Best Place to Work

Struggling with stress? Got the burnout blues? We’ve all been there. A long line of patients snaking out the pharmacy door; appointments running a half-hour late.

Yet not all things that trigger stress are bad—getting excited before running a race is stressful; so is falling in love.

“A little bit of stress is good,” says Dawn Clark, MD, an ob-gyn specialist and chief facilitator of physician wellness for the Southern California Permanente Medical Group. “It helps you avoid boredom and keeps you engaged and energetic. But too much stress burns you out.”

Unfortunately, the chronic stress that leads to burnout is commonplace in health care. A 2013 survey found nearly 60 percent of health care providers are burned out. A 2015 nationwide poll showed burnout affects nearly half of all physicians.

The result? A burned-out workforce is one with low morale and high rates of absenteeism, turnover and workplace injuries. Inevitably, service and quality of care slip.

This issue of Hank takes a look at the causes of health care stress and burnout—and at the solutions. Read on to find out more about how:

• Individuals can take steps to handle stress better.
• Leaders can be role models and make solving workplace stress a priority.
• Unit-based teams can address the root causes of burnout, finding remedies for lasting change.

Burnout: A widespread problem

Stress is the brain’s response to the demands put on us. Your pulse quickens, your muscles tense and you breathe faster. Everyday stresses are like small flames keeping you on alert. Burnout—which sets in when stress and frustration pile up without getting fixed—is your own personal forest fire.

Your body wears down as the constant flow of stress hormones suppresses your immune system and other functions. You don’t sleep well, and you become edgy, irritable and cynical. You don’t make good decisions. In short, you shut down. Making matters worse, your black cloud is contagious and can quickly spread to your co-workers.

Experts say burnout is usually caused by:

• inefficient work procedures—and no power to change them
• no sense of meaning and purpose to your workday
• lack of work-life balance

In health care, the problem is even more complex. Frontline employees are expected to be selfless and put others’ needs first. But patients may be unhappy or demand answers when there are no easy answers to give. That’s stressful, and even more so when busy schedules are factored in.

UBTs to the rescue

Poorly designed jobs and systems are a leading cause of burnout, which means UBTs have amazing power to improve matters.

Say, for example, overlapping processes make a member-patient feel like she’s getting tossed from department to department. Her justifiable frustration may get unleashed on employees. A UBT provides a forum where an employee can speak up and say: “This process needs to change. What can we do to make the system smoother for the patient?”

That’s what Michael Leiter, an expert on workplace stress, says has to happen to reduce burnout. To fix it, you need to “change something that really matters about how you participate in your job.”

Sometimes the solutions are relatively simple. For members of the Esoteric UBT in the Sherman Way Central Lab in Southern California, working in cold, noisy room that made it hard to concentrate was causing stress—but they worked together and were able to move a key piece of equipment to a more comfortable room.

“Now at the end of the day, it doesn’t feel like I’ve just finished climbing a mountain,” says Gene Usher, one of the team’s research scientists. “It was a UBT success.”

Working together on performance improvement can cure what ails a team, as the Revenue Cycle team at Roseville Medical Center near Sacramento discovered. It also learned—as many teams do—that before it could fix its processes, it had to clear up underlying tensions first.

The team had low People Pulse scores; old conflicts between co-workers had never been resolved. So the team chose to improve its response to the survey question about “having a say in influencing decisions.”

“We decided to do tests of change that involved the staff more,” says management co-lead and former UBT consultant Kimberly Jones.

Team members started working together on improving the annual vacation process—a big morale boost. The 37-member team also took customer service trainings and a Kaiser Permanente Courageous Conversations class, which teaches different ways of approaching conflict and taking responsibility for your actions.

The class “made it easier to approach someone if there was a work problem,” says Stacey Kearny, an admitting representative and SEIU-UHW shop steward. “Now we act more like a team. When we come onto our shift, we ask the person leaving, ‘Is there something I can help you get finished?’”

Fairy Mills, a pharmacy technician and member of UFCW Local 555, has worked for Kaiser Permanente for 29 years. Not long ago, however, there were days she left the Mt. Scott Pharmacy ready to cry, exhausted. Wait times were up and service scores had plummeted. She thought about retiring but decided to tough it out—and was voted in as the union co-lead for the department’s unit-based team.

