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Engaging Employees in Well-Being Moving From the Triple Aim to the Quadruple Aim

Barbara Jacobs, MSN, NEA-BC, RN-BC, CCRN-K; Julie McGovern, MA, SPHR, SHRM-SCP; Jamie Heinmiller, BS; Karen Drenkard, PhD, RN, NEA-BC, FAAN

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being with the assumption that employee well-being and employee engagement are interconnected. Improvements in employee well-being will result in increased employee engagement and will be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical Center successfully differentiated itself in the market by being the region’s high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. The financial, quality, and patient satisfaction results are in the top percentiles nationwide. However, as the pace of change accelerates and the organization faces increased pressure to improve outcomes, keeping employees from becoming burned out and disengaged becomes an increasing concern. The WellBeing framework was developed on the basis of the work of Tom Rath and Jim Harter as the model to support Anne Arundel’s WellBeing work. The efforts around well- being are comprehensive and impact all aspects of how work is conducted. Employee well- being has been elevated to an equal third prong along with providing high-quality low-cost care in a patient-centered environment. This focus on leading an employee WellBeing Program has resulted in improved engagement scores at Anne Arundel Medical Center. Key words: employee engagement, leadership, quadruple aim, WellBeing Program

W HEN ANNE ARUNDEL MEDICAL CEN-TER (“AAMC”) adopted its 10-year strategic plan, “Vision 2020” in 2009, it was developed around 5 strategic pillars: Qual- ity, Community, Workforce, Growth, and Fi- nance. The initial strategies tied heavily to the Triple Aim of improving the health of populations, improving the patient experi-

Author Affiliations: Anne Arundel Medical Center, Annapolis, Maryland (Mss Jacobs, McGovern, and Heinmiller and Dr Drenkard); and GetWellNetwork, Inc, Bethesda, Maryland (Dr Drenkard).

The authors declare no conflict of interest.

Correspondence: Karen Drenkard, PhD, RN, NEA-BC, FAAN, GetWellNetwork, Inc, 7700 Old Georgetown Rd, Bethesda, MD 20814 ([email protected]).

DOI: 10.1097/NAQ.0000000000000303

ence, and lowering the cost of care.1 Anne Arundel Medical Center had and continues to have excellent outcomes, regularly receiv- ing statewide recognition for high patient ex- perience scores as compared with the state of Maryland, better than average turnover scores, and being the first organization in the country to be awarded the Organiza- tion Patient Safety Certification by the Mary- land Patient Safety Center and the Courte- manche & Associates. The system continues to grow and be a financially strong, indepen- dent health system. In the early years of Vi- sion 2020, AAMC strove to differentiate it- self in the market by being the high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. Anne Arundel Medical Center

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232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

adopted a culture of continuous performance improvement by following Lean2 principles. In addition, AAMC began to include patients and families in all aspects of care delivery. By 2015, AAMC had 100 patient advisors actively participating on system committees at every level, including on the Board Quality Commit- tee and Physician Peer Review Committee.

As the pace of change accelerated, and AAMC faced increasing financial pressure along with ever-changing reporting mandates, concerns about staff fatigue and burnout sur- faced. Goals associated with the workforce pillar of the strategic plan focused on in- creasing employee engagement and decreas- ing turnover. Both were important goals but neither did enough to address employee stress and burnout. In 2014, Thomas Bodenheimer, MD, and Christine Sinsky, MD,3 published an article reporting that staff burnout and dissat- isfaction are associated with lower patient sat- isfaction, reduced health outcomes, and po- tentially increased costs. They recommended that organizations adopt the quadruple aim, citing that the fourth aim, improving the work life of health care clinicians and staff, is nec- essary to achieve the triple aim.1

In this same time period, Gallup (2013) published the State of the American Workplace,4 reporting that overall, in all cat- egories and all industry sectors, employee en- gagement continues to remain at 30% across the US workforce. They noted that the work environment has a significant impact on em- ployee well-being, and employees with poor

well-being were less engaged and more neg- ative about the workplace. The Gallup study reported that employees who had high well- being were more likely to be agile and re- silient, experience better health, and report higher job performance. It was suggested that making well-being an organizational strategy could be a way to improve employee’s lives while achieving organizational outcomes. Fur- ther research about well-being led to the work of Rath and Harter, published in the book Wellbeing: The Five Essential Elements.5

Rath and Harter define well-being as “the com- bination of our love for what we do each day, the quality of our relationships, the security of our finances, the vibrancy of our physi- cal health, and the pride we take in what we have contributed to our communities.”5 The core concepts of well-being transcend coun- tries, culture, and generations. For the pur- poses of this article, definitions spelled out in Table 1 are used to describe WellBeing at Anne Arundel Medical Center. Rath and Harter posture that organizations that invest in their employee well-being will gain an emotional, financial, and competitive advantage.5

The stressors at work were not the only stresses facing AAMC employees in 2014. The economy was improving, but in a national study that year, 76% of Americans surveyed cited personal finances as a leading cause of their stress.6 The survey revealed that many physician visits are related to financial stress while resulting in increased health care costs, prescription costs, and absenteeism.6

Table 1. Definitions of Well-Being at Anne Arundel Medical Center

Purpose WellBeing: Having something to do every day that is challenging and enjoyable. For most people, it is their jobs that contribute to their purpose.

