RamaOnHealthcare May 5, 2023
Returning Joy and Well-Being to Healthcare
Today, RamaOnHealthcare talks with Dr. Jeff Salvon-Harman, MD, CPE, CPPS, Vice President, Safety, Institute for Healthcare Improvement (IHI). He is a Certified Physician Executive, Certified Professional in Patient Safety, IHI Fellow, and is resolute about creating safety and belonging for patients and the health care workforce. He provides strategic leadership in safety, with deep operational expertise in implementing change initiatives and applying quality improvement methods. Dr. Salvon-Harman is a recognized subject matter expert in high reliability, patient and workforce safety, human factors application to root cause analysis, and system-level management of quality and safety.
RamaOnHealthcare (ROH): Mounting evidence shows, quality and safety of US health care lagged during the pandemic and has been slow to rebound. Now three years out from the onset of the crisis, what are the most significant safety learnings for the industry to take forward?
Dr. Jeff Salvon-Harman (JSH): The COVID-19 pandemic drove changes in practice, clinician turnover, and infection prevention and control (IPC) processes that at times negatively impacted health care quality outcomes and patient safety. While these factors were especially impactful in the early stages of the pandemic, we are still recovering from many of them today.
Some health care delivery systems faced unimaginable hardships early on with overwhelming numbers of COVID patients, shortages of Personnel Protective Equipment (PPE), and unclear IPC processes for a novel pathogen whose mode(s) of transmission were not entirely clear. From these experiences, we learned many important lessons – three of which rise to the top.
- Visitors to patients play an important role in supporting the healing process and often serve as members of the care team – monitoring phases of care, assisting with orientation of the patient, reinforcing clinical instructions to the patient, and providing early awareness to clinical staff of changes in patient condition. Moving forward, we will need to find a balance between restricting visitation (as a public health measure in hospitals) and supporting patient healing through the presence of family and friends.
- The pandemic taught us a great deal about managing supply chain and use of PPE with extension of use, re-use, and reprocessing, along with identifying unique alternatives. These extensions of PPE kept many clinicians safer than the alternative of going without or using known substandard types.
- With urgency, health care systems must address improving organizational culture for safety, quality, and belonging as key drivers to clinician retention. Pay incentives, wellness programs, and resources are insufficient retention instruments compared to strengthening organizational focus on system design for quality and safe care. Pandemic-specific clinician support strategies were relatively effective and well-received early in the pandemic but were either discontinued later in the pandemic (while still desirable) or became less desirable as they did not address the underlying friction, frustrations, and moral distress of health care service delivery in challenging and persisting conditions.
…health care systems must address improving organizational culture for safety, quality, and belonging as key drivers to clinician retention.
ROH: Clinician burnout has been an issue for years, but the pandemic illuminated and accelerated it in ways that the industry has not previously seen. Knowing that every system is perfectly designed to get the results it gets, what is it about our current system that’s contributing to increasing rates of burnout at all levels of health care – from the C-suite to the bedside?
JSH: Let’s first agree our focus should be on clinicians experiencing moral distress/injury instead of burnout. The distinction is crucial as moral distress has external drivers and does not pre-suppose inadequacy of the individual. Burnout on the other hand implies the system design is appropriate, but the individual does not possess sufficient resilience.
Health care systems have been over-reliant on individual resilience programs as the primary response to clinician moral distress/injury. The myriad health care workforce support and self-care programs do have a place in a larger System Resilience landscape but cannot be depended upon as the sole remedy to the challenges that pre-date the COVID-19 pandemic. Individual resilience programs have not borne the fruit expected of them by health system leaders, but they have become a means to place accountability for system design deficiencies on the shoulders of clinicians.
We cannot expect highly qualified professionals to outperform poorly designed systems in any industry, and health care has been slow to invest in systemic change to reduce friction, frustration, and moral distress of its clinical workforce. More demands of individuals in the workforce are made with little alteration in time availability, billing reform, work balance with homelife, workload reduction for increasing complexity of care, or civility in the care environment.
ROH: There’s a lot of concern around burnout (Just checking – is burnout the word you want to use here?) and its direct or indirect impacts on patient safety. Can you describe the relationship between these issues, and how IHI is approaching the dual challenge of workforce safety and patient safety?
JSH: The term burnout has become a sensitizing and often unwelcome epithet among many clinicians. The “long-term stress reaction marked by emotional exhaustion, depersonalization and a lack of sense of personal accomplishment” (AHRQ) is better identified as moral distress (emotional, social, or spiritual pain or suffering), which can lead to moral injury (lasting damage done to a person). When clinicians experience moral distress/injury in the workplace, it can erode their sense of belonging, engagement, and well-being within the system, organization, or practice. This evolving disengagement can manifest as loss of alignment with organizational values, team cohesion, and perceptions of value in the organization and the community. These elements correlate to a culture of safety in the care setting, and when present, contribute to lower adverse event rates. Perceiving a sense of belonging and well-being, experiencing trust, respect, and dignity, and aligning with organizational values supports and strengthens the culture of an organization, the loyalty of its workforce, and the retention of highly engaged professionals.
