topic: [[wellness]] people: #people/scottweingart created: 2023-05-07 *In burnout I have lost my the meaning in my work and have gone over the Frank-Starling curve of effort and connection.* ### what is it? The EmCrit burnout model is a multidimensional view of burnout and the strategies that can reduce likelihood of burnout are targeted at individual coaching processes, these are very helpful. The question at hand is are there any organizational approaches that can help. What I would add to the conversation is that we need to bring the [[The Basic Assumption (TM)]] to the relationship with our administrators. - They are also in crisis - Assume they want burnout to be better - Interesting questions to ask: - Since healing burnout would be an unfair market advantage for any organization in the face of staffing crises (everywhere), why isn't it happening? - ![[Burnout.pdf]] ### why does it matter? We can think about addressing burnout from the organizational or from the individual side. Most research has been done targeting the individual: especially creating better cognitive reframing, stress inoculation, and coping mechanisms like relaxation, exercise, affective training. These tend to impact the affective (emotional [[Purpose]]) dimension, but not depersonalization (demotivation [[autonomy]]) or reduced personal accomplishment [[mastery]]. Targeting organizations is harder and more expensive (theoretically) and doesn’t directly attack the individual. Paradoxically, the majority of the scientific research (Maslach, 2001) show that social and organizational factors play a much larger role, but are generally not the target. **Workplace interventions:** - _Job redesign: making the work better (hard hard hard: needs to be done at the unit by unit level)_ - _co-worker support: creating a community of support_ - _career counseling - not being locked in_, having choice is freeing - _Organizational Development - interventions that improve internal operations_ There is no universal organizational solution because each area has its unique stressors, thus by involving the workers in the process of identifying what’s important and trying to fix it (within their area) they can regain control burnout is reduced. # From the front line perspective: What can you do? ## An example - You may read about transforming healthcare and see the amazing results at some organizations with Lean Management (Kenney, 2011) (Toussaint & Gerard, 2010) and decide this is what your organization needs to be successful. - Since then, many hospitals have tried and failed to have the same results even though they used the same tools. - There is a good argument to be made that it is not the tools, or the philosophy, or the tools and philosophy, but instead the long-term commitment to the values of leadership humility, servant leadership, reducing waste, and focusing on value for the patient over short-term results and performance metrics that results in the sum-total of an organization being effective for a long-period of time. Additionally, the context that existed in the 2000's for these health systems no longer exists, so implementing over 20-year-old approaches to the 2023 world is not going to be successful, but maybe a commitment to the values will be. Don't forget, most change initiatives fail (Kotter, 1995), and always have, so don't focus on the outcome, focus on the learning. - Adopt a [[servant leadership]] perspective, work on _making other people look amazing_, this will move you from seeking control to seeking empowerment, which in turn will feel great for you and work on improving inter-professionalism and learning - Work to make your committees and projects have a learning [[Mindset]] and not a performance or outcome focus. The outcome to seek in your committees is learning, about yourself, the organization, and implementation. See below for effective meetings. - When you have an idea for a change, the ER mentality is idea->solution->implementation. The idea might be from a journal article you read or a book or a spontaneous idea. Lots of burnout comes from your interface with a organization that is tough to change. Instead of focusing on making the world look the way you want it to look, take a few steps back and follow these concepts: - Ask around, why is the thing you want already not happening? Ask a diverse group of people. - When you read an article that says "we did this thing and it made this difference" you are seeing the end result of a lot of failed efforts, dead ends, and frustrated nights without sleep. The publication at the end only shows the outcome, not the process. If you see an ER with no waiting, that was a decade of work for a whole organization, you won't get there in a few months. Focus on the values that go them the outcome, not the individual process steps. - Look at those values behind the project, how do they support or conflict with the _lived_ values of your organization? What's different about the organization that achieved those outcomes from yours. Since most published research has not been replicated or is even likely false based on biases and other challenges in bringing research through the process to publication (Ioannidis, 2005), as tempting as it is to try to achieve what others have published, it's really a challenging approach that can lead to your unhappiness. - Call the group that did the thing (for example, great flow in their ER), has it been sustainable? What has stuck and why? What hasn't and why? - Don't contribute your idea to the apparently near-unavoidable accumulation of "[[safety clutter]]" ## **Action Research** Workers participate in the identification and solving of problems they face, they gain internal job control as well as improvement in the work itself. _Increased sense of job control seems to be the mediator of the less exhaustion and disengagement._ This is akin to the philosophy (not the tools like Kaizen) of lean