In an environment of disengagement, re-engagement of staff can be achieved and is highly rewarding. To be successful, what is needed is a clear understanding of the health care context, the current state of patient safety, and why people behave the way they do. With this understanding, coupled with a process that respects it, engagement is not only possible but can be predictably achieved.
The first of three parts, this article presents an overview of the key concepts rather than an exhaustive exploration. Speaking of re-engagement in health care would be of little value topic of disengagement. It aims to challenge current thinking by bringing together key elements that make implementation of quality and patient safety initiatives challenging.
KEY WORDS: physician engagement, liberating structures, patient safety, quality assurance,
Speaking of re-engagement in health care would be of little value if light were not first shed on the topic of disengagement.
In 2015, only 57% of healthcare workers considered themselves engaged,1 10% fewer than only five years earlier. Almost (30%) considered themselves as “just contributing” to their role, and 13% assessed themselves as either “actively disengaged” or “hostile.” This situation has been steadily worsening since figures have been tracked.
What is engagement?
For physicians, engagement has positive contribution of physicians within their normal working roles to maintain and enhance the performance of the organization, which itself recognizes this commitment by supporting and encouraging high-quality care.”2
But looking solely at one profession when all are required for the organization to succeed is short-sighted. Thus, a broader definition of engagement includes: “a sense of work-related well-being associated with worker motivation.”3 Re-engaging the team will never succeed if one focuses on a uni-professional approach. As such, the rest of this series will speak of the issue from an interprofessional perspective.
Why has disengagement in health care become the norm?
Answers can be found if we just turn our attention inward. In early 2018, I facilitated a meeting involving a 55-hospital health system. Fifty senior leaders, middle managers, educators, and frontline team members came together to discuss how to improve the quality of care and life at work. The issue of disengagement came up, and I used a TRIZ (a liberating structure4) to help bring insight to the audience about some of the reasons.
A TRIZ invites participants to list activities that would contribute to creating the exact opposite of what is desired. In this case, participants were asked to express what would be needed to create the worst possible engagement in a healthcare quality project. As is often the case with TRIZ, participants thoroughly enjoyed the process as they listed elements that would result in total disengagement. Three scribes were required to of ideas!
The next step was to review the list and identify which elements, if any, were part of the system’s existing initiatives. A full 100% of the listed items — items that would contribute to disengagement — were acknowledged as present in their initiatives. Although the attendees were shocked, this should have come as no surprise to anyone.
Have we designed our health care system to disengage its own workers? Inadvertently, maybe we have. The following are some of the contributing factors.
The flavour of the week
Humanity’s desire for quick fixes extends into health care. This desire has led to a revolving door of programs, historically dubbed “the flavour of the week.” Reinforced by the requirements of regulating bodies, the issue is also known as “institutional attention deficit disorder” (M. Gardam personal communication, 2018).
This phenomenon has been accentuated by yet another revolving door: turnover among senior leadership teams. “The turnover rate for healthcare CEOs remains at a record high — 16–20% between 2011 and 2015.”1 New CEOs look to gain early wins and build legacies of success; and they want things done their way. New leadership teams lead to changes in processes and approaches, allowing only a few programs the time necessary to be fully implemented, monitored, and adjusted to actually make a difference.
The flavour of the week leads to worker fatigue and disinterest. Disengagement builds.
Just get it done
The perceived easiest way to implement anything is to have people simply do it through the management of hospital staff. Although this appears easy, as a strategy it does not succeed. After all, if it were that easy, it would have been done already. Why do we still have problems with hand washing?
Much of what we have to do to improve health care has already been described. It is the getting there that is the hard part.5 Experience reveals that the “just get it done” approach leads to unsustainable solutions and a weak team, and further contributes to disengagement.6
Buy-in: is it truly what we seek?
An extension of “just getting it done” is seeking buy-in. Leaders all too often seek buy-in from health care teams, which on the surface may appear to be a sound approach. Yet, if we dissect what this means, we begin to understand why it is not what leaders want at all.
Consider some context for this statement: when leaders seek buy-in, they are asking colleagues to accept the leaders’ solutions. This acceptance process occurs late in the development of the solution, a solution that likely had minimal input from the team that is asked to implement it.7 Leaders will rationalize that their colleagues were too busy to provide input and that they were doing colleagues a favour by doing all the work. In fact, leaders did not create the capacity for team members to take part. Simply put, in seeking buy-in, leaders are actually seeking the team’s acceptance of an externally created process.
What we need to create is not buyers of the change, but “investors” in it.8 Zimmerman and colleagues7 explain that if one actually achieves buy-in, it is evidence of an unhealthy organization, because the result is a team that is content to follow orders and put in time rather than engage. Furthermore, if something is wrong with the process, the team is quick to point to the leaders and state: your process, your problem.
The team remains disengaged and is not part of the solution, rather is part of the problem. Furthermore, evidence shows that such change, imposed by others, is often opposed overtly or covertly.9
Safety and quality
In our zeal to try to “fix” safety, safety is seen as distinct from quality. In 2017, Berwick observed that when he hears “quality and safety,” he hears “fruits and bananas.”10 In essence, safety has been severed from what he calls the “big tent” that is quality. When seen from a certain point of view, quality — which is the “evidence” — can be considered universal; the problem lies in its application, which is very much site and context specific.
