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.

David Jones, MD, works in the Georgia region with the Southeast Permanente Medical Group. He has been with the medical group for more than 11 years, and currently works in the Panola Medical Office. He spoke with LMP senior communications consultant Julie Light.

Q. What is your partnership role?

A. My role with the Labor Management Partnership in Georgia is assistant to the medical director for unit-based teams. I serve as the physician regional co-lead for all the UBTs for the region. I’m excited about this role and how it can help engage our physicians.In this role, I work closely with all of the teams, with a particular focus around supporting the physicians and helping them understand the value of UBTs and how UBTs really can improve what we do day to day in the offices and how they can improve the care for patients. It also means removing any potential barriers that the physicians may face, or anticipate, to allow them to be more engaged with the UBT process.  Another part of my role is working with our unit-based team’s resource team. In that capacity, I bring more of a clinical perspective to UBTs.

Q. How do teams improve care?

A. A project I had personal involvement with was the pediatric team at our Panola office, which addressed ADHD (Attention Deficit Hyperactivity Disorder) medication management. Before our UBT project, we were meeting the goal of having a follow-up visit within 30 days approximately 25 percent of the time. Through our UBT work, we increased those results to reaching and sustaining a rate above 90 percent after three months.

Q. Why haven’t more physicians embraced partnership?

A. The first thing I tell physicians about the UBTs is that it is about improving the work that we’re already doing. It’s not about adding more work, it’s about looking at the work that you're doing and figuring out how to do it better.

I think one of the barriers physicians face has been just lack of understanding. It wasn’t clear to physicians the value that UBTs can bring to the team. So it’s taking the UBT process and putting that into terms that are meaningful to physicians. Time is always a barrier for most people, and particularly for physicians. That’s why it’s important to have them understand that it’s not about doing more or working harder, it’s about working better. This is a very new way of thinking about teamwork. It’s about the physician being engaged and involved and still having a leadership role, but also embracing the value and the input, perspectives, talents and skills of the whole team, and understanding how everybody can share the same goal and work together and improve the accountability across the board.

What it really takes is physicians and teams going through the process. I can talk with them all I want, and tell them how it is in theory, but once they start to go through the process and see the results, and see how morale and efficiency improves—that’s when they become believers.

If you ask Los Angeles Medical Center sponsors Ilda Luna and Sanjit Sodhi for the secret to successful sponsorship, they’ll agree it boils down to investment—of time, trust and respect—in each other, in their teams and in the collaborative work process.

Luna, a family medicine receptionist, and Sodhi, the chief financial officer for LAMC, didn’t know each other when they were asked to co-sponsor the Health Information Management, Admitting and Patient Revenue, and the local business office teams—teams that were failing to meet performance goals and were entrenched in mistrust between labor and management.

“Sanjit said, ‘Tell me what I need to do to get us up and running,’ ” recalls Luna, a member of SEIU-UHW. “I said, ‘You need to meet with your teams. If you invest time in labor, you’ll get huge dividends.”

Like most investments, success didn’t happen overnight — and it wasn’t guaranteed. But after a year and a half of perseverance, dedicating time and hard work to supporting the work of those teams, the pair has watched the departments go from being in the red in most metrics to seeing huge improvements in areas like attendance and co-pay collection.

“We’re taking on types of projects that we could never have dreamed of a year ago,” Sodhi says. “And when you work though relationship issues and put the focus back on partnership and performance improvement, it’s highly satisfying.”

What’s so special about sponsors?

A  study by Johns Hopkins University, Rutgers University and Kaiser Permanente identified five key characteristics of high-performing teams, including “consistent, aligned and visible sponsorship.” It confirmed what has been seen throughout the organization—strong sponsorship and support from higher levels of leadership are key factors in a team’s success.

The reasons are straightforward. Many frontline workers say simply having leaders’ involvement and support gives their work validation, letting them know that what they’re working on is important, that their contributions matter. In addition:

• Sponsors mentor unit-based teams and connect them with effective practices and other resources to help them do their work.
• They help break down barriers and provide guidance on setting goals that line up with local and national performance goals.
• They act as role models and advocates for working in partnership.

“There are teams that need both management and labor sponsors to model partnership behaviors, who can agree to disagree and who can have some healthy courageous conversations till they get to an outcome,” says Vicki Barkan, the UBT consultant at the Los Angeles Medical Center. “Sometimes teams and co-leads haven’t experienced that, so they need to see it. It really helps to further the team dynamics.”

Sodhi agrees.

“As sponsors,” she says, “we have the same common goals and mutual respect for each other” that team members should have. “It trickles down to the rest of the UBT.”

“Sponsorship is a way to help move UBTs forward,” says Diane Ochoa, the regional director for Medical Group Support Services in Northern California and a former San Jose Medical Center medical group administrator. “It’s just like having a mentor, somebody you can talk to, to help you with issues and celebrate with you, and be there to really acknowledge the work you’re doing.”

So, what’s the problem?

Yet sponsorship is still a developing area in the partnership structure, even though many regions find that without active union and management sponsors, UBTs’ performance improvement work stalls.

Several challenges get in the way, and chief among those is time. Sponsors repeatedly cite the difficulty of finding time in their regular work to mentor teams. Labor sponsors face the added challenge of needing to cover their duties when they’re away from their usual post, lest those duties fall to colleagues.

