Caring for people is not a job for Emma Sandhu—it’s her calling. With beginnings as a pediatric intensive care unit (PICU) nurse, Sandhu spent years at the bedside pouring her heart into the care and cure of the children who were sickest and in the most pain. Today, she focuses on a different kind of care, albeit equally critical: the care of the caregivers.
“Our people are our most treasured assets. Without our people, we can’t do anything in a hospital,” says Sandhu, M.S.N., RN, CCRN-K, chief nursing officer, vice president and hospital administrator at CHOC at Mission Hospital, part of Children’s Hospital of Orange County’s (CHOC) pediatric health care system. “But across our system, we were seeing our caregivers expressing this sense of decreased joy and increased burnout.”
Sandhu’s story is all too familiar up and down hospital halls across America. Health care worker burnout has hit record highs—and children’s hospitals are not immune to it. “There’s this fundamental disconnect between what called people in the healing profession to their work and the environment they find themselves working in today,” says Jessica Perlo, M.P.H., senior director and improvement advisor at the Institute for Healthcare Improvement (IHI). “We’re seeing this with high staff turnover, absenteeism, burnout, poor mental health, and in some cases, suicide. It’s not new, but it has been exacerbated by the pandemic.”
And it has snatched the joy out of work for so many in health care—an industry where joy is not just a nice-to-have. According to Donald M. Berwick, M.D., president emeritus and senior fellow at IHI, joy in work is an essential resource for the enterprise of healing. “The gifts of hope, confidence and safety that health care should offer patients and families can only come from a workforce that feels hopeful, confident and safe,” he says.
The Joy in Work Framework
To help hospitals and health systems in this effort, IHI designed and tested the IHI Framework for Improving Joy in Work. Informed by experts and organizations both in and outside health care, the IHI Framework for Improving Joy in Work outlines nine critical components of a system for ensuring a joyful, engaged workforce and the steps leaders and teams can take to get there. It also provides assessment tools to set hospitals up for success.
The nine components:
- Physical and psychological safety.
- Meaning and purpose.
- Choice and autonomy.
- Camaraderie and teamwork.
- Recognition and rewards.
- Participative management.
- Daily improvement.
- Wellness and resilience.
- Real-time measurement.
Essential to all the components is fair and equitable treatment of all employees.
There are many ways to implement the components—from simple, immediate initiatives to long-term, system-wide projects—and what that looks like will vary depending on the organization and, especially, the leaders. Senior leaders are accountable for modeling and developing a culture, structure and vision that fosters trust, improvement and joy. Managers and core leaders have a pivotal role in everyday work by identifying what matters and developing practical strategies. All leaders can follow IHI’s four steps to implementing the framework.
Although leadership is crucial, IHI stresses that leaders are not solely responsible for improving joy and well-being in work. According to Perlo, everyone plays an important role in nurturing joy in the workplace by contributing to local improvement efforts to improve staff experience and working to support a more equitable work or learning environment.
Lastly, achieving joy in work requires measuring results. “It’s important for joy to be a key organizational metric on the same level as other organizational priorities and measures,” Perlo says. IHI provides a list of potential methods, but Perlo says the most practical approach is to leverage existing measurement data—such as satisfaction, engagement, burnout, turnover, retention and absenteeism—and to supplement with local measures where improvements are being implemented. Regardless of what is measured, leaders must track and share data regularly during the improvement process and make the results transparent.
Getting started with Joy in Work
As part of CHOC’s broader organizational strategy to take good care of its people, Sandhu and her team have been implementing IHI’s Joy in Work Framework since November 2021. They selected three areas to pilot the framework—one in each of their hospitals and one in a primary care office—and started right where IHI suggests: by asking people, “What matters to you?” at work. And they were surprised by what they found.
“I thought it would be easy,” Sandhu, who is known for engaging with staff at CHOC, says through a laugh. She quickly learned that some people hesitated to answer the question or just didn’t know how to answer it. So, they asked more specific questions like, “If at the end of the day, it has been a good day, what does that look like?” or “What brings you joy at work?”
Through these conversations, the team quickly discovered that the staff felt closely aligned with CHOC’s mission, but there were gaps in recognition and rewards. They asked the natural follow-up: “What kinds of rewards would be meaningful to you?” Based on the feedback, the team started by implementing some simple practices, such as recognizing people for making safety catches and writing personal notes to staff celebrating milestones.