management. "The people doing the work know the solutions." The philosophy of lean is present in much of my description. # My interventions target the organizational function, the _Organizational Development_ angle, how can the leaders and workers function better together. ## Stop pouring gasoline on the fire The first rule of firefighting isn't put water on the fire, it is to stop pouring gasoline on the fire. I hate to say it but lots of what you are doing is a big part of the causes of burnout. All you have to do is ask, really ask, what is pissing people off. - Inauthentic hiding vulnerability and imperfection - Negative bias in messaging and improvement - Silent departure of members of the team - Holding meetings without explicit purpose and rules - Unclear decision-making processes - Harmful incentives - fracturing a sense of community - Unresolved conflict is allowed to fester - Allowing poisonous people to stay in your organization - Allowing unresolved interdepartmental conflict to continue ### The focus here must be on system performance and trust building, and functional relationship between the management and the teams, and NOT individual or unit performance - A key idea is that everyone's performance improves when the system they perform in, and the trust with administration improve. If those are the focus, the negative outliers are managed with escalating, private interventions. - [[trust comes from transparency]], [[Leader humility]] and [[modeling vulnerability]] - management errors, such as putting in a pop-up alert that doesn't work as expected, are _opportunities to model humility and learning, NOT failures_ (Macht, 2016) (Edmondson, 2019) # Organizational approaches: ## Work towards Mastery, Autonomy, and Purpose - Mastery - opportunities for individual development - Autonomy - distribution of power back to the individual - Purpose - using [[Transformational Leadership]] to inspire with [[vision]] Consider the times you have touches on your teams, and how you are being intentional during those moments. Specific steps to take: ## Invert your Org Chart [[the inverted org chart]] ![[31434F5A-AAAF-47B2-A84E-98433493955D 1.png]] - This is a metaphor, but it can be a powerful tool for re-imagining your work as an administrator In effect, you are doing [[servant leadership]] and demonstrating it through these graphics. Servant Leaders are correlated to psychological empowerment, a key element of the feeling of autonomy. “Servant leaders possess a strong desire to serve the needs of their followers (Anderson & Sun, 2017). While transformational leaders focus on organizational goals, servant leadership broadens the scope of organizational stakeholders and emphasizes the development of the employees (Ehrhart, 2004). Servant leadership is different to transformational leadership because of its inherent moral foundation (Ehrhart, 2004, p. 69). Servant leaders want to improve their employees “for their own good, and view the development of the follower as end in and of itself, not merely a means to reach the leader’s or organization’s goals” (Ehrhart, 2004, p. 69).” (Schermuly et al., 2022, p. 77) (Schermuly et al., 2022) - The implementation of this that is associated with reduction in burnout is from the Mayo Leadership Survey (Dyrbye et al., 2020) (Shanafelt et al., 2015) - Evaluation of the effectiveness of managers needs to come largely from the **beliefs of the people they manage** - living the inverted org chart means that your success as a manager is not how well you report up to your boss, it is how successful your reports are in doing their jobs serving the community - If the whole organization flips its org chart, we start to see the world differently and move the way we see the world. - This may mean giving up some "important" organizational certifications, etc. There is definitely a tradeoff here. Our community gets a lot out of being us being a level II trauma center, although it is stressful and annoying, we get 24/7 IR, MRI, etc. We would not invest in those if it weren't "required." - A keystone habit for the leaders is to model vulnerability by starting the conversations with things they have learned, ideas that have changed for them, and other ways they have been imperfect. When [[Leader humility]] is modeled, everyone else's imperfection is all of a sudden ok. When leaders hide imperfections, a culture of undiscussables is created. (Battilana & Casciaro, 2021) ## Only hold meetings with explicit purpose and rules focused on wellness One issue in EM is that we are generally focused on the task and not the relationships. When we gather we need to be intentional about also focusing on the relationships. We gather on a daily basis in our huddles (See Circle Up) and on a regular basis in our meetings, as well as in our case reviews. Each of these needs a co-created set of norms that simultaneously achieve the purpose (daily readiness, learning) and the relationships. ## [[relational coordination]] - RC is the work done on how I understand your work, how you understand my work, how we understand how our work impacts one another, and how we learn about how our relationship impacts how we work together. It is, in its best form, a virtuous cycle. The more I understand how I impact you, and how you impact me, and how our relationship impacts both of those things, the better we are able to move from creating frustrations for each other to creating benefits for each other. [[first seek to understand]], don't try to fix. ![[CleanShot 2023-06-23 at 07.37.56.jpg]] (What Is Relational Coordination? 