual Measure
To measure joy in work in real time, IHI created a visual measure — a glass jar placed by the elevator into which staff drop one marble each day: a blue marble for a good day, where the individual made progress (-), or a tan marble for a day without progress (/). A designated staff member counts the number of blue and tan marbles each morning and tracks the total count. A quick glance at the jar enables staff to gauge the daily mood of the organization. Leaders also use this data to assess levels of joy in work over time.
When to use this tool: Real-time measurement can be used to engage staff in the daily assessment of joy in work. The data generated by even simple visual measurement tools — like the marble jar, or a whiteboard with two columns (one with a smiling face -, one with a frowning face /) on which staff indicate their “joy in work” for that day by putting a checkmark in the appropriate column — can help leaders quickly gauge the current environment on a daily basis.
Three Daily Questions
Derived from the work Paul O’Neill accomplished while leading Alcoa to be one of the safest organizations in the world, these questions have been adopted by the Lucian Leape Institute.2 To find joy and meaning in their daily work, each person in the workforce must be able to answer affirmatively to three questions each day:
x Am I treated with dignity and respect by everyone?
x Do I have what I need so I can make a contribution that gives meaning to my life?
x Am I recognized and thanked for what I do?
When to use this tool: Core leaders can use these questions as a basis for conversation in daily huddles or team meetings. Rather than being a measurement tool per se, the three questions can serve as an assessment tool by asking team members, “What would it look like if we could answer ‘yes’ for each question?”
Pulse Survey
Pulse surveys are a fast and frequent survey system, designed purposefully to avoid complex questions and give quick insight into the health of a company.
At IHI, pulse surveys are short (10 questions or fewer) questionnaires on a 5-point Likert scale (“Strongly Agree” to “Strongly Disagree”) that are distributed monthly or quarterly (as opposed to annually). They provide the organization with frequent data to assess overall staff engagement and to see whether the efforts to improve joy in work are making a difference. The use of short, more frequent surveys allows for regular data collection without overwhelming staff or causing survey burnout.
IHI includes a set of core questions in every survey, with additional questions focused on a different topic each time the survey is sent out.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 37
IHI Pulse Survey Core Questions (included in every survey):
x Overall, IHI is an excellent place to work.
x I believe IHI is going in the right direction.
x My immediate supervisor cares about the work that I do.
x I feel comfortable bringing up problems and tough issues.
x I feel that people at IHI respect and take into consideration all views expressed.
Example Topic-Specific Questions (included in one survey at a time):
January:
x I am confident about my future at IHI.
x My job makes me feel like I am part of something meaningful.
x I am satisfied with my work/life balance.
March:
x My current role enables me to build my professional skills.
x I feel like I have at least one person in a managerial/supervisory role at IHI who looks out for my professional development.
May:
x My immediate supervisor cares about me as a person.
x I have a friend at work.
x My colleagues at IHI regularly apply the IHI values in their day-to-day interactions.
x I am confident that I can participate effectively in efforts to improve IHI processes.
September:
x The IHI Executive Team cares about the work that I do.
x I feel well-informed about important decisions.
x I feel recognized for my contribution.
November:
x My pay is fair for the work that I do.
x My benefits package is good compared to others in the industry.
When to use this tool: The pulse survey can be used as part of your organization’s internal efforts to improve joy in work, regularly check in with staff members, and identify areas that need improvement. This is a good type of assessment to start with if your organization does not regularly assess staff engagement, satisfaction, and joy in work.
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 38
References 1 Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings. 2015 Dec;90(12):1600-1613.
2 Lucian Leape Institute. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA: National Patient Safety Foundation; 2013.
3 Antonovsky A. Health, Stress, and Coping. San Francisco: Jossey Bass; 1985.
4 Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1986.
5 West M, Dawson J, Admasachew L, Topakas A. NHS Staff Management and Health Service Quality. London: Department of Health, UK Government; August 31, 2011.
