TFME 2013 Organizational Professionalism Conference

1. Personal and OrganizationalPersonal and Organizational
Well-BeingWell-Being
John F. Christensen, Ph..D.
jchriste@lhs.org

2. DisclosureDisclosure
 I have no financial relationships with aI have no financial relationships with a
commercial entity related to thiscommercial entity related to this
presentation.presentation.

3. ““In the middle of theIn the middle of the
road of my life Iroad of my life I
awoke in a darkawoke in a dark
wood where the truewood where the true
way was whollyway was wholly
lost.”lost.”
– DanteDante

4. “It is good to feel lost... because it proves you
have a navigational sense of where "Home" is.
You know that a place that feels like being found
exists. And maybe your current location isn't that
place but, Hallelujah, that unsettled, uneasy
feeling of lost-ness just brought you closer to it.”
-Erika Harris

5. Continuum of ProfessionalContinuum of Professional
HealthHealth
Well-being Burnout Impairment
Individual Organization

6. Reciprocity betweenReciprocity between
professional and organizationalprofessional and organizational
healthhealth
 Organizational environments & processesOrganizational environments & processes
influence professional well-beinginfluence professional well-being
(sustainable lives & careers)(sustainable lives & careers)
 Professional well-being influences the well-Professional well-being influences the well-
being of organizations (sustainable missionbeing of organizations (sustainable mission
and profitability)and profitability)

9. SustainabilitySustainability
 Land use planningLand use planning
 C - L = M (capacity - load = margin)C - L = M (capacity - load = margin)
 +M = Sustainable growth+M = Sustainable growth
 -M = Degradation of landscape & resources-M = Degradation of landscape & resources

10. Signs of negative marginSigns of negative margin
 PersonalPersonal
– Sleep deprivationSleep deprivation
– FatigueFatigue
– IrritabilityIrritability
– Attention deficitAttention deficit
– DissociationDissociation
– DecontextualizationDecontextualization

11. BurnoutBurnout
 Emotional exhaustionEmotional exhaustion
 Depersonalization in relationshipsDepersonalization in relationships
– With coworkersWith coworkers
– With patientsWith patients
– With spouse and familyWith spouse and family
 Perceived clinical ineffectivenessPerceived clinical ineffectiveness
Spickard, Gabbe, & Christensen. JAMA 2002;288:1447-Spickard, Gabbe, & Christensen. JAMA 2002;288:1447-
14501450

12. Signs of negative marginSigns of negative margin
 OrganizationalOrganizational
– Decreased patient satisfactionDecreased patient satisfaction
– Decreased clinician satisfactionDecreased clinician satisfaction
– Staff turnoverStaff turnover
– Quality decrementsQuality decrements
– InefficiencyInefficiency
– Measuring & incentivizing “instrumentalMeasuring & incentivizing “instrumental
behavior”behavior”

13. Signs of negative marginSigns of negative margin
 PlanetaryPlanetary
– Global warmingGlobal warming
– Ozone layer lossOzone layer loss
– Acid rainAcid rain
– Groundwater contaminationGroundwater contamination
– Depletion of fisheriesDepletion of fisheries
– DeforestationDeforestation
– Species extinctionSpecies extinction

14. ““Engrossed late and soon in professionalEngrossed late and soon in professional
cares...you may so lay waste that you maycares...you may so lay waste that you may
find, too late, with hearts given way, thatfind, too late, with hearts given way, that
there is no place in your habit-stricken soulsthere is no place in your habit-stricken souls
for those gentler influences which make lifefor those gentler influences which make life
worth living.”worth living.”
Osler, 1889Osler, 1889

16. Organizational causes ofOrganizational causes of
negative marginnegative margin
 ““Hidden curriculum” in medical educationHidden curriculum” in medical education
 Exclusive focus on market shareExclusive focus on market share
 Subordinating process to outcomesSubordinating process to outcomes
 Rewarding overworkRewarding overwork
 Measuring productivity while failing toMeasuring productivity while failing to
measure quality of lifemeasure quality of life
 Lack of attention to meaning (intrinsicLack of attention to meaning (intrinsic
values)values)