2023) Every meeting needs a core principle for existing and a set of rules for how that meeting will be conducted. Make those explicit and negotiated. - I think this meeting is for ... and so the way we will conduct ourselves is ... and the people who are here are ... which will let us achieve ... That's how I see it, how do you see it? Read [[The Art of Gathering]] (Parker, 2018) and apply it to every time you are getting people together: #### Example agenda: Why do we meet? Wellness and community •       Build healthy careers in a connected and meaningful community of practice •       Be well informed of our professions, our department, our community, our health system •       Identify ways we support each other •       Prevent things from falling through the cracks “Rules” Draft #1 – open to change •       Hold the basic assumption: everyone at this meeting is intelligent, capable, cares about doing their best, and wants to improve © •       Help the facilitator and meeting stay on track •       Share the airtime •       Listen like an ally •       Speak up with your ideas ## Clarify the decision-making process If it’s a top down decision, just be transparent and ask for everyone’s input, if it’s a democratic decision, make sure it's democratic in the sense that everyone's voice is equally heard in the conversation about the vote. In a democracy, what is being voted on is just as important as the vote. Who is crafting the question being asked? Be transparent about why decision making process for that situation, explicit disagreement is better than an implicit misunderstanding  Some actionable ways of talking about this: - "This is a decision I have to make as the leader, but I want everyone's best input. I'm going to take the role of facilitator, ensuring the airtime is shared. I'm going to be quiet want to hear from all of you, get your best thinking, then I'll consider the tradeoffs and make a decision." Then as a facilitator your job is to get everyone an equal chance to talk since there is no relationship between a likelihood of talking and the presence of a good idea (Cain, 2012). - "This is a democratic decision since it impacts you all evenly and my job is to support the democratic process. That means I am going to give an overview of the topic, the next thing we need to do is even decide what the question we are trying to answer is. We will do that through a multidisciplinary work-group. Once we have satisfied that representatives had input on the question at hand, we will bring it back to the group for a vote. Our one rule though, is that by following this process, we need you to agree that the process was fair, so you don't talk outside this room about the process being unfair. Does everyone agree to that?" The assumption should be that the people doing the work are the ones with the solutions. At every branch ask, is there any way I have better information about the solution to my problem then the people doing the actual work? ## Collaborative Commitment at the higher levels of the organization - Collaborative Commitment is a way of being in leadership teams that changes the relationship between people on a committee. - Rules: Disagree as much as you want inside this room, we need to hear your voice! Disagreeing with the results of the decisions outside this room and you cannot be on the committee, those are the rules of joining. - [[The best indicator of future conflict is past unresolved conflict]] - If you are continuously seeing conflict between your reports and another department or division, it is the result of unresolved conflict between the leaders of those groups - As the leader, your job is to resolve this conflict ### Get rid of poisonous behaviors - Most poisonous behaviors come from people who are unaware and care, the first step is to let them know the impact of their behavior, and ask what support they need to change. Acknowledge your goal is the behavior ending, and that is for the health of the organization and the people in it. You hope to get there by helping them. - Use: - I'd like to talk about... - I say (heard) ... - I think .... the unintended impact of that was ... - What was going on for you? - [[Listening to Understand]] - A few people won't get the message, they need a stepwise intervention - Collaborative intervention: - Create guardrails to their behavior, make them explicit - Follow-up with an email that outlines what is out of bounds, and the dates and times of your attempts to intervene - A letter outlining that you will ask them to depart the group/organization if their behavior continues, what steps have already occurred to help them, what they already agreed to (as indicated in the email), the dates and times of previous attempts to improve, as well as what resources you are offering them right now (organization will offer to pay for an offsite coaching and wellness intervention). This letter is for them now, your HR, the judge, their lawyer, the jury. This should take place in consultation with the organization, HR, the CMO, whoever needs to be involved - Finally - some people may need to go Commitment to wellness is not in what you say you care about, but what you are willing to give up to get there. Do you care about people's mental health? You may need to get rid of the keystone provider for your service line, this will cause temporary harm to the organization, as well as a lot of work for you. It will be worth it. Do not judge yourself on your effort, judge yourself on your outcome. As a peer, you can do your part by having those peer level interventions in the right way. Do it in private, outside of the shift, and with true compassion for the human on the other side. ## Redesign Rewards towards community and cooperation: What are the policies and practices and how do they support or inhibit the building of community in your teams and units? _Transactional leadership_ is the style that believes that incentives through rewards lead to improvement. The data indicates that this form of leadership does the least towards psychological engagement. It can work, if the roles are very clear, and the path to reward is within the grasp of the individuals and helps them grow through the achievement. In general, our complex systems do not allow for clear linear relationships