Social WellBeing: Having strong relationships and love in your life. Having a supportive work environment with people who care about you and who you care about is critical for thriving social well-being.

Financial WellBeing: This element is about managing your finances in a way that provides long-term economic security.

Physical WellBeing: Employees with thriving physical well-being experience good health and have enough energy to get things done on a daily basis.

Community WellBeing: Being engaged with the community where they live and work enhances an employee’s overall well-being.

Engaging Employees in Well-Being 233

In addition, 69% of 2014 college graduates left college with student loan debt. Between 2004 and 2014, students’ average debt had increased 56%, from $18 550 to $28 950.7

Other research showed that people were more isolated and not connecting enough. This resulted in increased loneliness and poor social well-being.8 One comment from a survey participant was:

At one time, work was a major source of friend- ships. We took our families to company picnics and invited our colleagues over for dinner. Now, work is a more transactional place. We go to the office to be efficient, not to form bonds.8

By every measure, American workers were less healthy than at any other period in our history.9

It appeared that by focusing on WellBeing there could be improvement in the lives of employees while AAMC continued to meet the goals expressed in the triple aim.

There was early concern that focusing on employee well-being was getting the organi- zation too involved in employees’ personal lives. Questions were raised about what could actually be done to improve employee well- being. From the outset, AAMC leaders were determined to take demonstrable action to im- prove employee well-being as part of meeting the hospital mission: “To enhance the health of the people we serve.” Hospital employees are part of the community being served, and all stakeholders could see the direct correla- tion between employee well-being and the Vision 2020, “Living Healthier Together.” It was recognized that adoption of a WellBeing program would take careful thought and preparation. To get started, executive leaders participated in a retreat to immerse them- selves in the WellBeing model. The retreat’s objective was to help leaders understand what it means to commit to employee well- being and what outcomes they could expect from a formal program. There was honest dialogue about how work was impacting each executive’s well-being. The discussion centered on how individuals own their per- sonal well-being and the need to make small

shifts to improve work-life balance. Each executive committed to a personal action plan. A significant outcome of the retreat was recognition of the importance of executive role modeling. As a team, executives adopted several strategies to help with their own work-life balance, knowing full well that the changes they made would impact the larger leadership team. These strategies were to

• reduce many meetings from an hour to 45 minutes in order to allow time for bio- breaks, checking e-mail, and getting from one meeting to the next;

• stop sending e-mails between 7PM and 7 AM and on weekends, unless it was ab- solutely required;

• use texts and calls to reach a colleague (if necessary) in the “off hours.” This would reduce everyone’s need to constantly check e-mail. It was acknowledged that this was already a practice and which dif- ferentiated routine contact from urgent communication;

• role model well-being, while speaking openly at meetings about individual commitments to improve personal well- being.

The rollout of the WellBeing program to the employees was gradual, giving AAMC time to test the model, build infrastructure, and ensure support. Leaders monitored and rec- ognized the model’s swift adoption by staff and management as people saw relevance to their lives. All management staff received the book, Wellbeing: The Five Essential Ele- ments by Tom Rath and Jim Harter.5 A com- mittee was formed to conduct a needs as- sessment to identify the organization’s well- being strengths and opportunities for im- provement. The human resources (HR) de- partment reviewed its programs to determine how they could be redesigned to support well-being.

METRICS FOR SUCCESS

A key foundational strategy was to deter- mine, in advance of the rollout, how well- being would be measured and where the

234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

results would be reported. Ten initial work- force aims were identified. Each month a re- port is shared at the quality committee of the board of trustees. Each aim supports 1 or more WellBeing element. For instance, there is an aim to increase employee Financial WellBeing by increasing participation in the 401k plan. Another metric is to increase Physical Well- Being through increased sales of healthy food at all organization cafeterias and coffee shops. Purpose WellBeing has aims to increase the number of BSN-prepared nurses and to in- crease staff skills in Lean quality concepts. The Community WellBeing aim is developed around support for community service. Over time, the workforce aims have evolved. For example, feedback from employees who vo- calized concerns about employee safety has resulted in additional aims targeted at reduc- ing injuries to employees caused by patients.

