The workforce burnout and retention crisis has been dominating health care for the last three years, but data (finally) shows some encouraging trends. Analyses of survey responses from the last three years show that the decline in workforce “engagement” has flattened out and “resilience” is actually improving. The data also shows a spreading of the pack — with bigger variation between organizations where workforce morale and retention is improving versus others where the slide continues. This article will capture some of the best practices that have the potential to turn a vicious cycle into a virtuous one.
The following analyses are based on about 1.6 million survey responses from employees of U.S. health care organizations (including over 121,500 physicians) during 2020, 2021, and 2022 conducted by our company, Press Ganey. While burnout has been worsening for all types of health care professionals, three additional metrics provide a more complete picture of what is happening in health care:
During the last year, there has been a flattening of the downward trend for engagement, which measures employees’ emotional bond with the organization and their willingness to go above and beyond their job descriptions to meet the needs of patients and colleagues. Using a five-point scale, engagement declined .10 the year after the pandemic started (calendar year 2021) — the largest decline in engagement for caregivers that Press Ganey has observed, but the decline has slowed, with only a .02 decline in 2022.
There was a similar flattening of the rate of decline of alignment, which is assessed through measures that reflect providers’ perceptions of their relationship with organizational leadership. For example, if they do not feel respected or that their voices are heard in decisions that impact their practice, they are not likely to feel aligned with the organization even if they are proud of it. This helps explain why so many women physicians have quit.
There was actually some improvement in 2022 in resilience: the ability to find meaning in work (activation) and recharge when away from work (decompression). (See this article for specific survey items used to gauge both.) The good news is that activation remained stable throughout the pandemic for virtually everyone in health care. These are good people motivated by doing good. But the even better news is that decompression improved in 2022 after two years of steep decline. This data indicates that caregivers are learning how to cope with the stresses of this era, their organizations are doing a better job of supporting them, or both.
These three encouraging trends don’t apply to everyone. Our data shows a widening gap between the top 10% of organizations in workforce engagement and the bottom 10%. In short, employee engagement at many organizations is improving, while at others it is getting worse. The data suggests that some organizations are trapped in a vicious cycle in which stress is leading to burnout leading to worse performance leading to more stress. But other organizations (or sub-units of those organizations) are in a virtuous cycle in which pride among caregivers leads to better engagement which leads to better performance which leads to more pride.
The picture that emerges from this data is that health care has dedicated and hardworking people who have been through a lot but, in the right circumstances, still have more to give. What are those right circumstances? Data from organizations in the top decile of workforce engagement offers insights.
Top performers scored markedly higher than others in five specific domains: support from and confidence in senior leadership, recognition of the contribution of employees, respect and involvement in decision-making, manageable job stress, and adequate staffing.
How do we get from a vicious cycle to a virtuous one? By implementing these measures:
The first thing organizations and their leaders should (and can) do immediately is to listen and understand the challenges facing their individual employees and their leaders. What it means to authentically listen changed during the pandemic. It no longer means just getting out for “leadership walk rounds,” surveys every one or two years, or occasional town halls for the shift that happens to be on duty at midday. It involves not only amassing more information but also simultaneously showing employees that you are doing so.
Today, authentically listening requires a major shift in the frequency, breadth, and depth of listening, which can be accomplished thanks to technology. For example, new tools can empower managers to perform pulse surveys focused on specific issues or specific groups of employees and reveal opportunities to address their specific needs. Virtual focus groups and digital communities can “bring together” employees facing similar challenges and enable both connection and opportunity to collaborate and solve shared challenges.
Crowdsourcing technology allows managers and leaders to involve their front lines in identifying solutions to problems and prioritizing which solutions to start with. By leveraging artificial intelligence (AI) and natural language processing, employee comments can be organized and channeled to reveal both challenges and successes, both of which create opportunities to fix the problems and scale the existing successful solutions. Many leaders still shudder at the idea of surveying employees when they know the feedback will be painful, but authentically listening is a sign of respect.
Make engagement and well-being a priority.
While every organization will have different and unique results from its listening efforts, top-performing organizations all have one thing in common: Senior leaders (often including their boards) have prioritized the importance of employee engagement and well-being. They recognize that an engaged and healthy workforce is critical for them to provide excellent patient care and reduce patient suffering.
These top performers hold themselves accountable for improving every year and are making the investments to support this improvement. While they rely on their HR leaders heavily, they engage leadership across the organization, including nursing, physician, and quality and safety leaders to collectively address these issues.
Focus on three improvement areas.
Next, virtually all top-performing organizations focus on doing these things:
Tactics to support individuals should emphasize the importance of self-care — something done poorly in health care. Organizations should share positive feedback from colleagues, leaders, and patients (and the vast majority of patient feedback is positive) to demonstrate organizational gratitude and respect.
Organizations should both invest in peer-support programs so that colleagues can identify suffering in their ranks and design solutions that will help them. And they should continue their evolution from the traditional in-person workplace to one that embraces hybrid or remote work where possible — an evolution that introduces complexity for managers but can enhance resilience for their employees.
Support leaders and teams.
After listening, the best organizations take their data and go deeper. They identify teams that are facing more obstacles and leaders who are struggling. They support the managers of these units in developing improvement plans to address specific issues revealed through surveys, focus groups, and other listening approaches.
Developing leaders and building teams is also a critical tactic for maintaining virtuous cycles. This requires investments in coaching and more structured training. Focusing on the skills that leaders require to engender trust and confidence should be taught so that new leaders have the skills to support and build their teams. Ultimately the goal for leaders is to create a psychologically safe environment where those around them feel comfortable speaking up and out and actively contribute to improvement.
Fix broken systems and processes.
Finally, top-performing organizations demonstrate their commitment to fixing dysfunction in the systems and processes currently in place. They fix broken processes, leverage technology, and build teams so that they can all work smarter. And they know that to solve these problems, they must include the voices of their front lines. They have developed reliable processes for ensuring that those closest to the work are supported in solving the problems. Many organizations have adopted the approach of GROSS (“getting rid of stupid stuff”) and have put processes in place to listen to their front lines and then implement solutions. Others are using new crowdsourcing technology that enables employees to submit innovative solutions to challenges revealed through annual surveying; these organizations then use these submissions to blaze a path forward.
This continuous reevaluation of systems and processes must be built into the organizational frameworks of health care providers. This type of approach is one that many organizations have already taken to build a safety culture and improve quality outcomes for patients. It must now be applied to organizational efforts to improve engagement and resilience in order to retain the remarkable people who continue to work in health care.
Organizational leadership that embraces a coordinated strategy of authentically listening to its employees and patients, developing their leaders, and continuously improving workflows will drive the flywheel of pride and engagement necessary to sustain the virtuous cycle.
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