between incentives and rewards. Organizational conditions for wellness - focus on community, teamwork, collaboration: - Company or business wide policies and practices - Do they work in an integrated manor to support wellness? - Hiring (what are people assessed for and celebrated upon hiring?) - Promotions (who gets promoted, me first or team players?) How does this live up to what the organization says they value? - Rewards and recognition: This is about how you [[create the conditions]] - Asking if our rewards are getting us the outcomes we expected: - [[Show me the incentive and I will show you the outcome]] is often quoted, however, in complex systems we believe that there are linear cause and effect relationships, and that the incentives will drive _only_ the outcome desired. - The problem is that [[you can't only do one thing]], so if you create an incentive which is designed to get emergency physicians to bill at the proper rate and work as quickly as possible with 100% RVU driven compensation, you may get that behavior, but you get many other outcomes as well, including - undesirable outcomes of perceptions of competition for high value patients, instead of perceptions of working together to solve the problem of serving the community. - Divisions reduce the sense of community - Arguing about patients takes energy away from what the patients need - Perceptions of fairness (higher RVU shifts, times, APP's, etc. - A different approach would be to create a 100% RVU-based and 100% shared-RVU system, so all members are incentivized for the system to be as efficient as possible. What about free-loading? If a small percent are free-loading, you have to solve that with management interventions, not by throwing out the system. - [[balancing statistics]]: can I see the whole picture? How can I create an incentive set that balances the values we seek to endorse. Speed vs relationships, etc. - In our RVU example, how about adding to shared RVU other balancing statistics: patient satisfaction, colleague satisfaction, etc. - Incentives should be things that the recipient controls. If the recipient does not perceive that they control the outcome of the incentive, then they just develop resentment at the "fairness" of the situation. - [[remove to gain]] - what do we need to get rid of from an incentive standpoint that was put there for a reason but is not getting the outcome we desire. - [[How To Create The Conditions To Optimize Your Success.pdf]]? - [[How Will You Measure Your Life]]? - Do we know what jobs we were actually hired for? - How do we measure how well we do the job? - How are we helping people achieve the outcomes of the incentives? What coaching do they need? Who or what demonstrates [[positive deviance]], and how can we spread that in our group through [[peer support]]? - Can we use [[Appreciative Inquiry]] to look for the parts of your department and the people who are more successful and learn from them? This helps balance the negative view of improvement work. - Use a [[cognitive task analysis]] approach to learn how do they think, how did they come to think that way, and how does the application of what they think lead to the outcomes they get? - [[amateurs talk strategy experts talk logistics]] - figure out the logistics of what would it take for everyone to work the way this one person worked... - If your team is burned out and underperforming, an interesting question to ask is, why aren't they being more creative? - It's likely they are starved for resources, so instead of trying to solve problems, they are fighting your own organization for resources. That might be time, space, money, prestige, etc. ![[Resources and team effectiveness 1.jpg]] Leadership (Management Team consistency of behaviors and messaging: - “We suggest that these efforts be broadened to make TMTs aware of the consequences of these internal dynamics for employee work outcomes and the organization as a whole.” ([Raes et al., 2013, p. 185](zotero://select/library/items/L2N2UCWM)) ([pdf](zotero://open-pdf/library/items/MAH7UMX6?page=19&annotation=C9A6UKCR)) - “TMT behavioural integration impacts the employee outcomes of job satisfaction and turnover intentions both directly as well as through its impact on productive energy.” (Raes et al., 2013, p. 181) Take an afternoon with your leadership team and ask, "What have we done that has unintentionally created the conditions for the outcome we are getting, and what would we pay to fix this?"" What advantage could we obtain from just changing our incentives and signals so the underperforming team can get into a place of creativity, community, and performance. ## Positive messaging: ### Celebrate everybody’s contribution upon their departure. That person who created lots of trouble, also helped a lot of patients, had a team, and was a part of the organization. Thank them for their service to the community and the care they provided. If anyone disappears without notice, everyone wonders what happened, and worries about their own security. Of course, laws require certain elements are kept confidential. It's good practice to have a model, "When anyone departs this organization we thank them for their contribution and let them discuss as much as they want why they are leaving and what their next steps are." ### Balance of messaging: Estimates range and this hasn't been proven in healthcare, but a good concept is that we have a negative tilt in how we view the messages from admin: - Need to balance that with a 3-10:1 ratio of positive to negative messages - Do you report more positive then negative patient comments, or do you call people in for the few negatives they get? - How does your case review process select cases? Do you only review misses or do you take a safety II approach? - [[Appreciative Inquiry]] is an approach to improvement where we focus on what works as a way of making change. [[appreciation balances our negative tilt]] so this is a good place to start. [[Leading]] during these moments can be a real implementation of [[The Dichotomy of Leadership]], where one has to acknowledge the challenges but focus on the positives.