17. Organizational causes ofOrganizational causes of
negative marginnegative margin
 Absence of feedbackAbsence of feedback
 Absence of emotional supportAbsence of emotional support
 Inflexibility in schedulingInflexibility in scheduling
 Decision-making hierarchical rather thanDecision-making hierarchical rather than
sharedshared
 Sterile environmentsSterile environments
 Mindless assimilation of prevailing cultureMindless assimilation of prevailing culture

22. How dinosaurs died

24. The Singularity--2045The Singularity--2045
1 : 1
1 : 7 billion

25. Absence of depthAbsence of depth
 The Shallows: What the Internet is Doing toThe Shallows: What the Internet is Doing to
Our BrainsOur Brains. Nicholas Carr. Nicholas Carr
 Internet a distraction technologyInternet a distraction technology
 No unplugged space and timeNo unplugged space and time
 StillnessStillness

26. SustainabilitySustainability
 C > L = +MC > L = +M
 Individual clinicianIndividual clinician
 Health care organizationHealth care organization

27. The positive path aheadThe positive path ahead

28. Convergence of PositiveConvergence of Positive
TrendsTrends
 Positive PsychologyPositive Psychology
 Positive Change MovementPositive Change Movement
 Positive Organizational ScholarshipPositive Organizational Scholarship
 MindfulnessMindfulness
 Positive Economic ModelsPositive Economic Models
 Positive LeadershipPositive Leadership

29. Positive PsychologyPositive Psychology

31. Positive PsychologyPositive Psychology
 The Pleasant LifeThe Pleasant Life
– Positive experiences and emotionsPositive experiences and emotions
 The Good LifeThe Good Life
– Engagement and immersionEngagement and immersion
– FlowFlow
– Self-efficacySelf-efficacy
 The Meaningful LifeThe Meaningful Life
– Belonging, affiliationBelonging, affiliation
– PurposePurpose
– Connection with something larger than selfConnection with something larger than self

32. Evidence on HappinessEvidence on Happiness
 Seligman MEP, Csikszentmihalyi M (Eds.). Happiness,Seligman MEP, Csikszentmihalyi M (Eds.). Happiness,
excellence, and optimal human functioning. A special issueexcellence, and optimal human functioning. A special issue
of the American Psychologist 2000;55:5-183.of the American Psychologist 2000;55:5-183.
 Seligman MEP,Seligman MEP, Flourish.Flourish. Free Press, 2011.Free Press, 2011.
 Haidt J.Haidt J. The Happiness HypothesisThe Happiness Hypothesis. Basic Books, 2006.. Basic Books, 2006.
 Niven D.Niven D. The 100 Simple Secrets of Happy PeopleThe 100 Simple Secrets of Happy People. Harper,. Harper,
2001.2001.
 http://www.authentichappiness.sas.upenn.edu/http://www.authentichappiness.sas.upenn.edu/
 International Positive Psychology AssociationInternational Positive Psychology Association
– http://www.ippanetwork.org/http://www.ippanetwork.org/

33. Positive change movementPositive change movement

34. Individual changeIndividual change
 Motivational InterviewingMotivational Interviewing
– Elicit patient’s desired outcomesElicit patient’s desired outcomes
– Reinforce past successesReinforce past successes
– Scaling of “importance” and “confidence”Scaling of “importance” and “confidence”
 Ericksonian hypnotherapyEricksonian hypnotherapy
– Positive suggestionsPositive suggestions
– Imagery for future functional statesImagery for future functional states

35. Appreciative InquiryAppreciative Inquiry
 Strength basedStrength based
 Search for models of excellenceSearch for models of excellence
– IndividualIndividual
– OrganizationOrganization
 ““Mining for Gold”Mining for Gold”
 Finding examples of best practicesFinding examples of best practices
 Inductive processInductive process
 Brings forward into present the best of the pastBrings forward into present the best of the past

36. AI ApplicationsAI Applications
 Work teamWork team
 InstitutionInstitution
– Indiana University School of MedicineIndiana University School of Medicine
– Cottingham AH, et al. J Gen Intern Med 2008;23:715-22Cottingham AH, et al. J Gen Intern Med 2008;23:715-22
 Intimate partner relationshipIntimate partner relationship
 SelfSelf

