Critical Components for Ensuring a Joyful, Engaged Workforce


Open School Pie

Physical & Psychological Safety

Physical safety is feeling free from physical harm at work. Health care workers have high rates of acute and chronic musculoskeletal injuries, and high exposures to blood-borne pathogens and other infections. Across the US, there are increased incidences of violence in health care settings. To be fully present at work, colleagues need to feel like their workplaces have taken adequate precautions to protect them.

Psychological safety is feeling secure and capable of acclimating to change; feeling free to focus on collective goals and problems rather than on self-protection; and knowing no one will be humiliated or punished for speaking up. This is a team characteristic rather than an attribute of individuals. It is part of 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 being 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.

Change Ideas to Test Illustrative Examples
Dedicate leader time, attention, skill development, and necessary resources to improving physical and psychological safety. Leaders should be accessible, visible, and approachable; acknowledge limits of current knowledge; show fallibility and humility; invite participation; show respect for all staff; and view failures as learning opportunities. Leaders at Hospital Quality Institute in California regularly visit point-of-care staff to talk about what's important to them with respect to safety, and to thank colleagues for being open about safety risks and problems.
Establish policies and practices used by everyone to address harm and safety outcomes. Ensure that systems, assistive equipment, policies, and practices that address workplace injuries are in use at all times. Beth Israel Deaconess Medical Center in Massachusetts and Kaiser Permanente in California regularly track and address work days lost to injury and share this data with the leadership team and staff (via newsletter and their website). The organizations keep a running tally, updated monthly, of issues that are addressed.
Address professionalism or disrespectful behavior concerns through established mechanisms to hear and address complaints. Offer one-on-one, group, and peer support for general concerns, second victims, and adverse events. Brigham and Women's Hospital in Massachusetts invests operates a Center for Professional and Peer Support. The Center serves many functions, one of which is as a confidential resource for any employee to raise concerns regarding unprofessional behavior by a staff member.


Meaning & 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? There should be a line of sight for each person from daily work to the mission and goals of the organization.

Change Ideas to Test Illustrative Examples
Provide clear messages about organizational purpose and create a line of sight through clear and frequent guidance about the organization's mission and vision.  Many organizations conduct purposeful leadership rounds to engage team members in conversations about how they find meaning and purpose in their work.
Focus on who is being served by the work and put a human face behind every statistic.  Bringing in veterans to talk about their experiences in health care helped the staff at Veterans Health Administration in Arkansas connect daily tasks back to the work. 
Elicit staff participation in vision setting and critical analysis of the organization's mission and goals.  Starbucks helps staff document key elements of the desired culture in the organization through a mission review program. Staff are encouraged to speak up if they feel the organization is not living up to the mission or values.

Choice & Autonomy

A joyful work environment supports choice and flexibility in daily lives and work. Do people feel like they have choice in how they execute their daily responsibilities? Do they have voice in the way things are done in daily work? Are they a part of decisions on processes, changes, and improvements that affect them? Do they have information to make informed contributions to choices in their work?

Change Ideas to Test Illustrative Examples
Design systems where staff members can make the best choices they see fit, wherever possible. Atlassian, an Australian software company, gives their developers one full day every quarter to do whatever they want. The only requirement is that they share their results at the end of the 24 hours. These days of autonomy have resulted in software fixes that never would have existed otherwise. 
Make sure staff have opportunities to voice what matters to them in public and anonymously.  "Breaking the Rules" is a concept in which leaders ask their staff, "If you could break or change any rule in service of better care, what would it be?" IHI Leadership Alliance members found asking this question enabled their organizations to identify areas where they might take direct action to reduce onerous administrative waste, in addition to eliminating habits and rules that appear to be harming care without commensurate benefit. 
Develop systems so everyone knows how they are performing relative to goals and what to do to improve.  Job sharing and staff-managed work assignments are well-tested ways to ensure clinicians have a choice about what they do and how they do it. At Bellin Health in Wisconsin, teams redesigned the office visit to ensure that each team member was involved and working to the top of their degree in patient interaction. 


Recognition & Rewards

Effective leaders understand daily work, regularly provide meaningful recognition of colleagues' contribution to purpose, and celebrate outcomes. Some of the most meaningful rewards are rarely monetary. Organizations that are more successful in their efforts to improve joy in work begin to move away from traditional approaches that often have limited effectiveness. For example, while important for building camaraderie, parties and social gatherings alone are not sufficient to bring joy in work. It is the recognition, camaraderie, and celebration of team accomplishments that are validating, not the party itself.

Change Ideas to Test Illustrative Examples
Regularly recognize actions that reflect the mission and celebrate accomplishments or contributions consistent with organizational purpose.  Starbucks employees carry cards to give to co-workers whenever they witness a good deed or an action that reflects the mission. 
Provide meaningful celebrations and rewards frequently, emphasizing improvements, camaraderie, and teamwork.  Based on studies that show personal and private congratulations are more likely to result in behavior change than certificates or less personal rewards, Birmingham Children's Hospital NHS Foundation Trust are testing placing several boxes around the organization with notes for staff to thank one another. These thank you's were then emailed privately. Leaders shared overarchng themes publicaly as part of their organization's "resilience assets."
Use financial incentives and promotions in a fair and transparent way, recognizing that these rarely improve performance, but are important to individuals.  Veterans Health Administration and other organizations offer workload credits to staff for participating in initiatives outside of their job description that can be redeemed for perks and use of services.



Participative Management

Joy in work entails leaders creating the space to listen, understand, and involve colleagues in providing input into decisions as an essential step in co-creation and participative management. Decision making involves clear communication and consensus building.