Even with a commitment from facility and department leadership to backfill her position when her sponsorship work takes her away from her regular job, Luna, who is the union co-lead for the medical center’s LMP Council, says there isn’t enough time for everything she needs to do.

“But you have to make time,” she says. “I put in my own time, during lunch and after I clock out.”

Luna’s partner Sodhi agrees. The time challenge has to be reckoned with—but it’s a challenge worth solving.

“I’ve definitely made it a priority,” she says. “It was tiring devoting all that time, but I knew that I needed to do that to develop my relationships. In order to achieve any results, I knew I had to invest in time.”

“Capacity” is another word that surfaces when sponsors talk about challenges. Identifying people who can be strong sponsors and ensuring they have the tools and skills for the role is not easy. Labor bears the brunt of this barrier, in part because the unionized workforce typically has a smaller pool of leaders to draw from than management has. Many potential labor sponsors lack the consulting and facilitative skills required to mentor a team. As a result, union sponsors are in short supply, and those few become overwhelmed, with too many teams to support.

“I think that with labor, with so much work to do for our regular jobs, this is too much,” Luna explains. “So a lot of my peers didn’t want to do it. (Or) the ones who want to do it couldn’t get released because of operational needs. Patient care comes first, so operational need is a huge barrier.”

Some say successful sponsorship won’t happen until sponsors are held accountable, with their success tied to performance goals and financial compensation.

But in the meantime, many medical centers and regions are wrestling with finding other solutions to these issues. As a first step, some are revamping their training to clarify roles and responsibilities, which many sponsors — both labor and management alike — say have not been clear.

“It will be helpful for people to understand what they are supposed to do and see examples of how that’s done,” Ochoa says. “This is relatively new for some labor folks especially, and the more we can give them the tools to be a good sponsor, we need to do that.”

At the Los Angeles Medical Center, the facility’s LMP Council has made a series of changes in the last year it thinks will help shore up sponsorship. These include establishing criteria for becoming a sponsor, to make sure the right people are in the role and can model partnership and leadership behaviors; aggressively recruiting union co-leads of high-performing teams to become sponsors to increase the labor sponsor pool; and reassigning UBTs so a sponsor has no more than five teams.

Ultimately, time and commitment always will be challenges, but the potential rewards — the culture change and performance improvement work that come with high-performing teams — make the investment worthwhile. If sponsorship remains a barrier, there is a risk that teams will get discouraged.

As Luna says, “To be successful, we need successful sponsors and to build credibility with our teams. And we want to be successful.”

Linda J. Bodell has a simple formula for being a good sponsor of unit-based teams: Show up. Be of service. Clear a path. Bodell, a former clinical nurse specialist, spent much of her career in critical care settings where patient cases are often unstable and complex. She learned to be watchful and attentive. Today, those lessons define her as a sponsor of four teams at the Fontana Medical Center. She meets with her teams and her labor partners each month. Her personal goal is to understand what works and what doesn’t—and to get to the “why.” Bodell’s teams praise her for guiding them through facility and regional business goals, yet trusting the teams to find solutions that deliver needed results. She talked about being a sponsor with LMP senior communications consultant Anjetta McQueen.

Bodell was clinical director of Medical-Surgical Services at the time this article was written; she is now director of Clinical Care.

Q. Please share one of your best practices.

A. Show up at every team meeting, even if it’s only just one 15-minute window. It’s once a month per team. It’s essential. There is no substitute for being present. Let your teams tell you what they are currently working on. You tell them what’s going on…because they need it to complete their projects successfully. They haven’t had a bloodstream infection in 16 months? They need to hear where they are being successful.

Q. Would you describe an instance when you removed a barrier?

A year and a half ago, an RN and PCA (personal care attendant) from one of my teams asked to get a blood pressure machine that could stay in the patients' rooms. I did that—we had a department closing. I acquired a unit that could stay in one of the isolation rooms. It’s just those little things that make a difference in their work experience every day.

Q. Are there aspects of your past experience that have enhanced your sponsorship?

A. I have served on several nonprofit boards and as a volunteer, in different areas of health care and in Oman and South America, and that’s about taking a service to people, and it’s the same thing I do here as a sponsor. It’s my job to serve them so that they have everything they need to do their job the best they can. I know they care about their patients and their colleagues. They need to know that I care about them and what they do, and that it matters.

Q. Have your teams ever solved something you thought was unsolvable?

A. I would ask them! But the 4 West Med-Surg team was having a difficult time with workflows and getting to their supplies. They work where there are long hallways, where the 34 beds are arranged in a rectangular shape around the unit. This did not look like a process that could be fixed. They did the spaghetti diagram on how many steps nurses take. And the staff, together, made decisions about how to change, where they have their supplies, and how they were arranged. They worked on their workflow. Now the service scores are phenomenal.

Q. What inspires you each day in your duties as a sponsor?

A. So when you know what the goals are and what the actual plans are, and you go out and round on the department, and you can see those in living proof. It’s just exciting to see that this process really affects practice and activity at the unit level.

Words from the front line

“She really has an open door and an open heart. Linda has been a wonderful mentor. She is patient and stays calm under pressure. She knows how to lead you without just handing you the answers. She keeps you focused on what’s important.”—Letty Figueroa, RN, assistant clinical director and management co-lead, 4 East Med-Surg UBT, Fontana Medical Center