37. Positive OrganizationalPositive Organizational
ScholarshipScholarship
 Focuses on dynamics in organizations that lead toFocuses on dynamics in organizations that lead to
– Developing human strengthDeveloping human strength
– Producing resilience and restorationProducing resilience and restoration
– Fostering vitalityFostering vitality
– Cultivating extraordinary individualsCultivating extraordinary individuals
 Draws from full spectrum of organizationalDraws from full spectrum of organizational
theoriestheories
 Center for Positive Organizational Scholarship
(www.bus.umich.edu/positive)

39. Positive OrganizationalPositive Organizational
PracticesPractices
 CaringCaring
 Compassionate supportCompassionate support
 ForgivenessForgiveness
 InspirationInspiration
 MeaningMeaning
 Respect, Integrity, and GratitudeRespect, Integrity, and Gratitude

40. Positive Practices:Positive Practices:
ForgivenessForgiveness
 Managing mistakesManaging mistakes
– Protected forum for sharing mistakesProtected forum for sharing mistakes
– ““Fallibility Rounds” (Vanderbilt)Fallibility Rounds” (Vanderbilt)
– CME: TFME workshops on mistakesCME: TFME workshops on mistakes
 Christensen JF, et al. J Gen Intern Med 1992;7:424-431Christensen JF, et al. J Gen Intern Med 1992;7:424-431
 Second Victim Response TeamSecond Victim Response Team
– Missouri University Health CareMissouri University Health Care
– 3-tiered support for clinicians involved in mistake3-tiered support for clinicians involved in mistake
 Scott SD, et al. Joint Comm J on Quality & Patient SafetyScott SD, et al. Joint Comm J on Quality & Patient Safety
2010;36:233-2402010;36:233-240

42. Positive Practices:Positive Practices:
InspirationInspiration
 Legacy IM resident well-beingLegacy IM resident well-being
– Well-being part of curriculumWell-being part of curriculum
– Periodic retreatsPeriodic retreats
– Annual assessmentsAnnual assessments

46. Psychologically HealthyPsychologically Healthy
Workplace AwardsWorkplace Awards
 Oregon Psychological AssociationOregon Psychological Association
– City of Albany Public Works DepartmentCity of Albany Public Works Department
– The Subway GroupThe Subway Group
 American Psychological AssociationAmerican Psychological Association
– http://www.phwa.org/awards/http://www.phwa.org/awards/
– College of Physicians & Surgeons of NovaCollege of Physicians & Surgeons of Nova
ScotiaScotia
– Kaiser Permanente Center for Health Research,Kaiser Permanente Center for Health Research,
OregonOregon

47. Oregonian Top WorkplacesOregonian Top Workplaces
 Mid-Columbia Medical Center (The Dalles)Mid-Columbia Medical Center (The Dalles)
– #6 among top 10 large companies#6 among top 10 large companies
 Good Shepherd Medical CenterGood Shepherd Medical Center
(Hermiston)(Hermiston)
– #7 among top 10 large companies#7 among top 10 large companies
 NW Renal Clinic (Portland)NW Renal Clinic (Portland)
– #12 among top 40 small companies#12 among top 40 small companies

48. High-functioningHigh-functioning
Organizational CulturesOrganizational Cultures
 Facilitative leadershipFacilitative leadership
 Shared goals and expectationsShared goals and expectations
 Context of mutual supportContext of mutual support
 Shared knowledge as foundation forShared knowledge as foundation for
interactionsinteractions
 Effective conflict-management & problemEffective conflict-management & problem
solving strategiessolving strategies

49. Legacy Clinics Program forLegacy Clinics Program for
Physician Well-BeingPhysician Well-Being
 Organizational interventionsOrganizational interventions
– Control, order, and meaningControl, order, and meaning
– Commitment of leadershipCommitment of leadership
 Measurement of physician satisfaction andMeasurement of physician satisfaction and
burnout, and organizational healthburnout, and organizational health
 Significant decreases over study period inSignificant decreases over study period in
emotional and work-related exhaustionemotional and work-related exhaustion
 Dunn, Arnetz, Christensen, & Homer, 2007Dunn, Arnetz, Christensen, & Homer, 2007