To get a baseline on employee engagement and well-being, AAMC implemented a WellBe- ing survey that included the Gallup Q12 and Gallup’s Well-Being 5 View assessment.10 As of 2018, AAMC has 3 years’ worth of data. Each year, goals are set at the system level as well as the department level to increase employee well-being and engagement. In ad- dition, HR has built the concepts of WellBe- ing into the core structural practices of re- cruitment, staff and leadership development, and goal setting. Some examples include the following:

• WellBeing is integrated into the leader- ship framework. Leadership behaviors at AAMC are guided by the leadership frame- work of “Team, Change, Business.” To be a leader, each manager must excel at managing his or her team by serving as a coach, serving as a mentor, assuring staff well-being, and encouraging team diver- sity. Leaders are expected to demonstrate changes in a transformational and inno- vative way. The framework’s reference to business means that leaders need to understand the business of health care, their role in it, and the basic skills of man- agement. WellBeing concepts have been woven into the “Team, Change, Business”

framework, making the commitment ex- plicit.

• The electronic performance appraisal and goal-setting system is used to have all employees develop personal well-being goals. By doing this, leaders have the op- portunity to learn more about their teams. They can better determine whether there are ways to support staff members with their goals. Employees determine how much they want to share. Many have found it beneficial and are getting sup- port from their teams, as they seek to improve their own well-being. Develop- ment of personal well-being goals is vol- untary and not part of the weighted per- formance appraisal.

• The WellBeing concepts are woven into orientation and into the leadership devel- opment curriculum.

• Interviews for new leaders highlight the importance of well-being for both them- selves and their staff members. When new leaders are onboarded, they receive training on the well-being principles along with an introduction to their role in promoting employee well-being.

• Organizational goals to improve well- being outcomes were set in year 2 and have been applied to all leaders.

COMMITTEE FORMATION AND PARTICIPATION

Once the commitment was made by the or- ganization to embrace employee well-being as a core differentiator, education was done with key constituents. These included the nursing leadership team and the Nurse Professional Practice Council. Each presentation was well received and resulted in volunteers to help roll out the strategies. A structure was devel- oped that supports well-being across the or- ganization and includes staff at all levels. The structure includes a steering committee and 5 subcommittees, 1 for each of the 5 Well- Being elements. The steering committee is led by the VP of HR, and there is an iden- tified executive champion for each of the 55

Engaging Employees in Well-Being 235

committees. In addition, there are 3 additional staff committees to represent night shift as well as off-site stakeholders. Membership ap- plications are taken through an intranet ap- plication system in which employees can ex- press their interest to serve on a committee of their choice. Employees are asked, but not required, to attend the meetings in person or virtually. Conference line numbers are pro- vided for meeting times. Members have be- come champions within their departments, constantly communicating efforts. Commit- tee participation started at about 40 employ- ees and has surged to more than 160 partici- pants organization-wide during a 3-year time period. There has been consistent participa- tion due to expressed employee passion for the work. Some participants like to work at the organizational level while others focus at the department level. The committees have developed strategic objectives to guide the committee work and set priorities. This step has been pivotal in ensuring that work is measurable and tied to the overall well-being objectives. These objectives are shared in Table 2.

Each year, the committees reevaluate goals and develop actions for the coming year. Suc- cessful programs are continued and unsuc- cessful programs are revisited, either to revise objectives or to develop new ones.

A big challenge for this work is prioritiz- ing the interventions so that goals can be met. The employees on these committees drive the work and take ownership for the initiatives. Because all stakeholders are involved in the process, well-being actions have been imple- mented for all shifts and sites. The commit- tee members supporting the Eastern Shore (approximately 25 miles from the main cam- pus and part of the organization consisting of physician practices and small ambulatory sites) focused on Purpose, Social, and Physi- cal WellBeing. They increased the amount of education available to staff and held a fun, competitive Field Day. They provide tips and ideas about what individuals could do to im- prove personal well-being.

The other regional committee serves a larger population in 1 locale. Over the course of 6 months, this group flourished. There is consistent committee participation from 15 team members. The committee has planned social gatherings, hosted a farmer’s market over the summer months, implemented morn- ing stretching sessions, reinstituted a popular weight loss program, and planned a yearlong Financial WellBeing series for employees. A significant accomplishment was the addition of food trucks to compensate for the lack of a cafeteria. Staff members regularly comment about the commitment to increase their well- being and how they do not have to leave the site to achieve it. The well-being scores in one department at this site increased by 7% over the course of 3 years.