About the same time, Linh Chau arrived as the new supervisor. He wasn’t sure what he’d stepped into. “It was the perfect storm,” he says. “The team was stressed out, members were unhappy, membership was up, and in the midst of it all, we were implementing a new software system.”

Pharmacies in the Northwest region were in a tough spot a year or so ago—and that was especially true for the Mt. Scott Pharmacy. Part of the Sunnyside campus, it’s the second busiest pharmacy in the region, seeing an average of 500 patients a day and filling nearly 1,000 prescriptions.

Although other regions had already made the transition to ePIMS, a software system that syncs up with KP HealthConnect®, the migration process hadn’t been easy.

“We had to reenergize the team,” Chau says.

Chau and Mills’ first strategy was to give staff members confidence that things would improve. The two co-leads began rounding, checking in with UBT members regularly and making sure everyone had a chance to offer suggestions for improvement— giving them the power to shape how things are done, one of the key elements for beating back burnout.

Eager for strategies to tackle workplace stress, a group of nurses in Southern California—including Denise Duncan, RN, president of UNAC/UHCP—sought out a workshop on the issue.

Workplace stress undermines employee health and safety, they knew, and erodes patient care and service.

But what they learned at the conference, which was offered by an outside organization, rang hollow.

“They told us the work isn’t going to go away: Have a hot bath, light candles and take a deep breath,” says Duncan. “You can work a 12- or 14-hour day. Go home and relax. The same workload is going to be there again the next day.”

A majority of workers in the United States—especially those in health care—tell researchers their main source of stress is at work, not home. Long hours, job insecurity, poorly designed workflows and fear of violence or injury top nearly every list of common causes.

Focusing on the individual’s behavior may help a person cope with such issues, Duncan says, but does nothing to address the root of a problem that some studies suggest affects three in four U.S. workers. Part of what’s needed, she says, is more accountability from both management and the unions to fulfill the National Agreement’s commitment to fixing backfill shortages. The safe-staffing campaign UNAC/UHCP ran last year was part of that call to action.

Duncan and her fellow leaders in the Coalition of Kaiser Permanente Unions want to step up the conversation on workplace stress and make sure it:

• includes worker voices on scope of practice and other issues
• addresses unhealthy work environments
• develops resources in partnership

 “We have talked about work-life balance. I am not sure there is one yet,” Duncan says. “We are at a tipping point.”

Opportunity for action

“Issues related to workplace stress are often collectively caused,” says Ron Ruggiero, the president of SEIU Local 105 in Colorado. “They need a collective solution.”

Kaiser Permanente is not immune. In a survey done before 2015 National Bargaining, 94 percent of workers represented by a coalition union placed a high priority on reducing stress in the workplace. Scores on the “KP supports me in having a healthy and balanced life” question on the annual People Pulse survey have stayed flat, with mid-range favorable ratings, from 2007 through 2015. 

But partnership and unit-based teams offer an opportunity for action, says Ruggiero, whose union represents 3,000 KP employees.

“At each and every worksite,” he says, “workers should be listened to and solutions could be figured out—and implemented.”

Part of a manager’s job is to look at the big picture—and job stress and burnout are usually part of the picture in health care. Operational leaders from two regions share their thoughts on keeping workplace energy and morale high.

Wendy Watson (Northwest)
Regional vice president, Professional, Clinical and Continuing Care Services 

There’s very little downtime in our work. We want to deliver great service, quality, affordability. The pace is fast, as our industry is changing rapidly. That can be a formula for stress. No one can do this work alone—we all need to support one another.

Build strong teams

High-performing unit-based teams are part of the solution. Solving even one problem at a time can help a team increase job satisfaction and get results, and that reduces stress. If you are leading teams you have to be very purposeful—making time with your team, creating space to talk and making our meeting time productive and solution-focused.

Some of our facilities have Living Room huddles, where people from all departments gather before the start of business, and one department presents a topic. It’s an opportunity to learn and build relationships across the facility. The more connected we are, the more we can support each other.