6 Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2016. http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health- Equity.aspx
7 Department for Business, Innovation, and Skills. The Business Case for Equality and Diversity: A Survey of the Academic Literature. (BIS Occasional Paper No. 4) London: Government Equalities Office, UK Government; January 2013. https://www.gov.uk/government/publications/the-business-case-for-equality-and-diversity-a- survey-of-the-academic-literature
8 Robinson D, Perryman S, Hayday S. The Drivers of Employee Engagement. Brighton, UK: Institute for Employment Studies; 2004. http://www.employment- studies.co.uk/system/files/resources/files/408.pdf
9 Bassi L, McMurrer D. Maximizing your return through people. Harvard Business Review. March 2007. https://hbr.org/2007/03/maximizing-your-return-on-people
10 MacLeod D, Clarke N. Engaging for Success: Enhancing Performance Through Employee Engagement: A Report to Government. London: Department for Business, Innovation, and Skills, UK Government; July 2009. http://hdl.voced.edu.au/10707/149387
11 Harter JK, Schmidt FL, Hayes TL. Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes: A meta-analysis. Journal of Applied Psychology. 2002;87(2):268-279.
12 Burton J. The Business Case for a Healthy Workplace. Industrial Accident Prevention Association; 2008. http://www.iapa.ca/pdf/fd_business_case_healthy_workplace.pdf
13 Paller DA, Perkins E. What’s the key to providing quality healthcare? Gallup Business Journal. December 9, 2004. http://www.gallup.com/businessjournal/14296/whats-key-providing-quality- healthcare.aspx
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 39
14 Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Annals of Surgery. 2010;251(6):995-1000.
15 Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research. 2014;14(325). http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-325
16 Swensen S, MD, Kabcenell A, Shanafelt TD. Physician–organization collaboration reduces physician burnout and promotes engagement: The Mayo Clinic experience. Journal of Healthcare Management. 2016;61(2):105-127.
17 Scutte L. What you don’t know can cost you: Building a business case for recruitment and retention best practices. Journal of Association of Staff Physician Recruiters. Summer 2012. http://www.aspr.org/?696
18 Martin J, Schmidt C. How to keep your top talent. Harvard Business Review. May 2010. https://hbr.org/2010/05/how-to-keep-your-top-talent
19 Kim S. Participative management and job satisfaction: Lessons for management leadership. Public Administration Review. 2002;62(2):231-241.
20 Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2013. http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx
21 Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and 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
22 Shannon D. Physician well-being: A powerful way to improve the patient experience. ACPE Physician Executive Journal. July/August 2013. http://www.mdwriter.com/uploads/1/8/0/3/18033585/acpe_physician_well-being- _a_powerful_way_to_improve_the_patient_experience.pdf
23 Barry MJ, Edgman-Levitan S. Shared decision making: Pinnacle of patient-centered care. New England Journal of Medicine. 2012 Mar;366(9):780-781.
24 Shanafelt TD, Gorringe G, Menaker R, et al. The impact of organizational leadership on physician burnout and satisfaction. Mayo Clinic Proceedings. 2015;90(4):432-440.
25 Martin A. The Changing Nature of Leadership. Center for Creative Leadership; 2007. https://www.ccl.org/articles/white-papers/the-changing-nature-of-leadership-a-ccl-research- white-paper/
26 Poston B. An exercise in personal exploration: Maslow’s hierarchy of needs. The Surgical Technologist. 2009 Aug:347-353.
27 Institute for Healthcare Improvement. “How to Improve: Science of Improvement.” http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 40
28 Schein E. Organizational Culture and Leadership. San Francisco: Jossey-Bass; 1985.
29 Pratt S, Kenney L, Scott SD, Wu AW. How to develop a second victim support program: A toolkit for health care organizations. The Joint Commission Journal on Quality and Patient Safety. 2012;38(5):235-240.
30 Ulrich BT, Buerhaus PI, Donelan K, Norman L, Dittus R. How RNs view the work environment: Results of a national survey of registered nurses. Journal of Nursing Administration. 2005;35(9):389-396.