The smaller number of staff on the night shift creates challenges for bringing events and programming to employees. The night shift committee has developed creative ways for programs designed for the day shift to be successfully replicated for the night shift, in- cluding specially designed physical challenges and a stress reduction fair. The night shift WellBeing champions have encouraged an increase in social activities. They are coordi- nating the financial series for this staff as well. The committee challenges the organization to include them in activities and has taken ac- countability to help increase night shift mem- ber participation at programs. The success of the committees is driven by interested and engaged leaders who can facilitate a philo- sophical conversation, understand the limita- tions of what can actually be achieved, and encourage the committee to follow through on planned actions. Employees do not have to wait for someone else to make a change. Changes can be made at the organization level or department level through committee work or by the individual. The steering com- mittee, executive champions, and the VP of HR are available to remove obstacles or to guide actions so that they are aligned with the overarching strategy and plans for the organization.

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Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018

WellBeing Element Strategic Objectives Completed Tactics over the last 3 y

Purpose Evaluate opportunities to increase reward and recognition for individuals and departments

Provide additional opportunities at all levels to participate in career development opportunities

Expand coaching and mentoring throughout the organization

Promote empowerment philosophy

$250 000 scholarship program for nonclinical employees; career exploration fair for internal applicants looking to explore opportunities or transfer to new jobs; 100% e-mail access for all employees; increased number of employee classes; monthly newsletter to all employees with education offerings; leadership essentials program for new leaders; panel sessions focused on balancing work/life; national speakers on WellBeing topics

Social Provide increased opportunities for employees to participate in system-sponsored social events

Develop strategies to increase social WB at unit level

Provide education and support to employees to learn impact of others on their social WB

Thank You Card program; NYC Bus Trips; Baseball Game; Book Club; Movie Nights; Increased recognition training; Best Friend at Work campaign; Art in the Café; free tickets to local baseball and lacrosse games; guidance to departments for how to host their own department events focused on Social WB; EAP hosted a class on toxic people

Financial Increase participation in retirement program

Increase financial education for all staff

Financial education series; auto enrollment for retirement plan; home buying course; enhanced pharmacy benefits; partnership with financial planners that offer complimentary introduction and reduced fee; financial fitness fair; vendor fair to explore discounts; additional vendors added to employee discounts; promotion for EAP; combined leave benefit revision

Physical Promote healthy eating/ healthy food choices

Provide stress-reduction programming

Promote health/opportunities to stay active

Develop executive-level/ leadership involvement

Fresh fruit tastings with recipes in cafeteria; cancer screenings and education for employees; Wellness Wednesdays and Fitness Fridays; Walk with an Executive series; reduced soda and unhealthy snacks; enhanced signage; healthy cooking classes; New Year’s resolution events; WellBeing+ (a wellness portal to track challenges and overall health); free seated chair massages; fryerless Fridays; whole fruit at cafeteria registers; stress reduction fair; stress reduction baskets to departments

(continues)

Engaging Employees in Well-Being 237

Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018 (Continued)

WellBeing Element Strategic Objectives Completed Tactics over the last 3 y

Community Increase communication about current AAMC community activities

Create additional opportunities for employees to participate in community service

Recognize and support employees for community service

Food collection for local women’s shelter; backpack collection and delivery for foster children transitioning to homes; sock drive; United Way campaign; cultural diversity series; partnership with project clean stream; CEUs for community education; employee hardship assistance fund; community events at other well-being fairs (such as packing lunches or can drives); more than 200 000 h in community benefit hours

Abbreviations: AAMC, Anne Arundel Medical Center; CEUs, continuing education; EAP, employee assistance program; WB, WellBeing.

INVESTMENTS, ACTIONS, AND OUTCOMES

The initial investment in WellBeing was the implementation costs of adding the WellBeing survey to the employee engage- ment survey and the training of leaders on WellBeing. A WellBeing manager was hired to help facilitate the work of the committees, conduct training, and oversee the survey and action planning. The AAMC WellBeing budget is small but it pays for 1 national external pre- sentation a year as well as the supplies needed to support committee activities. Significant changes, such as alterations to the retirement program, are funded through the annual ben- efits budget. The majority of activities are low cost and free. Whenever possible, WellBeing concepts are interwoven into existing activ- ities such as Nurses Week. Each WellBeing element (Purpose, Social, Financial, Physical, and Community) had specific activities that have been implemented across the organiza- tion. Each is described in more detail later:

Purpose WellBeing

There is a direct correlation to Purpose WellBeing and high employee engagement.11

Anne Arundel Medical Center internal data show that departments with high levels of

well-being are 12 times more likely to have engaged employees. The Purpose WellBeing committee has embraced career development and has implemented an annual career de- velopment fair. In addition, the committee has raised awareness of the needs of entry- level employees. As a result, an “Expanding Horizons” program has been created in collaboration with the Purpose WellBeing committee to provide opportunities for career exploration, career paths, and advancement for entry-level staff within AAMC. Resources have been invested to ensure that all staff have e-mail access along with basic computer skills. Entry-level staff now have access to career coaching, basic skills assessment, and devel- opment activities. Service department lead- ers support and encourage their staff to take advantage of these opportunities, which in- crease promotion potential. The focus on Pur- pose has resulted in the development of a ca- reer ladder for patient care technicians in the hospital. As a result, there are currently 35 patient care technicians on the ladder, and several ancillary support service employees have been promoted. System benefits include reducing turnover and improving retention.