Change Ideas to Test Illustrative Examples
Ensure that leaders are visible and connected by doing purposeful rounds at all sites. Seton Healthcare (Texas) internal data showed that structured leader rounding by executives with managers and staff had a strong positive impact on engagement.
Create systems to cultivate capable and talented core leaders, specifically equipping them with skills in building trusting relationships, participative management, team building, and improvement methods. Executives at Barry-Wehmiller, a global technology and services supplier based in Missouri, teach listening to their leaders through a training course which includes storytelling, to help managers value listening to understand.
Use "What matters to you?" conversations (1:1, huddles, or group brainstorming) to ensure all colleagues have a voice in how to improve joy in work. Team members from the University of Virginia School of Nursing used the "What matters to you?" conversations with faculty to identify that emailing on the weekends was a source of stress and should be the first focus of the improvement team.


Camaraderie & Teamwork

Social cohesion is generated through productive teams, shared understanding, and trusting relationships. Do people feel like they have mutual support and companionship? Do they feel that they are part of a team, working together towards something meaningful? Do they have a friend or someone who cares about them at work whom they can regularly ask for advice? Do they trust the organization's leadership? Do leaders regularly practice transparent communication? Do team members regularly express appreciation for each other's work?

Change Ideas to Test Illustrative Examples
Build and support teamwork by making sure all colleagues are clear on their responsibilities and are working at the top of their skill sets. Assess responsibilities of each discipline and cross-match with licensure limits and skill sets to maximize performance. Re-design workflows that are unclear and standardize where it makes sense.
Attend to the relationships and camaraderie within the team/unit by inviting participation on all topics, encouraging team members to work together and learn from each other. Consider organizing social events for staff and families. Menlo Innovations, a software company in Michigan, builds familiarity and connections among staff by assigning teams of two. Every week, the teams switch, encouraging knowledge sharing and capacity building, and ensuring that everyone has a chance to work together before they work in projects that need larger teams.
Encourage commensaility to build rapport. Studies have shown that when encouraged to take meals together in a designated cafeteria space, firefighters exhibited enhanced work-group performance and cooperation on the job.
Train interdiscplinary staff in professionalism, communication, and other skills. Hospital Quality Institute in California builds teamwork between departments by holding mini-courses on quality and leadership with an interdisciplinary group of staff. Leaders also go on rounds with staff to understand experience at the point of care.



Daily Improvement

The organization uses improvement science to identify, test, and implement improvements to the system or processes. Teams and the wider organization undertake regular proactive learning from defects and successes. Improvement in processes is part of daily practice. 

Change Ideas to Test Illustrative Examples
Ensure all leaders have the required skills to lead improvement in daily work, are skilled in the identification and elimination of waste, and can coach teams to participate in improvement activity.

A common list of actions for daily improvement collected from several sites includes:

  • Standardize what makes sense.
  • Make sure everyone at every level of the organization knows what they are supposed to do and knows to get help if they need it.
  • Employ visual management practices so key measures are tracked and visible to all.
  • Standardize use of problem-solving tools.
  • Create protocols for escalating problems to the right level.
  • Practice intentional integration to consider the impact of improvements across the organization.
Use visual tracking of successes and failures of interventions.  Teams at East London NHS Foundation Trust use "Kanban boards," which are improvement visualization boards to communicate status, progress, and issues related to staff satisfaction.
Ask all team members to speak up with ideas, concerns, questions, and commit to improving performance and work processes daily. Many of IHI's partners use structured methods to reduce work inefficiencies. One example, "waste walks," which help employees identify and communicate wasteful work regularly.


Wellness & Resilience

The organization demonstrates that it values health and wellness of all employees. This goes beyond workplace safety to cultivating personal resilience (i.e. the ability to bounce back quickly from setbacks) and stress management; utilizing practices to amplify feelings of gratitude; understanding and appreciation for work/life balance and the whole person and their family; and providing mental health (depression and anxiety) support. Taking care of oneself is part of a larger systems approach to joy in work, not a standalone solution. 

Change Ideas to Test Illustrative Examples
Encourage wellness and resiliency in staff so each team member has the tools to better handle stress and turn to healthy coping mechanisms.

At Mayo Clinic, core and senior leaders have incorporated the following Healthy Habits into daily practice and encourage colleagues to use them:

  • Engage in physical activity
  • Practice forgiveness
  • Manage portion Sizes
  • Participate in preventative health care testing
  • Get adequate sleep
  • Increase strength and flexibility
  • Spend time with family and friends
  • Address addictive behaviors
  • Quiet your mind and focus on gratitude
Employ mindfulness techniques Iora Health Primary Care Practice offer staff the chance to participate in five-minute meditations in the mornings
Encourage team members to practice gratitude Team members at many organizations report using the Three Good Things activity by having team members reflect on three good things every day. This boosts morale and encourages team members to build gratitude into daily practice.


Real-Time Measurement

Measurement systems enable regular feedback about system performance to facilitate improvement. Daily, weekly, or monthly feedback is the norm to ensure effective data for ongoing improvement.

Change Ideas to Test Illustrative Examples
Create measurement systems that track and display real-time data and ongoing improvement The Veteran's Health Administration created a mobile app to track personal burnout and wellness, as well as to provide tips and information on how to improve levels of both.
Look for existing data in engagement surveys, safety culture surveys, turnover rates, vacancy rates, lost workday injury rates, or burnout scores regularly. Baylor Scott & White Health in Texas survey primary care physicians about their five-year plan to gauge burnout.

Foster regular and open discussions about what is (and what isn't) working via regular huddles, workgroups, and team meetings. Don't forget to share bright spots.

IHI has standing monthly coffee meetings, facilitated by leadership and open to all staff, to create space for colleagues to give feedback on changes in the organization.

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