50. Thriving primary careThriving primary care
practicespractices
 Mindfulness (emotional intelligence)Mindfulness (emotional intelligence)
 Diversity of mental modelsDiversity of mental models
 Heedful interrelatingHeedful interrelating
 Mix of rich & lean communicationMix of rich & lean communication
 Mix of social & task-related interactionsMix of social & task-related interactions
 Mutual respectMutual respect
 TrustTrust
 Safran GD, et al. J Gen Intern Med 2006;21:S9-15Safran GD, et al. J Gen Intern Med 2006;21:S9-15

51. Organizational models ofOrganizational models of
excellenceexcellence
 Southwest AirlinesSouthwest Airlines
 Tom’s of MaineTom’s of Maine
 Celestial Seasonings TeaCelestial Seasonings Tea
 Robert Bosch GmbHRobert Bosch GmbH

52. Influence of relationship-Influence of relationship-
centered care on healthcarecentered care on healthcare
organizationsorganizations
 Patient safety, reduced errorPatient safety, reduced error
 Decreased mortalityDecreased mortality
 Better functional outcomesBetter functional outcomes
 Shorter length of stayShorter length of stay
 Improved workforce morale, decreasedImproved workforce morale, decreased
turnoverturnover

53. How organizations influenceHow organizations influence
professional well-beingprofessional well-being
 Organization is a series of conversations.Organization is a series of conversations.
 Language of conversations consists notLanguage of conversations consists not
only of words, but also symbols andonly of words, but also symbols and
gestures.gestures.
 ““How do organizational conversations inHow do organizational conversations in
health care affect the ability of peoplehealth care affect the ability of people
working within them to express who theyworking within them to express who they
are, grow, connect with others, andare, grow, connect with others, and
contribute meaningfully?”contribute meaningfully?”
– Suchman AL, 2001Suchman AL, 2001

54. MindfulnessMindfulness

55. Impact of mindfulnessImpact of mindfulness
training on physicianstraining on physicians
 70 primary care physicians in Rochester70 primary care physicians in Rochester
 Intensive educational program in mindfulnessIntensive educational program in mindfulness
 Significant outcomesSignificant outcomes
– Improvements in mindfulnessImprovements in mindfulness
– Burnout reducedBurnout reduced
– Mood disturbance decreasedMood disturbance decreased
– Empathy toward patients increasedEmpathy toward patients increased
– Improvement in personality factors ofImprovement in personality factors of
conscientiousness and emotional stabilityconscientiousness and emotional stability
Krasner MS, et al. JAMA 2009;302:1284-1293Krasner MS, et al. JAMA 2009;302:1284-1293

56. Impact of mindfulnessImpact of mindfulness
training on physicianstraining on physicians
 Qualitative study of 20 physician-Qualitative study of 20 physician-
participantsparticipants
 Three aspects of training most helpfulThree aspects of training most helpful
1.1. Sharing personal experiences with colleaguesSharing personal experiences with colleagues
reduced isolation.reduced isolation.
2.2. Mindfulness skills improved attention andMindfulness skills improved attention and
deep listening, developed adaptive reserve.deep listening, developed adaptive reserve.
3.3. Developing greater self-awareness wasDeveloping greater self-awareness was
transformative.transformative.
 Beckman HB, et al. Acad Med 2012;87:1-5Beckman HB, et al. Acad Med 2012;87:1-5

57. Osler’s “Aequanimitas”Osler’s “Aequanimitas”
(1889)(1889)
 Calmness in the midst of turbulenceCalmness in the midst of turbulence
 Ability to “still the waves”Ability to “still the waves”
 ImperturbabilityImperturbability