Data from the annual WellBeing survey in- dicated the need to invest more in the de- velopment of leaders. Programs have been

238 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

expanded to support leaders through the en- tire life cycle of leadership. The AAMC “Lead Academy,” an emerging leaders program, was started in Nursing and was then expanded to all leaders throughout the organization. In ad- dition to learning basic leadership skills, Lead Academy participants must complete a year- long project. Several projects tie directly to the WellBeing work, such as one study in- troducing mindfulness to AAMC, and another that researched the impact of sleep depriva- tion on patient care.

Social WellBeing

This element has been widely embraced at all levels of the organization. Under So- cial WellBeing, the focus of the work is on bringing employees together socially. It also focuses on reducing stress, increasing em- ployee safety, and reducing bullying. There is overlap between Physical WellBeing and Social WellBeing in developing and execut- ing programs. Examples of activities include well-loved programs such as bus trips to local attractions, family movie nights, sports out- ings, book clubs, and art nights. Employees of all backgrounds help organize the events, and participation is consistently high. Depart- ments have worked hard to conduct and sup- port social activities. Some combine social activities with community support, such as volunteering together at the local homeless shelter.

One area of concern to AAMC team members is that health care workers today feel more threatened and less safe in the workplace.12 Anne Arundel Medical Center is able to leverage the WellBeing strategy to address employee safety concerns. The workplace safety committee has been rein- vigorated. Members connect their work to improving employee well-being. The most recent AAMC Patient Safety Culture Survey experienced a 16% increase in participation, and 11 of the 12 composite areas went up significantly. The composite score for Handoffs and Transitions went from 43% to 77% and the composite score for Nonpunitive

Response to Errors increased from 41% to 72%. This is an example of how employees are beginning to see the connection of well-being to all facets of their work life.

Nationally, it has been well documented that relentless change and ongoing pressure to improve quality and reduce cost have led to increased stress and dissatisfaction for clinicians.13 The AAMC WellBeing Steering committee has spearheaded more efforts to- ward reducing stress within the organization. The committee sponsored a speaker who came to the organization to talk about burnout and techniques to combat it. A stress reduc- tion fair is hosted each year to give employ- ees the opportunity to explore offerings such as acupuncture, zero balancing, and mindful- ness. Anne Arundel Medical Center also con- tracts with local providers to offer employees a discount on these services. One of the most successful, yet simplistic, tactics has been to create a stress reduction basket that contains a plethora of stress reduction massage tools along with tips for stretching. These baskets rotate around the organization, and many de- partments take matters into their own hands by purchasing their own supplies for a “relax- ation station.”

The medical staff has also championed physician well-being. An annual physician WellBeing conference attracts approximately 100 to 200 physicians. A physician well-being survey is currently being implemented to identify areas for improving provider well- being. The physician lead for this work and the manager of WellBeing are working to- gether to create synergy between efforts.

Financial WellBeing

Financial WellBeing is the most difficult ele- ment for leaders to address. Leaders across the organization express discomfort when deal- ing with this subject. There is not an expec- tation that leaders need to discuss personal financial planning with their staff. Rather, leaders need to be aware of how financial worries impact employee well-being and, po- tentially, job performance. Leaders can be the

Engaging Employees in Well-Being 239

conduit to the growing library of information the organization has to offer. The Financial WellBeing committee arranged for a financial series that offers opportunities for employ- ees to learn about topics ranging from retire- ment, home buying, credit card theft, improv- ing credit scores, simple budgeting practices, and loan forgiveness programs for health care workers. Programs are offered in person and online. The goal is to encourage individuals to manage their financial resources (rather than the misconception that the organization fo- cusing on Financial WellBeing was going to give everyone a raise). At the system level, AAMC has taken significant steps to increase employee Financial WellBeing. The Expand- ing Horizon program was developed to en- courage a career path for entry-level employ- ees. As part of the evaluation of the Expanding Horizon program, the minimum starting wage was strategically increased by almost $3.00 an hour over 2 years, with plans to continue to invest as resources allow.

