Strategies for Health Organizations

Aligning values requires organizations to:

• Center the organizational mission around patients, communities, and workers and learners, and
• Intentionally engage workers and learners to establish a shared mission.

‍Evidence

Organizations’ espoused values often are not aligned with the behaviors they demonstrate, such as excessive, low-value clerical work, short office visits, and tactics that limit access to care based on ability to pay.¹ Perceived discrepancies between health workers’ values and that of their organizations are predictive of lower job satisfaction and higher burnout and absenteeism.² Values discrepancy is also central to the experience of moral injury when workers experience situations in which their professional ethics are compromised because they cannot act in the patient’s best interest.³

Resources

The National Academy of Medicine National Plan for Health Workforce Well-being provides 8 strategies for institutionalizing the well-being of workers and learners in organizational strategic plans and core values, which include: 

• Explicitly communicating that worker well-being is essential for high-quality patient care
• Committing to infrastructure, resources, accountability, and culture that supports well-being
• Providing coverage and compensation for workers to engage in decision-making forums

The Institute for Health Care Improvement (IHI) provides a number of resources to help leaders and organizations intentionally establish shared mission and trust:

•  “What Matters to You?” Conversation Guide for Improving Joy in Work helps leaders understand what’s meaningful to staff and the factors that contribute to burnout.
• The IHI Organizational Trustworthiness in Health Care presents a framework and strategies to rebuild and strengthen trust with communities and clinicians of a health care system, addressing: 1) Acknowledging past breaches of trust; 2) Redressing & Closing Trust Gaps in the present; and 3) Building systems to strengthen Trust for the future. It also spotlights examples of organizations working with communities to implement identified strategies. 
• Quality Improvement at the Speed of Trust (In partnership with the American Board of Internal Medicine (ABIM) Foundation) identifies key organizational-level drivers and change ideas that repair, build, and strengthen trust between health care organizations and clinicians, and between health care organizations and the communities they serve. This report describes a three-step approach with specific change ideas and associated measures for improvement.

Spotlights
‍
‍University of Virginia Darden School’s Giving Voice to Values curriculum equips leaders, workers, and learners to have conversations about values and handle ethical conflicts in the workplace. It has been piloted in over 1,000 schools and includes practical exercises, cases, modules, and teaching plans for handling a range of ethical conflicts. 

ChristianaCare works to create a culture of wellbeing for its employees by acknowledging the multiple factors that contribute to “worklife wellbeing”, working to create a shared sense of safety, equity, connection, purpose, and autonomy, and providing a broad range of wellbeing services. Further, the organization lives out worker well-being as a value by partnering with professional organizations to advocate for well-being needs beyond the control of individual organizations.  ‍

References

¹ Shanafelt TD, Schein E, Minor LB, et al. Healing the Professional Culture of Medicine. Mayo Clin Proc. 2019 Aug;94(8):1556-1566. 

² Pavlova A, Paine SJ, Sinclair S, O'Callaghan A, Consedine NS. Working in value-discrepant environments inhibits clinicians' ability to provide compassion and reduces well-being: A cross-sectional study. J Intern Med. 2023 Jun;293(6):704-723.

³ Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447.

While the risk of moral distress and moral injury is inevitable, suffering from it is not. Organizations can intentionally invest in strategies to mitigate moral distress and moral injury.

Evidence

Evidence suggests physician discussion groups aimed at improving reflection, empowerment, and engagement at work resulted in lower burnout and depressive symptoms, and improved job satisfaction.^1,2 A study of the Mindful Ethical Practice and Resilience Academy (MEPRA) curriculum with nurses in 2 hospitals, aimed at improving confidence and competence to confront ethical challenges, found benefits for work engagement, resilience, burnout, depression, and anger.^3,4

One study of nurses during the COVID-19 pandemic found that effective pathways for requesting ethics consults or advice, in addition to other organizational effectiveness areas, was associated with lower moral injury.⁵ 

Resources

The Commonwealth Fund’s Responding to Burnout and Moral Injury Among Clinicians describes the problem of moral injury and developing programs to address the problem, including Mayo Clinic’s COMPASS, OSU’s Brief Emotional Support Teams, Johns Hopkins Mindful Ethical Practice and Resilience Academy (MEPRA), and others.

Moral Injury of Healthcare are the leaders in moral injury and how this relates to healthcare, having written the sentinel STATNews article Physicians aren’t ‘burning out.’ They’re suffering from moral injury in 2018. Their website, book, and podcast contain content related to moral injury education and mitigation.

The National Association of Community Health Center’s Conversations about Moral Distress and Moral Injury aims to open conversations about moral distress and moral injury among members of primary care teams. It contains suggestions about how to start talking about moral distress and moral injury, examples of clinical situations that may cause them, and recommendations from experts about what to do if and when a team experiences them.

The Rushton Moral Resilience Scale is available at no cost to assess healthcare professionals’ self-reported level of moral resilience (response to moral adversity, personal integrity, moral efficacy, and relational integrity).

Spotlights
‍
‍The Mayo Clinic established COlleagues Meeting to Promote And Sustain Satisfaction (COMPASS), as part of a multipronged organizational approach, to build on a sense of shared community as a virtue of being a physician. The evidence-based program aims to encourage collegiality, shared experience, connectedness, mutual support, and meaning in work through small group reflection and dialogue.     

Rushton, et al.’s Mindful Ethical Practice and Resilience Academy (MEPRA) aims to support ethical competence and moral resilience in concert with mindfulness training and practice. The MEPRA curriculum features facilitated discussion, role play, guided mindfulness, reflective practices, case studies, and high-fidelity simulations. One study with 245 nurses demonstrated positive worker impact in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger. 

