Psychological safety

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?’”

Bringing joy and meaning to work may sound like a lofty aspiration. But if your workplace is lacking these things, it's more than dreary—it’s also dangerous, according to the Lucian Leape Institute at the National Patient Safety Foundation.

Start with the fact that health care itself is dangerous. The institute’s March 2013 report on workplace injuries in health care, “Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care,” noted that:

• Health care workforce injuries are 30 times higher than other industries
• More work days are lost due to occupational illness and injury in health care than in such industries as mining, machinery, manufacturing and construction
• Seventy-six percent of nurses in a national survey said unsafe working conditions interfere with the delivery of care
• An RN or MD has a five to six times higher risk of being assaulted than a city cab driver
• Emotional abuse, bullying, threats and learning by humiliation often are accepted as “normal” conditions of the health care workplace

These conditions are harmful to patients, caregivers and the organization, according to the report:

“Workplace safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”

Role of leaders

The authors conclude, “The basic precondition of a safe workplace is the protection of the physical and psychological safety of the workforce.”

Physical and psychological safety is also a precondition to “reconnecting health care workers to the meaning and joy that drew them to health care originally,” said Lucian Leape Institute President Diane Pinakiewicz, at Kaiser Permanente’s second annual Workplace Safety Summit February 12.

“These preconditions enable employers to pursue excellence and continuous learning,” she said. “The purposeful maintenance of these preconditions is the primary role of leadership and governance.”

Systemic causes of harm

While pointed in their assessments, Pinakiewicz and the report’s authors refrain from finger-pointing. Pinakiewicz outlined systemic organizational stresses that work against workforce and patient safety. These include:

• People feeling overwhelmed (58 percent of workers surveyed by the American Society of Professionals in Patient Safety cited overwork as an issue)
• The volume of non-value adding work
• Workforce safety and patient safety being managed separately and non-systemically
• Operating pressures exacerbating traditional behavioral norms

The report identifies several “exemplar organizations,” including the Mayo Clinic, Virginia Mason Medical Center, Kaiser Permanente and the Coalition of Kaiser Permanente Unions, that are working to “create cultures of safety and respect.” KP’s 2012 National Agreement provisions for workforce total health and interest-based problem solving are cited as contributors to that culture.

Seven strategies for improvement

The Lucian Leape Institute offers seven strategies for improving safety and restoring joy and meaning to the health care workplace:

1. Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.
2. Adopt the explicit aim to eliminate harm to the workforce and to patients.
3. Commit to creating a high-reliability organization and demonstrate the discipline to achieve highly reliable performance.
4. Create a learning and improvement system.
5. Establish data capture, database and performance metrics for accountability and improvement.
6. Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.
7. Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and our patients.

“Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care” is available online from the Lucian Leape Institute at the National Patient Safety Foundation.

The theme of the 2012 Union Delegates Conference was “You Gotta Move”—and Amy Edmondson’s advice for the delegates was “you gotta learn.”

The Harvard Business School professor studies what she calls “learning environments.” To support innovation and teamwork, it’s essential the Labor Management Partnership and unit-based teams foster learning environments throughout Kaiser Permanente.

Imagine the ideal learning environment: People feel free to take risks. They feel psychologically safe. They believe they won’t be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. “Without that kind of psychological safety, it’s very hard for an organization to learn,” says Edmondson.

Now imagine the opposite of a learning environment, one where no one speaks up. “Nobody ever got fired for being silent,” says Edmondson. “And yet many bad things happen as a result of silence. Silence is a strategy for individuals to stay safe, but not necessarily for patients to stay safe or for organizations to stay vibrant.”

Creating a learning environment is up to leaders—to those people with influence, whether or not they have a formal leadership role.

“Leaders have to go first,” Edmondson says. They “have to be willing to ask questions themselves, invite participation, acknowledge their own fallibility, and to explicitly state we don’t know everything yet.” These behaviors help an environment where others can take the risks of learning.

But, she cautions, “The learning environment doesn’t live at the ‘organization’ level. For the most part, there are pockets of learning environments.…In a large, complex system, answers don’t come from central headquarters or the CEO. The answers come from the people at the front line doing the work.”

A labor management partnership like the one at Kaiser Permanente “is an important foundation” for building a learning environment, says Edmondson. “A true partnership is completely consistent with the context for mutual learning.”

Both management and union UBT co-leads can help create a learning environment by articulating the unit’s or department’s purpose and goals “in a meaningful way that touches hearts and minds, that motivates and encourages,” she says.

They can—and must—also reduce the fear people experience that makes them reluctant to speak up. The LMP helps develop and support people, helping them be their best and most courageous, Edmondson says.