Gallup data indicate that individuals who take steps to increase their long-term eco- nomic security enjoy higher well-being over- all. This information led to the system increas- ing the retirement match an additional 1% and automatically enrolling employees in the re- tirement program with an auto escalation. To- day there is a 95% participation in the retire- ment program. This investment in Purpose and Financial WellBeing for entry-level staff has resulted in a 24% decrease in first-year turnover.

A source of huge pride at AAMC is the im- plementation of the Auxiliary Scholarship pro- gram for entry-level staff. The volunteer aux- ilians were educated about the principles of WellBeing and then decided to build a pro- gram for staff with the greatest need. The Auxiliary donated $250 000 to start the pro- gram. This competitive, scholarship program is helping to build the pipeline for career progression in the organization. Scholarship winners are paid for full-time work but are scheduled only 20 hours per week, allowing them to enroll in school full time. All recipi- ents are assigned a coach and a mentor. They

take classes that lead directly to a degree or a certification for a job at AAMC. Once an individual is close to successfully completing his or her program, the desired department works to hold a position for the employee. On average, there has been an increase of 25% to the employee’s base rate of pay in the schol- arship group. Twenty-three employees have successfully completed the scholarship in 7 fields. Currently, through the Foundation, 20 nursing scholarships are offered annually that go beyond regular tuition reimbursement.

Physical WellBeing

Prior to the adoption of the WellBeing framework, AAMC had a wellness initiative called “Energize.” This successful program provided on-site exercise classes and offered weight loss reduction programs along with healthy challenges. Since the adoption of WellBeing as a program, participation in En- ergize programs has increased by 75%, with 4300 employees participating in the program. The Physical WellBeing committee expanded the scope of Energize. Members work directly with the dietary department to decrease the sale of unhealthy food in the cafeteria. Sale of healthy food now contributes 66% of all revenue in system eateries. Soda has been eliminated from the conference center, and the sale of sweetened beverages has been re- duced by 24%. In addition, a cooking class is being hosted for employees. They can come to the organization’s kitchen to learn how to cook simple, easy, and healthy dishes at home. They get to taste the food, too! Many departments have developed programs and challenges to promote a healthy lifestyle. The benefits of these programs cross over to in- creased Social WellBeing. A number of em- ployees have made significant gains in improv- ing their health. Their accomplishments are celebrated on the internal AAMC WellBeing Web site.

Community WellBeing

A few of the actions that were taken early on were about building and expanding what

240 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

was already successful in the organization. Two examples came directly from the nursing division. Long before Community WellBeing was being planned, the nursing staff had organized a committee called the Community Service Initiative. This group planned sponsored community drives and collections for local shelters and schools. The Community WellBeing committee built upon the nursing structure and expanded it throughout the organization, thus allowing more collections and drives. For many years, the nursing staff did community outreach to the local homeless shelter by providing a health clinic twice a month. The Community WellBeing committee expanded that support by formally agreeing to support 2 families annually as they transition from the shelter to a home. Anne Arundel Medical Center employees collect both new and used goods that could outfit an entire house, including furniture, kitchen supplies, and the hundreds of basics it takes to make a home for a family. A future challenge for the Community WellBeing committee is to develop ways to encourage employees to get involved in their own communities and help leaders recognize staff who do. The efforts around Community WellBeing have increased employee pride in working for AAMC. The Community WellBe- ing score has experienced the largest increase over the 3 surveys, with a 5% improvement.

NURSING LEADERSHIP AND WELLBEING INITIATIVES

As the manager of the largest employee base in the health system, the chief nursing officer’s (CNO’s) involvement and passion for this work are essential for the system’s success in deployment. The AAMC National Database of Nursing Quality Indicators (NDNQI) nurs- ing satisfaction results were above benchmark in all major categories, but it was clear from employee feedback that the radical changes occurring in health care and the stresses of the workplace today have strained the staff. The CNO must take an active role in educat- ing nurse leaders on the positive impact of in-

creased employee well-being. He or she must support the training and education needed to properly support this type of change. One of the core principles of a nursing Magnet hospi- tal is to create a work environment supportive of nursing professional practice and develop- ment. The CNO should act as a role mode or executive leader in this work by clearly demonstrating to a large employee base that the well-being of our staff is a priority for the organization.

The development of the WellBeing initia- tives, with the strong involvement of frontline staff, has complemented work being done to enhance Magnet performance and to maintain a supportive work environment. In addition to initiatives developed by the staff, national experts were invited to provide educational programs for frontline and leadership staff to add to the WellBeing work. One, particularly focused in Nursing, was centered on bullying and incivility. Another was to provide tech- niques for helping staff develop resiliency in these times of change. Both courses were received very positively by the staff and augmented work being done through the WellBeing committees.

