Strategies for Health Organizations

Organizations have invested, for decades, in programs to address burnout by focusing on well-being. These approaches include:

• Developing a strategic plan to address well-being of all workers across the organization
• Establishing a formal well-being committee 
• Establishing an executive leadership position (e.g., Chief Wellness Officer) with appropriate funding and authority
• Engaging key departments, such as Human Resources, in worker well-being 

Workforce distress has proven surprisingly resistant to these solutions alone, though, which suggests they are an incomplete solution. Broadening the approach to include strategies, guided by accountable, resourced, and empowered leaders, that mitigate the risk of moral injury is necessary.  

‍Evidence

An organizational level pilot intervention to improve well-being across five health systems, including a comprehensive culture assessment, leadership and team development, and redesign of daily workflows, noted that the absence of organization-level supports (lack of sufficient leadership support, absence of budget, organizational priorities deemed more pressing, and poor understanding of the link between well-being and organizational performance) for interventions can be a barrier to implementation.¹

‍Resources

The Impact Wellbeing Guide developed by NIOSH and the Dr. Lorna Breen Heroes' Foundation provide 6 practical actions and resources for hospital leaders to accelerate their work to improve professional wellbeing. Key principles of the guide include using a systems approach and building trust. Actions include:

• Action 1: Review your hospital's operations
• Action 2: Build your professional wellbeing team
• Action 3: Break down barriers for help-seeking
• Action 4: Communicate your commitment to professional wellbeing
• Action 5: Integrate professional wellbeing into quality improvement
• Action 6: Develop your long-term professional wellbeing plan

AMA Joy in Medicine^TM Health System Recognition Program: provides a Roadmap to reduce burnout and build well-being in 6 areas, including commitment. Commitment resources (pp. 25-32) include:

• Case Studies and a How-to-Guide with Eight STEPS for establishing a CWO position
• Chief Wellness Officer Road Map with nine STEPS for leading change as a CWO
• Organizational Cost of Physician Burnout calculator
• Sample Program and Committee Charters and CWO Job Descriptions
• Links to other publications, resources, and case examples for making the case for infrastructure supports

‍Spotlight
‍
ChristianaCare: created a Center for WorkLife Wellbeing. AMA’s Steps Forward features their 5-year-roadmap; the National Academy of Medicine published additional details on team structure and overall approach; and lessons learned during Covid-19 are described in the American Journal of Medical Quality.  

‍References

¹ Pierce RG, et al. Results from the National Taskforce for Humanity in Healthcare's Integrated, Organizational Pilot Program to Improve Well-Being. Jt Comm J Qual Patient Saf. 2021 Sep;47(9):581-590.

Shared governance is an organizational model designed to engage workers in collaborative decision-making and the ongoing work of organizational assessment and improvement. Approaches include:

• Creating governance structures where workers are actively involved in decision-making processes (e.g., formal staff associations, committees, councils)                                  
• Establishing rules and procedures to address suggested improvements in patient care and worker well-being
• Tracking and sharing plans and implementation of recommended actions              

‍Evidence

Studies of shared governance models, largely focused on nurses, have found improved job satisfaction and worker engagement, reduced turnover and sick leave, improved quality of care, and lower costs.^1,2 Models of shared governance have included the American Nurses Credentialing Center (ANCC) Magnet Recognition Program® for hospitals and Labor Management Partnerships (LMPs). 

Studies of magnet hospitals have found lower rates of burnout and higher job satisfaction for nurses, and better patient outcomes.^3,4 Nurses in one magnet hospital affirm shared governance provides a pathway for nurses to have a strong voice, sense of ownership for a best practice environment, and engaged disciplines across the hospital to identify and determine solutions.⁵ Of note, a large-scale randomized control trial of the magnet model is ongoing in Europe.⁶

Case studies of four health systems with LMPs, where employers work with unions, found LMPs improved staff interactions with management, reduced turnover, and supported front-line staff and management to come together to address quality improvement, safety, cost control, and work process redesign.⁷ Another study found LMPs can improve trust in management and employee patient-care voice (perception of how much say one has over patient-care), although this effect was mitigated by LMP quality.⁸

‍Resources 

Forum for Shared Governance: hosts a clearinghouse of resources for shared governance. Resources include:

• Shared Governance White Paper provides background, common models (Councilor, Administrative, and Congressional Models), and examples
• Measurement tools: Index of Professional Nursing Governance (IPNG) and Index of Professional Governance (IPG) measure governance among nurses and all healthcare professionals
• Accreditation standards and a list of SG Hospitals
• Staff, manager, and executive education resources and a SG Articles repository

‍Labor Management Partnership: a partnership between Kaiser Permanente (KP) workers, manager and physicians, the Coalition of KP Unions, and the Alliance of Health Care Unions. Resources include: 

• LMP Learning Roadmap guides users to tools on partnership agreements, LMP methods, unit-based teams, and value compass  
• Path to Performance organizes resources to establish teams and improve work
• Library of help videos, tools, and stories on LMP Processes, Workplace Safety, Metrics, and others. Also provided in LMP Focus Areas, such as Free to Speak, which provides practical tools to make it safe for staff to speak up.
• Hank a quarterly publication with practical tools for effective LMP practices

Charter and the Aspen Institute's playbook entitled The Shared Power Advantage: How to Build a Thriving Company Where Workers Have a Seat at the Table provides an introduction to the mechanisms by which employers can create a democratic, collaborative, and fair workplace, enabling employers to to view worker organizing as an opportunity, rather than a threat.

‍Spotlights
‍
‍Hospital of the Future Project describes participative governance approaches across 7 acute hospitals in Ireland. The report describes participative governance practices across hospitals and finds participative practices were associated with lower staff turnover and sickness absence. The report also provides an integrated model of participative governance and management (p. 88).

‍Lazes (2012) How Labor-Management Partnerships Improve Patient Care, Cost Control, and Labor Relations: Case Studies of Fletcher Allen Health Care, Kaiser Permanente, and Montefiore Medical Center’s Care Management Corporation explores how healthcare unions engage with management through partnerships to control costs and improve patient experience, clinical outcomes, workplace environment, and labor relations.

‍References

¹ O’May F, & Buchan J. Shared governance: a literature review. International Journal of Nursing Studies. 1999;36(4):281–300.

² Siller J, et al. Shared Governance and Work Engagement in Emergency Nurses. J Emerg Nurs. 2016 Jul;42(4):325-30.

³ Aiken LH, et al. The Magnet Nursing Services Recognition Program: a comparison of two groups of magnet hospitals. J Nurs Adm. 2009 Jul-Aug;39(7-8 Suppl):S5-14.

⁴ Kutney-Lee A, et al. Changes in patient and nurse outcomes associated with magnet hospital recognition. Med Care. 2015 Jun;53(6):550-7.

⁵ Winslow S, et al. The voice of the nurse...what's being said about shared governance? Nurs Manage. 2015 Apr;46(4):46-51.

⁶ Sermeus W, et al.; Magnet4Europe consortium. A workplace organisational intervention to improve hospital nurses' and physicians' mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial. BMJ Open. 2022 Jul 28;12(7):e059159.

⁷ Lazes P et al. How Labor-Management Partnerships Improve Patient Care, Cost Control, and Labor Relations. Cornell University. 2012.

⁸ Avgar AC, et al. Labor–Management Partnership and Employee Voice: Evidence from the Healthcare Setting. Industrial Relations (Berkeley), 55(4), 576–603.