[[you amplify what you focus on]], so appreciative inquiry seeks to focus on what works, because mostly things kinda work! - So, what are our routines in our work as managers and how do they lead to us seeing the world and the performance characteristics as a set of negative outliers? - What is the data we get from our organization about performance? Is it just "negatives" that we feel the need to play whack-a-mole with? Or do we get the right balance? Can we retune the data inputs so we can see our world differently? ## Daily Readiness ### [[Circle Up]]: A daily process for units to be aware, connected, and ready at the start of the day, and let go at the end of the day - [[boundary rituals]] - what is the process, how does this differ from usual case briefs and debriefs? - Brief Purpose: - typically only situational awareness sharing, - Circle up includes planning for and mentally rehearsing any new processes or risks: "we are short x today so if ... then we will do y, let's try that out and see how it feels" - Also planning our support plan: Dr. Jones is in triage, and she's pumping, how are we going to cover her today when she needs to step out? - Finally: How else will we support each other today? Plan for community - [[peer support]]: what this looks like is noticing when someone has had a difficult moment, and offering to support them: "It looks like you just had a tough conversation, can I cover you for a few minutes? How else can I support you right now? Want to debrief?" Not "Damn, you look bad" - Want a valuable training? Train people in peer support, it can be a quick demo at the stand-up huddle. Role play for 3 minutes. ## Control and Autonomy: - Balancing the framework and the freedom, create a framework of behavior and allow freedom within that framework for unusual circumstances. The question isn't "How do we get everyone to act a certain way for consistency?" in a complex world of professionals, it is "What is the right amount of variability for the situation people are in?" - If changes to a system are required, use [[Kotter's 8-Steps]]! The cost of creating change for managers should be _very high_ because the cost of that change on the people doing the work is equally _very high_. It is critical that people feel represented in any change process by way of the volunteer army. - You must avoid the goal of 100% at all times. Trying to get to 100% is rarely a good thing. - A switch here for your organization is to move from the Joint Commission to DNV for accreditation. DNV focuses on movement in the right direction, as opposed to 100% compliance, which can change the narrative around difficult conflicts. I have no affiliation with either body. - Commitment is not what you care about it is what you are willing to give up. Are you willing to give up 100% compliance to treat an RN with respect? To focus on their wellness, to live the Just Culture you stay you have? ## Mandatory Trainings: When you are given a job to check a box, and you want to get it off your plate as quickly and painlessly as possible, make sure the people who are responsible for you having checked your box can do it with as little annoyance as possible. Avoid the temptation to try to get people to learn something, it is impossible for a mandatory module in isolation to change behavior. Whenever possible, integrate this box clicking with another box clicking. - Do you need people to validate that they know the state rules around sexual harassment? - Good: send an email with a one step process, "By clicking this box I acknowledge that I know and am responsible for upholding the state rules around sexual harassment." Link to the state rules. Let them click the box and be done. - Even better, have this integrated into the biannual re-credentialing process - Do NOT hire an outside firm to make them watch a different log-on process, a 1 hour video, and mandatory multiple choice answers, this will not be any better and will make people angry. If you do decide there is an initiative worth investing in, you need to do the whole [[Kotter's 8-Steps]], as well as a PDSA study on what is actually happening as a result of your intervention. - Do you have a high-value communication strategy you think everyone in the organization needs to start doing? GREAT! - Is there any way a 15 minute video will get you there? NO - Harness the power of your organizational development team, your education team, your routine and daily communication huddles, etc. It will take YEARS of continuous communication, about how this connects to the organizations values, real stories from from-line people about how they are using this knew tool. Stories from patients about what it meant to them. If you don't do all this work, you are rendering yourself out of touch with the reality of the organization, and you are increasing burnout. - You will need to pilot your education for a year minimum, you will need people willing to give you real feedback, use the Net Promoter Score for feedback on everything you send out. %% Individual approaches: - [[Coaching]] - [[cognitive reframing]] - [[failure friend]] - [[Forest Bathing]] and other restorative off work actions - [[Mindset]] - learning or performance - [[Design my life to live]] the way I want it to exist - [[remove to gain]] - what do I need to let go of? - [[mastery]] - how do I know I am good at what I do? - [[autonomy]] - every day is a choice - [[Developing Values]] and connecting those values to [[Purpose]] with active [[cognitive frames]] - %% tags: #note/idea | #on/engagement | #on/leadership | #on/wellness | #on/appreciation ##### Sources: https://emcrit.org/emcrit/burnout-model Battilana, J., & Casciaro, T. 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