Building and Sustaining an Engaged Culture: The Experts Weigh In

Added on Apr 21, 2016

Building and Sustaining an Engaged Culture: The Experts Weigh In
By Diana Mahoney
From Industry Edge April 2016

“It is a privilege to care for, facilitate and lead workforces in the health care industry,” Debra Plousha Moore, chief human resources officer at Carolinas HealthCare System, said in the opening session of the Press Ganey 2016 Engagement Summit held in Palm Beach, Fla., in late March.

This sentiment was a common theme throughout the event, during which executives from leading health care systems discussed challenges and strategies for creating and sustaining an engaged health care workforce.

“Our most meaningful work comes from valuing the people who come to work every day ready to serve, yet much of our time and energy is spent on the small percentage of the workforce who are not compliant, not committed,” Moore said, pointing to the irony that so many of today’s HR policies and procedures that address employee behavior and performance were created for a very small percentage of outliers.

“The question we must ask ourselves continuously is ‘How do we intuitively change the human resources landscape and the body of our work for the majority of employees who are committed and compliant— the ones who come every day ready to serve and do this noble work of taking care of patients?’”

The answer, she said, is by nurturing and sustaining a culture that values the contributions of all “teammates” and respects their differences, and by creating a sense of belonging and providing meaningful work. At Carolinas HealthCare, the seeds for this culture are sown during the new-teammate onboarding. Called “Caring for New Teammates,” the comprehensive program is designed to be both educational and informational, providing new employees with an understanding of the Carolinas HealthCare brand.

“We empower our teammates with the knowledge that makes it easy for them to become part of our best-place-to-work culture and part of One Team,” Moore said.

Specifically, the strategic objectives of the program are as follows:

  • To help new teammates feel engaged and welcomed from the start
  • To provide them with the tools they need to feel fulfilled and productive on the first day
  • To give them a sense of pride in being part of the organization
  • To acclimate them to the culture
  • To provide leaders with resources to assist new teammates through their first 90 days
  • To ensure that all teammates understand they are part of “one system, one team, one belief and one mission”

Because the One Team culture is so essential to organizational success at Carolinas HealthCare, with its 39 hospitals and more than 900 care locations throughout North and South Carolina, monitoring the health of that culture through engagement surveys is an ongoing priority.

“The survey provides a narrative for what’s going on in the workplace. It is the root of understanding the pulse of the organization at all times, and it creates a conversation about what is going on in our work,” Moore said. “We are able to dive into these surveys, with the richness of the information they hold, to set strategy.”

Integrating Engagement Surveys to Streamline Caregiver Feedback

The importance of capturing the voice of the caregiver was also addressed in a session presented by Cleveland Clinic’s Anthony Warmuth, enterprise quality administrator, and Christy Barnes, RN, senior director of Quality & Patient Safety. The duo presented an overview of Cleveland Clinic’s work with Press Ganey to create a single, concise survey instrument that integrates the various engagement, safety culture and nursing surveys, with an eye toward reducing survey fatigue among providers and making the survey relevant to all caregivers—inpatient and outpatient; direct and nondirect—across the organization.

“Like many organizations, we were conducting a smattering of different surveys—our annual caregiver survey, pulse surveys, the Magnet survey, a safety culture survey, caregiver panel surveys, independent physician surveys and intranet surveys—and many of them contained similar items,” Warmuth said. “Response rates for the different instruments varied, and our leaders were struggling with multiple reporting and action-planning platforms. We wanted one survey that would enable us to streamline these processes.”

Additional key considerations with the integration were ensuring that Magnet expectations would be addressed and updating some of the language of the Agency for Healthcare Research and Quality survey, Warmuth explained.

In evaluating the various surveys, the development team observed synergy across many of the questions. “We worked with Press Ganey to identify areas where we could reduce and eliminate redundancies through a single ask,” Warmuth said. “We found questions that straddle engagement, safety and Magnet, which makes sense when you think about communication and teamwork, concepts that really bridge the cultures.”