Make time for yourself

Running is my No. 1 antidote to stress. I try to run regularly—early in the morning before the workday, and longer on weekends. It’s my way to expend physical energy and feel mentally reenergized.

You have to make time for yourself, and that includes exercise. It’s not easy to do. But when you make exercise a priority, you create energy to be able to deal more effectively with stress.

Corwin Harper (Northern California)
Senior vice president, Area Manager, Napa-Solano

It’s hard to generalize about stress because everybody has a different stress meter. We all handle things differently. It’s an issue of work-life balance, and we’re in an industry where we all invest our personal energy, because health care is about caring for others.

People have to be aware of that and think about what they can do to manage their energy and stress levels. We should proactively manage things at work that sap energy and invest in things that raise our energy.

How do you help others?

As a leader, I have to be aware of what I can do to minimize energy-wasters and reduce job stress.

We talk about stress in our workplace safety conversations. I address it as part of leadership rounding. And rounding is not just checking the box. It’s focused on engaging with people about how they’re doing, letting them know you care, encouraging them to spend time with their families and calling out work-related issues that are barriers to performance.

We focus on creating a culture where we understand and respect one another.

Know yourself

I hate sitting all day long. I do core exercises at work in my spare moments. You have to know when to step away and recharge. I try to eat right, exercise, listen to music and pray. I’m still working on getting enough sleep.

Rounding for results

Rounding is a powerful tool for creating a culture where employees are free to speak. Having a short list of open-ended questions to ask each person on a regular basis makes it easier for staff members to raise concerns—and that, in turn, helps reduce stress levels.

Katie Richardson, MD, is a master juggler: She’s a pediatrician at Highlands Ranch Medical Office in Colorado two days a week and the director of Physician Experience for the Colorado Permanente Group (CPMG) the rest of the week; she’s a sponsor of the CPMG Physician Wellness Committee; and at home, she’s the mom of an 11-year-old daughter. Dr. Richardson recently talked about the pressures of practicing medicine and what the Colorado region is doing to help its doctors sidestep stress and burnout.

Q: Why do so many doctors suffer from stress and burnout?

A: As physicians, in general we are not as good at taking care of ourselves as we are at taking care of others. We don’t tend to ask for help—and we need to change that culture. There are a lot of clinicians out there who are suffering and they don’t recognize the signs of burnout or know what to do.

Q: What happens when physicians are burned out?  

A: We are the leaders of the health care team. We’re trained to solve diagnostic dilemmas and do what is best for our patients. If we’re burned out, we may not think through our decisions as well. Healthy, happy physicians take better care of their patients. We want to make sure that we take care of our physicians.

Q: How do you help doctors deal with stress?

A: We know this is a high-pressure environment and look for resiliency in our physician hiring process, which helps us identify candidates who have experience managing stress. In addition, our yearly physician survey includes questions around burnout and resilience. We use that information to identify strategies to improve the physician experience.

We are trying to foster conversations around stress and burnout. We’re encouraging physician chiefs to meet with their physicians regularly and ask, “How are you doing?” Educating providers to look for signs that they might be experiencing stress, as well as providing education about available resources, will help. The first step is letting people know we are aware there is an issue.

The chances are good you are a person who deals—directly or indirectly—with life and death every day. You might be an EVS worker who keeps patient rooms germ-free to reduce the odds of infection, or an ER nurse helping a baby with a high fever. If you are not on the clinical front lines, you likely support this honorable work from behind the scenes.

We put others first. We give everything to give the best care to our patients. But far too frequently, we don’t leave anything in reserve. We neglect to take care of ourselves. This imbalance undermines the admirable ethic of our modern health care system.

One survey showed 60 percent of health care providers are burned out. In this issue of Hank, we provide practical tips and tools that individuals, leaders and teams can use to reduce workplace stress.

But more than that, we challenge the notion that the responsibility for preventing burnout lies solely with one of these groups. Let’s call it the “yes, and” approach. Yes, individuals need to eat better, exercise more and cultivate a positive outlook to reduce their own stress. And, leaders need to ensure safe staffing levels and create a solution-oriented workplace culture.