An example of frontline nursing staff contributions toward the development of a project for one of our committees is the “Petals of Purpose.” Discussions at the pro- fessional practice committee have included conversations about the personal impact of remembering why individual nurses chose the profession. These thoughts were shared through the Purpose WellBeing committee and resulted in a systemwide “petals of pur- pose” project, which has resonated strongly with the nursing staff. Employees were given paper petals on which they wrote their pur- pose, and each unit created a poster in which these are mounted in their unit (see Figure 1).

Overall, this work supports the joy of practice14 and is in line with the latest white paper released by the Institute for Healthcare Improvement13 on bringing joy back to the workplace. This joy optimizes performance, reduces turnover, and improves quality of care. The 2017 IHI Framework for Improving

Engaging Employees in Well-Being 241

Figure 1. Emergency department “petals of purpose.” Used with permission from Anne Arundel Medical Center.

Joy in Work summarizes the importance of leaders by stating that “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.”13 At AAMC, the success of this work in each department was made a part of in- dividual nurse leaders’ performance evalua- tion. Regular pulse surveys are done to give snapshot views of progress. Combining in- formation from the employee engagement survey and the NDNQI survey, nurse leaders worked to develop action plans that tie the work together in order to prevent duplica- tion of plans. The pulse surveys ask 5 or 6

questions and allow monitoring the success of work occurring on different units.

It is very important for staff to see the CNO and all executive leaders as promoters of this work. Discussing these initiatives with large groups of nurses provides an excellent opportunity to allow employees to see that the organization is supportive of this work to benefit them. The success of major cul- tural change initiatives like this is dependent on executive leaders actively demonstrating their support. In partnership with the VP of HR, nurse leaders can customize some of this work for Nursing and then develop appropri- ate training. Frontline leaders need to receive excellent coaching so that they can support changes in their individual departments.

242 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

IMPLICATIONS FOR BOARD MEMBERS

The CNO has an active role with HR to underscore the importance and then the success of the WellBeing work to the board of trustees. When quality efforts and initiatives emerge for health systems, the role of the board of trustees is critical. Board member engagement at the right level and at the right time is essential for large-scale change efforts to be successful. Appropriate board-level engagements in understanding the strategic priority, the expected outcomes, and the necessary resources are all areas that board members should be attuned to. “For the not for profit hospital, the highest order stake- holders are the patient and community”15(p59)

and by extension the community of care- givers who provide that care. Board members

need to understand the impact of a healthy employee population on the care of patients. They should take the employees’ needs for well-being into account when considering resource allocation and strategy decisions. Board roles in this work include activities such as approving high-level organizational goals and policies, overseeing project perfor- mance at a strategic level through review of performance metrics and results, and acting as an advocate within the community for im- portant initiatives.16 The management team of AAMC has created “True North” metrics of operational measures that include the Well- Being efforts to improve workforce health. Table 3 shares the extended well-being goals and measures. Metrics are tracked monthly and quarterly and are presented at each meet- ing to both the quality and safety committee

Table 3. Workforce Goals and WellBeing Framework

AAMC Workforce Aims WellBeing

Framework Last Year

Result (2017) This Year

Goal (2018)

Reduce year 1 turnover Purpose WellBeing

38% staff turnover 33% staff turnover

Increase number of diverse candidates for leadership positions

Purpose WellBeing

Community WellBeing

New 80%

Increase participation in defined contribution plan

Financial WellBeing

87% of staff participating

92% of staff participating

Increase employees participating in fitness challenges

Physical WellBeing

Social WellBeing

4306 employees participating

4737 employees participating

Increase sales of healthy foods in cafeteria

Physical WellBeing

65% 67%

Reduce number of products offering sugar by 65%

Physical WellBeing

168 products in cafeterias

59 products in cafeterias

Reduce number of injuries from combative patients

Physical WellBeing

17 employee injuries

14 employee injuries

Financial WellBeing

Maintain contributions level to United Way

Community WellBeing

$123 000 in contributions

$120 000 in contributions

Implement pulse surveys and track improvement in Great Places to Work survey

All WellBeing and Engagement

Dimensions

New TBD

Abbreviations: AAMC, Anne Arundel Medical Center; TBD, To be determined.

Engaging Employees in Well-Being 243

of the board and the entire board of trustees. The review and directional progress toward annual goals are discussed in subcommittee and committee meetings. Board members are expected to ask knowledgeable and appro- priate questions of management16 in order to exercise the decision-making function and the oversight function. The board members serve as excellent external advocates for the initiative. They realize that the approximately 4800 employees at the health system are also members of the community, and that their well-being has an impact on the ability of the system to have a robust workforce to provide high-quality, consistent care. Annually, progress toward goals is reviewed, and board approval is sought when setting new targets. In addition, top leadership and executive performance reviews are tied to achievement of annual operating goals. In this way, alignment occurs throughout the organization, and the management team can be rewarded for reaching goals.