Motivated by this recognition of the inextricable links between workforce well-being, workforce safety, and patient safety, IHI is working toward integration of all three domains with the vision of the best care and health possible.
- We are examining the applicability of patient safety event learning methods to workforce safety events;
- We are supporting workforce well-being change initiatives and launching a new Leadership for Workforce Well-Being development program;
- And we have recently published on our website the Preventing Verbal and Physical Violence Across the Health Care Workforce toolkit providing guidance to health systems on protecting the workforce amidst escalating incivility in care environments.
…inextricable links between workforce well-being, workforce safety, and patient safety, IHI is working toward integration of all three domains….
Our goal is to share principles and techniques that enable a safe workforce, that can truly thrive, not just persevere.
ROH: What are [three] things that health care leaders can do in the near-term to turn the tide and reduce harms to patients and staff?
JSH: First, health care leaders (including governing boards) must prioritize safety for patients and the workforce as a system and culture attribute. This can take the form of involving patients, families, home caregivers, and the health care workforce in co-design of safe, timely, efficient, effective, equitable, and patient-centered service delivery reforms. This can also take the form of always leading from the perspective of safety “We will safely deliver high quality care” as opposed to “We will deliver high quality care safely.” Prioritizing rapid and assertive management of identified patient and workforce safety risks throughout their system demonstrates commitment to safe care and a safe workplace. Most important is to begin right away on this.
…prioritize safety for patients and the workforce as a system and culture attribute.
Second, health care leaders can collaborate beyond their walls with other health systems to create a safety learning and sharing environment that does not compete on safety. Leaders should not view safety performance as a competitive advantage when instead it should be universally shared without competition. This spirit of open sharing and collaboration to advance safety will be on full display at this year’s 2023 IHI Patient Safety Congress.
Third, the health care workforce needs to see relief from non-value added work and assurance of a safe working environment. Both of these factors detract from finding purpose and belonging in health care service delivery. They also add cognitive load in an already highly complex environment, which thereby increases the risk of undesired events. Reducing low-value administrative burdens, actively addressing and preventing incivility, and protecting patients and the workforce from physical, psychological, and administrative harm can restore engagement and joy in work.
ROH: Looking at the big picture, how does the US health care system need to change to ensure a safe and equitable environment for all patients, families, and workers?
JHS: US health care cannot meet the needs of patients, families, and the workforce in its current form or by attaching appendages to an antiquated spine, at its core. Disruptions to traditional models of health service delivery that have accelerated in this pandemic era, like telehealth and Hospital-at-Home, represent early design modifications that are being well received by patients and the workforce. Implementing Patient Centered Medical Homes in Primary Care represented pre-pandemic capacity for change with patients at the center.
We are at a critical inflection point in which we need to partner equitably with patients and their families in the co-design of health care delivery services, framing the new design with safety and equity for patients and the workforce as the foundation – all in alignment with the mantra, “Nothing for them without them.” They need to see their ideas and creative solutions taken to heart and implemented. We need to flood the market with demonstration projects and creative, safe, highly reliable innovations of health service delivery across environments of care that will capture the attention of payers, delivery systems, practices/groups, and regulators. Workflows should follow human-centered design principles that are supported by streamlined and effective electronic medical records (EMRs), rather than designing and implementing workflows with EMRs and expecting the workforce to adapt.
Workflows should follow human-centered design principles….
Recognizing that staffing and revenue generation are top-most of mind for health care CEOs currently, the evidence base for quality and safety in health care service delivery reminds us that costs are reduced, patient flow is improved, and staff satisfaction and engagement increase – all of which contribute to an improved bottom-line from revenue generation and cost avoidance. Quality and Safety in health care is the answer to staffing and revenue concerns.
Quality and Safety in health care is the answer to staffing and revenue concerns.
ROH: Transforming health care is no easy task. What gives you hope for the future?
JSH: Despite the historic modes of health care service delivery in the US, I find hope in the adaptability of health care delivery systems and the workforce. Technologies, scientific knowledge, precision medicine, patient-centered care, and many more advances have been adopted both pre- and intra-pandemic, demonstrating the willingness and ability of systems, teams, and individuals to change. Harnessing the creativity and innovation of systems thinkers, engaging with payers and regulators to support patient-and workforce-centered improvements, re-thinking current boundaries and being able to ask “Why” fill me with optimism that health care in the US is not at the end of a road, but just at the beginning.
…health care in the US is not at the end of a road, but just at the beginning.
About Dr. Salvon-Harman
Previously, he was the Chief Patient Safety Officer/VP, at Quality Institute and Medical Director of Infection Prevention and Control for Presbyterian Healthcare Services in New Mexico. He is retired from the US Public Health Service, where he dedicated 20 years to the Indian Health Service and the US Coast Guard in roles ranging from clinical service delivery to management and leadership. Dr. Salvon-Harman completed his residency in Family Medicine at Carilion Health System in Roanoke, VA, after graduating from Tufts University School of Medicine in Boston, MA.