31 Edmondson A. Psychological safety and learning behavior in work teams. Administrative Science Quarterly. 1999;44(2):350-383.
32 Edmondson A. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass; 2012.
33 American College of Healthcare Executives and NPSF Lucian Leape Institute. Leading a Culture of Safety: A Blueprint for Success. Chicago: American College of Healthcare Executives; 2017.
34 Heathfield SM. 20 ways Zappos reinforces company culture. The Balance. June 28, 2016. https://www.thebalance.com/zappos-company-culture-1918813
35 Judge TA, Piccolo RF, Podsakoff NP, Shaw JC, Rich BL. The relationship between pay and job satisfaction: A meta-analysis of the literature. Journal of Vocational Behavior. 2010;77(2):157-167.
36 Herzberg F. One more time: How do you motivate employees? Harvard Business Review. January 2003. https://hbr.org/2003/01/one-more-time-how-do-you-motivate-employees
37 Epstein RM, Krasner MS. Physician resilience: What it means, why it matters, and how to promote it. Academic Medicine. 2013;88(3):301-303.
38 Leveck ML, Jones CB. The nursing practice environment, staff retention, and quality of care. Research in Nursing and Health. 1996;19:331-343.
39 Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2013.
40 Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.
41 West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician wellbeing, job satisfaction, and professionalism: A randomized clinical trial. JAMA Internal Medicine. 2014;174(4):527-533.
42 Goleman D, Boyatzis R, McKee A. Primal Leadership: Unleashing the Power of Emotional Intelligence. Harvard Business Review Press; 2013.
43 Hayes C. “Highly Adoptable Improvement.” http://www.highlyadoptableqi.com/index.html
WHITE PAPER: IHI Framework for Improving Joy in Work
Institute for Healthcare Improvement • ihi.org 41
44 Hektner JM, Schmidt JA, Csikszentmihalyi M. Experience Sampling Method: Measuring the Quality of Everyday Life. Thousand Oaks, CA: Sage Publications, Inc.; 2007.
45 Sherwood R. Employee engagement drives health care quality and financial returns. Harvard Business Review. October 2013. https://hbr.org/2013/10/employee-engagement-drives-health- care-quality-and-financial-returns
46 Balik B, White K. Listen to Understand: Conversation Guide. June 2017.
47 Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2013.
48 Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.
49 AustralianArmyHQ. “Chief of Army Lieutenant General David Morrison Message about Unacceptable Behavior.” June 12, 2013. https://www.youtube.com/watch?v=QaqpoeVgr8U
50 Duhigg C. What Google learned from its quest to build the perfect team. The New York Times Magazine. February 28, 2016. https://www.nytimes.com/2016/02/28/magazine/what-google- learned-from-its-quest-to-build-the-perfect-team.html
51 Berwick D, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. Journal of the American Medical Association. 2017 Jun;317(21):2161-2162.
52 Atlassian. “ShipIt.” https://www.atlassian.com/company/shipit
53 Reichheld FF. The one number you need to grow. Harvard Business Review. December 2003. https://hbr.org/2003/12/the-one-number-you-need-to-grow
54 Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research. 2006 Apr;6:44.
55 Agency for Healthcare Research and Quality. “Surveys on Patient Safety Culture.” https://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
56 Maslach C, Jackson SE, Leiter M. The Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press; 1996.
57 American Medical Association StepsForward. “Mini Z Burnout Survey.” https://www.stepsforward.org/modules/physician-burnout-survey
58 Alexander GC, Lin S, Sayla MA, Wynia MK. Development of a measure of physician engagement in addressing racial and ethnic health care disparities. Health Services Research. 2008;43(2):773-784.
59 Hackman JR. Motivation through the design of work: Test of a theory. Organizational Behavior and Human Performance. 1976;16(2):250-279.
Institute for Healthcare Improvement 20 University Road Cambridge, MA 02138 USA