EVALUATION AND NEXT STEPS

Anne Arundel Medical Center surveys for both engagement and well-being at the same time. The organization uses the Gallup Q12 for staff engagement and the Gallup- Healthways Well-Being 5 View to measure staff well-being. Survey results show that work groups that are high in engagement also tend to have higher well-being scores. Thirty-eight percent of employees are highly engaged at AAMC, while 14% are disengaged. Employees who are thriving in well-being tend to be more highly engaged. The latest survey results show that

• 74% of employees who are thriving in all 5 WellBeing elements are engaged;

• 48% of employees who are thriving in 3 of the 5 WellBeing elements are engaged; and

• engagement drops to 10% for employees thriving in zero WellBeing elements.

In addition, metrics for the WellBeing pro- gram measure specific criteria reported to the board of trustees (Table 3). Anne Arundel has

seen the following improvement since the program began:

• Physical WellBeing: There has been an im- provement in participation in physical ac- tivity programs (called “Energize”) from 2466 participants in 2014 to 4298 partic- ipants in 2017. This represents a nearly 75% increase. In addition, the system had a 65% reduction in cafeteria prod- uct offerings of sugared beverages. This resulted in the elimination of 68 sugar products.

There was an improvement in staff percep- tion of feeling active and productive and hav- ing physical health near perfect.

• Purpose WellBeing: Twenty-three em- ployees enrolled in the “Expanding Hori- zons” program that resulted in promo- tions and pay increases. There was an improvement in staff rating of “liking what I do every day,” and learning and doing something interesting every day.

• Social WellBeing: Because of all of the ac- tivities and social events that have been conducted, there has been an improve- ment in employee perception of receiv- ing positive energy every day.

• Financial WellBeing: Over 3 years, par- ticipation in defined contribution plans rose from 75% to 95%. There was a de- crease in employee perception of “being worried about money in last seven days” as well as an increase in employee per- ception of “having enough money to do everything.”

• Community WellBeing: Contributions to United Way increased. An employee hard- ship fund was launched as part of the AAMC Foundation Annual Giving Cam- paign, which gave employees the oppor- tunity to designate funds to help fellow employees during a financial emergency. Employee perception was highest in “re- ceiving recognition for helping to im- prove the city where I live.”

Next steps for AAMC include a program evaluation and further analysis of data. For ex- ample, the organization will evaluate different

244 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

workforce strategies and stratify them by gen- eration. Data will be analyzed to see whether there are differences in perception based on age category. Another step will be to further enhance the opportunities for employees to more completely develop their own personal well-being plan, along with individual mile- stones that are easily tracked at the individual level. Determination of the most valuable elements of the WellBeing program from the employee perspective will allow the leader- ship team to further develop the most valuable components of the program. In addition, linking the WellBeing program outcomes to employee engagement scores will ultimately lead to reduced turnover and improved employee satisfaction.17 Ultimately, these metrics will be linked to organizational patient satisfaction and quality-of-care outcomes.

CONCLUSION

As the work in WellBeing at AAMC has evolved, one lesson learned has been that the success of this initiative is dependent on working with employees to own their own WellBeing journey. The organization is providing resources that employees can choose to utilize as they desire. In this way, employees are truly engaged in their health and well-being. There is an expectation that there will be an increase in the emotional commitment that the employee has to the or- ganization and to the “community we serve.” The program will continue to be expanded. It will include more frontline employee par-

ticipation, stronger frontline leadership, and enhanced education about the importance of whole-person well-being for employees. On- going evaluation of progress will continue. Opportunities for research in this space exist, and data evaluation and linkages can continue to be made by linking well-being to employee engagement. Ultimately, this improvement in employee well-being will lead to better outcomes, as demonstrated by documented studies that show that engaged employees lead to better service, quality, and productivity.6 Anne Arundel Medical Center is well on its way to reaching the quadruple aim through well-being of employees.

Engaged employees who feel cared for by their employer through initiatives like our WellBeing programs positively influence an organization’s performance. The work done at AAMC provides a framework, and gives suggestions to others, around the process of developing a robust employee WellBeing program.

Many health care organizations have exclu- sively focused on Physical WellBeing, under the moniker, Wellness, and are now contem- plating moving toward a more comprehensive well-being strategy. Anne Arundel Medical Center started out with a broader WellBeing platform. Our wellness initiatives were placed under Physical WellBeing as just one com- ponent. This has allowed us to communicate with our staff members in a direct way. We have embraced the quadruple aim not just in theory but through demonstrable actions, actions that any leadership team can embrace.

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