Cleveland Clinic introduced the “One Ask” model to its workforce in 2014. “We surveyed all of our 40,000 direct and indirect caregivers, as well as 3,000 physicians and 1,500 residents, fellows and trainees. Our overall participation rate was 85% in 2014, and that rose to 87% in 2015,” Warmuth said. “We’ve found that when we’re not surveying them constantly, we can really engage our caregivers in the process.”

One of the goals with the One Ask approach, according to Barnes, “has been to discover which items and measures are correlated and which are not, and to investigate the trends.” For example, analyses of the 2014 data indicate that performance on safety and engagement trends in the same direction, and that these areas also appear to trend in the same direction as patient experience outcomes, said Barnes. “The takeaway from this is that improvements to any of these areas will influence the others.”

On the horizon for the One Ask project at Cleveland Clinic, said Barnes, is to correlate survey results with outcomes data, validate the survey instrument and leverage the results to drive improvement.

Survey integration is one step in this ongoing process. “We are talking about culture—safety culture, learning culture, improvement culture, empathy culture—and you can’t just manage culture in silos. We have to look at how to connect the survey instrument to what the [outcomes] mean to the organization,” Warmuth said. “This means talking to our quality people, HR professionals and the patient experience office and developing robust education and development opportunities for caregivers around culture and experience.”

Identifying Challenges, Developing Solutions

Among the additional Summit presentations, Barbara Reilly, PhD, senior vice president of Employee, Nurse and Physician Engagement at Press Ganey, presented some of the national trends in caregiver engagement and clinician alignment and the implications of these trends on organizational performance. In particular, rising rates of clinician burnout influence the readiness of work units to engage in improvement strategies.

“When enterprisewide surveying identifies individuals at the work-unit level who are very disengaged, organizations can and must customize engagement approaches to the needs of those work units,” Reilly said, referring to a work-unit tiering system to characterize work-unit engagement and improvement readiness that she described in a recent white paper.

Based on performance on a set of survey questions that are key drivers of engagement, work units may be designated as Tier 1, Tier 2 or Tier 3. “Tier 1 units demonstrate the highest performance on key drivers of engagement, whereas Tier 3 units  perform significantly poorer on the same drivers,” Reilly said. Because a struggling work unit needs more support than a high-performing unit, adopting a cookie-cutter approach across the organization will not meet the needs of both groups.

The relationship between safety and engagement was another prevalent theme across the presentations. Craig Clapper, chief knowledge officer for HPI (Healthcare Performance Improvement, a Press Ganey company), talked about starting a “virtuous cycle,” in which the development of a safety culture drives workforce engagement, which then feeds back into safety. According to Clapper, clinicians who respond positively to the comment “I would feel safe as a patient on my unit” are engaged and personally committed to the unit’s outcomes and are open to learning and improvement around safety and reliability. This feeds back into the feeling of personal safety they experience and the likelihood they would feel safe as a patient, he said. In order to start a virtuous cycle, the organizational culture must be one defined by mutual respect, meaningful work and a commitment to improving the systems in which people work, he added.

The following industry leaders also presented at the Summit:

  • J. Bryan Sexton, PhD, director of the Duke Patient Safety Center at Duke University Health System, who described the interrelationship between societal and nursing-unit stress and care quality, and provided insight into the science of resiliency
  • Organizational engagement and culture experts from Trinity Health, who described that organization’s novel system approach to harmonizing colleague and physician engagement, safety culture and patient experience efforts, built on integrated data and advanced analytics
  • New York-Presbyterian/Columbia University Medical Center’s Courtney Vose, chief nursing officer, and Tony Dawson, senior vice president and chief operating officer, who discussed the importance of patient experience and interdisciplinary team engagement in delivering the optimal patient experience

The Press Ganey Executive Summit Series provides a unique opportunity for health care leaders and executives across the care continuum to share insights, ideas and strategies for next-generation performance improvement.