In other words, while quality is overarching and can be broadly applied, safely is more site-specific and must be locally determined. As a result, many of us have witnessed excellent evidence-based processes that are simply not safe in certain contexts: in the brick-and-mortar structure/ design of a unit, in combination with existing processes, to the population served, or even in the geographic location of service, to name but a few.
We must bring safety back into that big tent and accept that the process can, and should, be adapted to local context. If a team knows an evidence-based process to be faulty in the context of its practice, it will not use it, thereby decreasing trust in other processes and further fueling disengagement.
Data glut and its impact
Don Berwick10 identified the quagmire that is “big data” today. He says: “In pursuit of incentives, we’ve glutted ourselves with metrics. I think we are way beyond a level of toxicity. It’s not just safety. We have to go on a diet.”
Front-line teams often have data used against them, what I call the “weaponization of data.” We are scolded for our caesarean section rates, or we lose funding because of our unit’s low census.
Finally, imposed targets and key performance Indicators can have unintended consequences and lead to “perverse outcomes.”9,11
We need to flip data on its head. Data can, and must, drive engagement. Data must become the reward of a job well done. Accordingly, what is measured needs to be relevant to the team tracking it. It must be produced within a reasonable time from the implementation of an intervention and must be in a form that speaks to the unit.12
Challenge the myth of the disinterested
Disinterest may be resistance to change. People will resist change for many reasons; however, in their own personal context, their resistance (whether passive or not) makes sense. It is critical to develop ways to engage these people. It should come as little surprise that a person may become disinterested if they have tried to contribute and make change and seen nothing come of it. In fact, these resisters may become the most engaged contributors when they see the results of renewed efforts for change that include them.8
Is it disengagement or burnout?
Burnout has been defined as: a job-related emotional response to stress in the work environment characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.13
The physical attributes of burnout and disengagement are the same. In other words, a disengaged person will look the same as a burnt-out colleague. Furthermore, burnout in healthcare is difficult to self-identify, as many of the warning signs have been trained out of us through our educational processes. As a result, by the time it is diagnosed, it has taken strong hold on the individual, often leading to the abandonment of a career — or worse.
How prevalent is burnout? “Burnout in medicine is an epidemic hiding in plain sight.”14 Burnout is omnipresent in today’s health care environment and has been called an occupational hazard with a reported rate of anywhere from 25% to 75% depending on the area of health care.15 Burnout must be addressed urgently; with far too many of our colleagues succumbing to it.16
Because of its focus, the Salus Global Corporation is not considered a commercial interest under Accreditation Council for Continuing Medical Education standards. It is owned by the Society of Obstetricians and Gynaecologists of Canada, the Healthcare Insurance Reciprocal of Canada, and the Canadian Medical Protective Association.
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- Employee engagement in healthcare: three key ingredients to cultures that save more lives. Omaha, Neb.: Quantum Workplace; 2015. Available: https://tinyurl.com/y6ptpce2 (accessed 20 March 2018).
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- Bakker AB, Schaufeli WB, Leiter MP, Taris TW. Work engagement: an emerging concept in occupational health psychology. Work Stress 2008;22: 187-200. https://doi.org/10.1080/02678370802393649
- Making space with TRIZ. Liberating structures. Creative Commons; n.d. Available: https://tinyurl.com/my7ckcz (accessed April 2017).
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- Flanagan ME, Welsh CA, Kiess C, Hoke S, Doebbeling BN. A national collaborative for reducing health care-associated infections:current initiatives, challenges and opportunities. Am J Infect Control 2011;39(8):685-9. DOI: 10.1016/j.ajic.2010.12.013
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- Bailey S, Bevan H. Quality improvement: lessons from the English National Health Services. Healthc Pap 2017;17(1):49-55.
- Braithwaitte J. Changing how we think about healthcare improvement. BMJ 2018;361:k2014. DOI: 10.1136/bmj.k2014
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- Mannion R, Braithwaite J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service. Intern Med J 2012;42(5):569-74. DOI:10.1111/j.1445-5994.2012.02766.x
- Gardam M. The complex road to lasting change. Breakfast for the Chiefs. Toronto: Longwoods; 2017. Available: https://tinyurl.com/y343vr2b (accessed 18 Oct. 2017).
- Mossburg, SE, Dennison Himmelfarb C. The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review. J Patient Saf 2018;25 Jun. DOI:10.1097/PTS.0000000000000519
- Gautam M. Workshop’s focus: ‘critical issue’ of burnout among women physicians. CSPL e-newsletter 2019;8 Jan. Available: https://tinyurl.com/y4evutne (accessed 9 Jan. 2019).
- Portoghese I, Galletta M, Coppola RC, Finco G, Campagna M. Burnout and workload among health care workers: the moderating role of job control. Saf Health Work 2014;5(3):152-7. DOI:10.1016/j.shaw.2014.05.004
- Clinician well-being is essential for safe, high-quality patient care. Washington: National Academy of Medicine; 2018. Available: https://tinyurl.com/y8eptwbx (accessed 12 Nov. 2018).