References

¹ West CP, Dyrbye LN, Satele DV, Shanafelt TD. Colleagues Meeting to Promote and Sustain Satisfaction (COMPASS) Groups for Physician Well-Being: A Randomized Clinical Trial. Mayo Clin Proc. 2021 Oct;96(10):2606-2614. 

 ² West C.P., Dyrbye L.N., Rabatin J.T., et. al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014; 174: pp. 527-533.

³ Rushton CH, Swoboda SM, Reller N, et al. Mindful Ethical Practice and Resilience Academy: Equipping Nurses to Address Ethical Challenges. Am J Crit Care. 2021;30(1):e1-e11. 

⁴ Rushton CH, Swoboda SM, Reimer T, Boyce D, Hanson GC. The Mindful Ethical Practice and Resilience Academy: Sustainability of Impact. Am J Crit Care. 2023;32(3):184-194. 

⁵ Rushton CH, Nelson KE, Antonsdottir I, Hanson GC, Boyce D. Perceived organizational effectiveness, moral injury, and moral resilience among nurses during the COVID-19 pandemic: Secondary analysis. Nurs Manage. 2022;53(7):12-22.

Organizations demonstrate their commitment to patients, communities, workers and learners through their investments and advocacy for policies that advance the well-being of those they serve and those who serve. This includes intentional investments and advocacy for policies that will advance patient-centered care, health equity, and worker and learner well-being.

Evidence

Patient-centered care is associated with less health worker burnout and higher morale.^1-3 A study of primary care physicians serving low-income populations showed that organizational capacity to address patients’ social needs mitigated burnout symptoms.⁴ One study of federally qualified health centers administrators found that promoting organizational mission and providing exposure and support for upstream health equity work were common strategies to enhance staff’s meaning in work and professional identity.⁵ Conversely, a majority of physicians report insufficient resources to address patients’ social determinants of health and feelings of burnout when trying to address their patients’ social determinants of health (SDOH).⁶ One study of US hematologists and oncologists found compensation plans based on RVU productivity were associated with high burnout.⁷

Resources

The Joint Commission Health Care Equity Accreditation Resource Center is designed to help organizations prepare to meet Joint Commission’s new health care equity accreditation standards to increase focus on health care equity as a patient safety and quality priority. Of note, the Joint Commission has also recognized the need to reassess their standards and the associated burden. As of January 1, 2023, 168 standards were deleted and 14 revised.

The American Hospital Association’s Patient and Family-Centered Care: A Hospital Self-Assessment Inventory is intended to help organizations think about how to operationalize patient and family-centered care. Another assessment tool, the Organizational Ethics Dashboard aims to assist health care leadership in identifying ways they can align organizational values and mission to influence daily operations and culture, as well as to monitor the success of these efforts.

The SIREN Evidence & Resource Library includes peer-reviewed publications and other types of resources such as webinars and screening tools/toolkits on medical and social care integration.

Community health needs assessments (CHNAs) have been shown to promote local partnerships and reflection on the role of hospitals in the community. Several toolkits for designing and implementing a CHNA exist to help organizations understand and respond to priority community needs, including:

• The American Hospital Association’s Community Health Assessment Toolkit
• The Prevention Institute’s THRIVE: Tool for Health & Resilience in Vulnerable Environments
• The Community Tool Box guidance on Assessing Community Needs & Resources

‍Spotlights
‍
‍The California Accountable Communities for Health (ACH) Initiative brings health care organizations, schools, parks, businesses, and community members to “transform the health of entire communities, not just individual patients.” Although, research examining the effect of ACHs on professional burnout is a noted area of need. 

The Commonwealth Fund highlights three examples of hospitals leveraging their purchasing decisions, charitable dollars, and community investment funds to promote the whole health of the communities they serve, including:
- ProMedica, which allocates millions of dollars in Michigan and Ohio to assess and address food insecurity; 
- Bon Secours in Maryland, which has taken a multi-faceted approach to ameliorate poverty and its effect in its service communities; and
- Trinity Health, which provides $80 million in grants, low- or no-interest loans, and technical assistance to community coalition partners to address issues like teen smoking and obesity.

CEO of the University of Pennsylvania Health System, Kevin B. Mahoney, came out in support of the legislative bill that would establish nurse-to-patient ratios in Pennsylvania hospitals. 

References

¹ Nelson KM, Helfrich C, Sun H, et al. Implementation of the Patient-Centered Medical Home in the Veterans Health Administration: Associations With Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and Emergency Department Use. JAMA Intern Med. 2014;174(8):1350–1358.

² Lewis SE, Nocon RS, Tang H, et al. Patient-Centered Medical Home Characteristics and Staff Morale in Safety Net Clinics. Arch Intern Med. 2012;172(1):23–31.

³ Alhalal E, Alrashidi LM, Alanazi AN. Predictors of patient-centered care provision among nurses in acute care setting. J Nurs Manag. 2020 Sep;28(6):1400-1409. 

⁴ Kung A, Cheung T, Knox M, et al. Capacity to Address Social Needs Affects Primary Care Clinician Burnout. Ann Fam Med. 2019 Nov;17(6):487-494.

⁵ Martinez-Hollingsworth A, Kim L, Richardson TG, et al. Supporting "Bleeders" and "Billers": How Safety-Net Administrators Mitigate Provider Burnout During the COVID-19 Pandemic and Beyond. J Ambul Care Manage. 2021 Jul-Sep 01;44(3):172-183. 

⁶ The Physicians Foundation 2022 Physician Survey. Published April 5, 2022. 

⁷ Lee AI, Masselink LE, De Castro LM, et al. Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support. Blood Adv. 2023;7(13):3058-3068.