Our Labor Management Partnership gives us a third “yes, and”: Yes, individuals and leaders matter. And, our unit-based teams can fix inefficient processes that cause unnecessary stress and interpersonal conflict.

Every day, Kaiser Permanente’s 3,500 UBTs use performance improvement tools that make our work go more smoothly. Moreover, those tools and the foundation of trust and openness fostered by partnership give everyone a voice in making improvements.

And that also reduces our stress.

The Mid-Atlantic States region has approximately 220 unit-based teams with more than 5,200 members. 

One problem, though: Some of those who belong to UBTs don’t know it.

The region’s seven UBT consultants, who made a commitment to work together as a UBT themselves, are trying to change that.

“Employees can’t contribute to the success of the team if they don’t know they are part of the team,” says Tracy Schrader, one of KP’s UBT consultants in the region, who is also an improvement advisor and OPEIU Local 2 member. “They don’t realize they can speak up.” 

From their travels around the Capital Beltway to team meetings and huddles, the consultants—each of whom supports about 35 teams—knew there was a disconnect for some UBT members. So when they established their own team’s 2015 goals, they planned two main tactics: to host several UBT Fairs to raise the profile of UBTs, and to improve communications so all UBT members know they are on a team.

The fairs, which the consultants originally were planning to hold at the region’s largest centers over the summer, would showcase the work of the teams at that facility and highlight such LMP initiatives and priorities as Total Health, Workplace Safety and the Ben Hudnall Memorial Trust, which provides a variety of resources for career-advancing education.

“We wanted to hold fairs that would have a strong impact,” says Jennifer Walker, RN, a lead UBT consultant and improvement advisor.

Surprising news

Then—just as happens with frontline teams—they received some data that surprised them. The 2014 People Pulse results showed that some locations the consultants thought would score poorly on UBT-related questions scored well and vice versa. Armed with that data, the consultants decided to hold the first five fairs at the centers that had the most teams with more than 10 percent of members answering “no” when asked “are you in a UBT?”

“It was a real eye-opener,” says Preena Gujral, another MAS UBT consultant and improvement advisor who’s a member of OPEIU Local 2. “Data is very important. It’s perception versus reality.”

The data also led the consultants to combine their two tactics:  The fairs would be the method for communicating the message that all work group members are indeed part of a UBT.

Walker, one of the region’s lead consultants, says it can be difficult to get the message across, especially with large departments. Unlike small departments where everyone participates in UBT meetings, larger departments typically have a core group of employees who attend UBT meetings as representatives of everyone on staff. Employees who aren’t representatives don’t always realize that they are part of the team, too.  

The energy and attendance of the first UBT Fair that the consultants sponsored, held at the end of June at the Fair Oaks Medical Center in Fairfax, Virginia, was higher than they expected, with more than 150 employees stopping by.

“The participation was fantastic,” says Wendy Williams, RN, a UBT consultant and member of UFCW Local 27.

Irene Taliaferro, a gastroenterology nurse practitioner, attended the fair at Fair Oaks in late August. She hadn’t realized she was a UBT member.

“I came to find out more about UBTs. Before I came to the fair, I knew nothing about them,” says Taliaferro. “We have a representative who goes to meetings. I don’t know much about it.”

Providing incentive—and a model

Steve Pereira, UBT consultant and improvement advisor, hopes the blitz of UBT Fairs gives workers like Taliaferro a better understanding of the partnership and an incentive to be more involved.

“People want to know more than their 9-to-5 jobs,” Pereira says. “This is the opportunity for that.”

Because of their commitment to use the same tools as frontline UBTs, the consultants have been using the Plan, Do, Study, Act cycle of the Rapid Improvement Model in planning and holding the fairs.

So, Walker says, “We structured it so the fairs happen before the annual People Pulse is taken again, in September”—that way, the fairs serve as a test of change. Will the communication provided by the fairs improve the score on the “I’m in a UBT” question?

“We’ll look for the next People Pulse results to validate whether this was the best way to go,” she says.

Watch for an update on the consultants’ efforts next year on LMPartnership.org, after the 2015 People Pulse results are in.