“In the beginning, we were not working on these gigantic, fundamental changes that were going to bring everyone joy instantly,” says Sandhu. “We did some of these quick things to help people see that the organization really does care about their joy at work.”
"Our people are our most treasured assets. Without our people, we can’t do anything in a hospital."
Lindsay Carter, M.D., a pediatric hospitalist and inpatient director for Quality and Safety at Mass General Hospital for Children in Boston, started a Joy in Work program after attending the IHI annual National Forum and being moved to focus on staff well-being.
In line with the framework’s method to involve senior leaders, managers and frontline workers within various components, their Joy in Work implementation team consisted of nine members, including the vice chair of the department, a speech language pathologist, a pediatric pharmacist, and an administrator from the quality and safety team. They chose team members based on their skills and personality, which is another recommendation from IHI. “They are very approachable people,” she says.
To get started, the team had a lot of “What matters to you?” conversations with staff. They tried a variety of formats, including small groups and written questionnaires. But the team found that the most fruitful approach was spontaneous, one-to-one conversations—when a team member stopped a colleague in the hallway and asked, “Can we chat for a few minutes?” They found that staff tended to be more forthcoming in these informal dialogues without the pressure of a larger audience or having the time for a dedicated meeting. The conversations followed a general set of questions: Why do you work here? What makes a good day? What gets in the way of a good day? What are your biggest barriers to being able to provide care?
These questions led to large-scale and long-term efforts as well as some small, quick wins. One example of the smaller changes at MassGeneral reflects Joy in Work’s daily improvement component: Physicians had become frustrated with pagers, particularly because they had trouble getting ahold of the person who paged them. So, the team adopted a secure two-way messaging app, which physicians could download on their personal phones. Now, paging is reserved for high-acuity situations, and the app makes communication more efficient.
These kinds of quality-of-life changes quickly got employees on board with the Joy in Work approach. “People are engaged in a way that they weren’t before,” Carter says.
Adapting the Joy in Work Framework
While there is a hierarchy to the framework, an industry like health care can be full of challenges that require organizations to reorient their priorities. When RSV, COVID-19 and influenza collided for a tripledemic last year, Sandhu adjusted their plan to account for employees’ safety.
“In 30 years, I had never experienced any sort of surge like that,” she says. “We had to shift focus entirely.” Sandhu and her team used various methods to learn what mattered to employees in real time. They used an app they had developed and a QR code staff could scan to rate the kind of day they had on a five-point scale and provide comments. They discovered that in addition to needing staffing support, employees needed support for traumatic or stressful events. This insight revealed a different way of recognizing staff during a challenging time. “We reprioritized the physical and psychological safety component and put the others on pause,” Sandhu says. “The idea was that we can’t be prioritizing autonomy and control, rewards and recognition, when people do not feel safe.”
"People are engaged in a way that they weren’t before."
Sandhu’s team launched several initiatives in response: chaplain visits, a space for debriefs, a wellness area where employees can decompress, and—one of the most popular additions—massage therapists who go floor to floor giving 10-minute treatments to staff, day and night.
Like Sandhu, Carter’s Joy in Work priorities shifted suddenly when faced with a major crisis. When the pandemic first arrived, the hospital converted the pediatric unit to an adult unit on an emergency basis. After that, Carter says the joy wasn’t as apparent, so they decided to go back to basics and focus on psychological well-being and wellness.
The team launched several projects to improve wellness and resilience, such as redesigning the morning discharge huddle, spearheading a newsletter to staff, and displaying “joy communication boards” on which the team could share information and staff could provide feedback and note their needs—always keeping up with what mattered to them so they could adapt accordingly.
Future plans for Joy in Work
Looking forward, both CHOC and MassGeneral plan to refocus on larger-scale changes. Though the pandemic set back MassGeneral’s larger projects, “change takes time,” Carter says. “It will take multiple changes to find what works. And you need to stay positive about that journey.”
For CHOC, it’s early in their process to adopt the framework, and the next step is to make some concrete decisions. About 30 multi-disciplinary leaders from across CHOC are convening this spring to see where they should take their learnings, including the resources and tools they need, how they will measure results and where and how they will spread efforts that have already been spreading joy across their teams.
Perlo says organizations can find success in this effort by starting small, listening closely and going where there is initial energy for change. Test strategies and improvements before making larger-scale changes, really listen to understand staff members’ needs and experiences, and tap into a leader or champion with willingness to get creative and get started.