58. New model of mindfulnessNew model of mindfulness
 Capacity-building (adaptive reserve)Capacity-building (adaptive reserve)
 Stress inoculation/reductionStress inoculation/reduction
 Enhanced empathyEnhanced empathy
– Nonjudgmental attention to feelingsNonjudgmental attention to feelings
– Emotions regarded as “weather”Emotions regarded as “weather”
 Error reductionError reduction
– Self-awareness of cognitive biasesSelf-awareness of cognitive biases
– Use of higher order decision rulesUse of higher order decision rules

59. Positive economic modelsPositive economic models
 Health & Productivity Management (HPM)Health & Productivity Management (HPM)
– Integrated employee health, safety and productivityIntegrated employee health, safety and productivity
managementmanagement
– Driven by rising health care costs to employersDriven by rising health care costs to employers
 Direct: Health benefitsDirect: Health benefits
 Indirect: Lost productivity, hiring replacement workers,Indirect: Lost productivity, hiring replacement workers,
increased safety risk, toxic effects of bad behaviorincreased safety risk, toxic effects of bad behavior
(presenteeism)(presenteeism)
– Focus on prevention (safety and productivity benefits ofFocus on prevention (safety and productivity benefits of
good employee health)good employee health)
 Goetzel RZ. Steps to Healthier U.S. Workforce, 2005.Goetzel RZ. Steps to Healthier U.S. Workforce, 2005.

60. Positive economic modelsPositive economic models
 Integrating employee health promotion withIntegrating employee health promotion with
occupational injury & illness reductionoccupational injury & illness reduction
– Spillover effect between non-occupational andSpillover effect between non-occupational and
occupational healthoccupational health
– Health promotion is a goodHealth promotion is a good
 Decreased health benefit costsDecreased health benefit costs
 Increased productivityIncreased productivity
 Minimizing workplace costs of “bad behavior”Minimizing workplace costs of “bad behavior”
 Seabury SA, et al. RAND Institute for Civil Justice, 2005Seabury SA, et al. RAND Institute for Civil Justice, 2005

61. Positive leadershipPositive leadership
 Facilitates “positively deviant performance”Facilitates “positively deviant performance”
 Affirmative biasAffirmative bias
 Fosters virtuousnessFosters virtuousness
– Eudaemonic assumption: inclination in allEudaemonic assumption: inclination in all
human systems toward goodness for itshuman systems toward goodness for its
intrinsic valueintrinsic value

63. Positive leadershipPositive leadership
strategiesstrategies
 Positive climatePositive climate
 Positive relationshipsPositive relationships
 Positive communicationPositive communication
 Positive meaningPositive meaning
 Cameron K.Cameron K. Positive LeadershipPositive Leadership. Berrett-Koehler, 2008. Berrett-Koehler, 2008

64. Heroic LeadershipHeroic Leadership
 Ignatius Loyola (1491 – 1556)Ignatius Loyola (1491 – 1556)
 Leadership principles:Leadership principles:
– Self-awarenessSelf-awareness
– IngenuityIngenuity
– LoveLove
– HeroismHeroism
 Lowney C.Lowney C. Heroic Leadership.Heroic Leadership. Loyola Press, 2003.Loyola Press, 2003.

65. Contemplative in ActionContemplative in Action
 Simul in actione contemplativusSimul in actione contemplativus
 Everything is sacredEverything is sacred

66. We must be still and still moving
Into another intensity….
-T.S. Eliot

67. OrganizationalOrganizational
conversationsconversations
 What changes in your organization wouldWhat changes in your organization would
build capacitybuild capacity??
 What changes in your organization wouldWhat changes in your organization would
reduce loadreduce load??

68. Implications of physician well-Implications of physician well-
being for organizationsbeing for organizations
 Relates to patient satisfactionRelates to patient satisfaction
 Affects recruitment and retention of physiciansAffects recruitment and retention of physicians
 Increases productivityIncreases productivity
 Prevents impairmentPrevents impairment
 Promotes good behavior (vs. toxic environment)Promotes good behavior (vs. toxic environment)
 Increases patient safety and reduces errorsIncreases patient safety and reduces errors
 Optimizes utilization (tests, referrals)Optimizes utilization (tests, referrals)

69. “Not until we are lost do we begin
to understand ourselves.”
-Henry David Thoreau