JOY IN THE WORKPLACE FORCE FIELD ANALYSIS

 

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)

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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.

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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

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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

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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.

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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.

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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

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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

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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.

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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

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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.”

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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.

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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

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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.

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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.

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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.

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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

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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