“It isn’t joy in work; joy IS the work” - Kate Hilton (IHI Open School), Helen Bevan (NHS England), Hans Hartung (NHS Scotland) and Marianne McPherson (IHI 100 Million Healthier Lives)
10 May 2017
Kate Hilton of the IHI Open School, Helen Bevan of the NHS England, Hans Hartung of NHS Scotland, and Marianne McPherson of the IHI 100 Million Healthier Lives team describe how leaders can embrace their role as facilitators of joy in work.
Improvement guru W. Edwards Deming had a clear vision of a leader’s role: “Management’s overall aim should be to create a system in which everybody may take joy in his [or her] work.” Studies have shown that joy in work leads to:
- higher service user satisfaction
- better staff engagement
- more cooperation among staff
- higher productivity, and
- more efficiency.
But what exactly is “joy in work,” and how can we, as leaders, elicit it? We tackled that question during a unique session at the 2016 IHI Nationanl Forum.
As we prepared for the session, we wanted to develop a shared understanding of joy from our work as leaders of large-scale change efforts. We believe joy is a lived experience, not a theoretical one. While we may possess strategies and methods for creating joy, they must pass the “sniff” test: we know when we feel “joy” — and when it is inauthentic or forced. We experience joy as a feeling of pleasure, happiness, and wellbeing that results in energy, connection, a sense of purpose, meaning, and fulfilment. In other words, we all have an internal “joy calibration system.”
We took that knowledge and challenged ourselves to teach about joy with joy at the Forum, where we gathered with 20 frontline leaders of change in health care. As pre-work, we asked participants to submit “personal anthems of joy,” which played throughout the session. As participants entered the room, we welcomed, acknowledged, and thanked each one of them for their presence. We asked them questions about themselves, helped them find their seats, and introduced them to one another. We shared pictures and stories of who we are and what brings us joy. We ignited the senses in small groups around smell, touch, taste, sound, and breath. And during our break, we conducted a “Randomized Coffee Trial” to deepen authentic connections.
Our workshop’s aim was to create a Joy Manifesto that explored how we experience joy from within, together, and across a system. The following seven design principles for joy emerged from the group’s work. Central to these principles is the understanding that while joy is a lived experience at personal and interpersonal levels, creating the sustained conditions for joy is a system responsibility. These system conditions, then, lead to personal and interpersonal joy at work:
- Create conditions for people to identify sources of joy from within. We cannot give what we do not have. Because joy lives within, we must identify the personal practices and habits that connect us to our internal sources of joy, like journaling, being in nature, exercising, meditation, and singing. Test to Try: Notice for yourself: what makes you joyful?
- Encourage people to bring their whole selves to work. This is about moving from knowing what brings you joy to living it at work. How might you bring other joyful parts of your life into the workplace? Participants offered examples like writing thank-you notes to others at work, building a quiet walk into each work day, and sharing a joke, personal stories, or pictures. Test to Try: By next Tuesday, what one joyful life practice can you integrate into your work day?
- Create conditions for human connection. To live is to be connected to — and helpful to — each other. Human connection is an organic process that emerges whenever people meet. Workshop participants noted that connections amplify collective learning by building on one another’s strengths and recognizing weaknesses. The quality of our connections is a predictor of our happiness. Sharing stories and facilitating a social environment help to build authentic connections. Attentive listening without interruption, humble inquiry, and genuine curiosity are human ways to build empathic bridges. Test to Try: In the next week, listen to someone without interruption and with curious interest in what they want to share. How is it different?
- Make it safe to be joyful. Deming also said, “Drive out fear, create trust.” Trust and absence of fear are the foundation to go beyond “safe space” to “brave space” where people can try new things and be vulnerable, honest, and light-hearted together. Joy lives at the edge of taking risks and knowing that it is okay to fail forward. Ask “open and honest” questions, demonstrate acts of kindness, greet everyone within a 10-foot radius, adopt an “eyes up, hearts open” hallway culture with no smart phone use, and celebrate courage. Be nice, consistently. A culture that values recognition and respect encourages trust. Leaders have a particular responsibility to create these conditions by modelling these behaviors. Test to Try: Put away your smart phone for one day and acknowledge those around you. See what happens.
- Create a space for others to lead. Be authentic. Don't give power and take it away; instead, help others see and use their agency. Ignite people’s autonomy by asking them to break the rules when the rules stop serving the intended purpose. Empower people to refine and redefine measures that don’t make sense. Replace micro-management with mutuality by spending time at the front lines to speak with and listen to people. Test to Try: This week, make rounds on the floor or in the field with the intent of unleashing others’ capacity and will to solve their own problems.
- Build systems for joy: When we think about joy, we typically think about intrinsic motivation: connecting with people’s internal motivation, linking with their values and the things that matter to them at the deepest emotional or spiritual levels. But we can also create systems of extrinsic motivation to support joy. By this, we mean introducing levers or system drivers that encourage specific behaviors or “prod” people to engage in particular activities. Examples include:
- Defining joy as a stated value of the organization, developing metrics around joy, making joy a deliverable to which all staff dedicate a percentage of time each month, and including joyfulness as a qualification in job descriptions
- Creating conditions for joy to emerge, as Swedish leaders do with “FIKA,” a break with coffee and cake
- Backing off if incentives are experienced as "compliance for joy,” making them inherently un-joyful
Test to Try: By the end of the month, explore one concrete step for your organization to take to design for joy.
- Create conditions for people to learn, improve, and innovate. Having fun designing joy in work, actually enjoying the process, was one of the most exciting insights from the workshop. Improvement and innovation stimulate creativity and intrinsic motivation, resulting in joy. As Deming noted, “Innovation comes from people who take joy in their work.” Co-ownership, playful improvisation, experimentation, valuing failure, the appreciating of stories behind the data, and a focus on collaboration make change come alive. Joy in improvement work results from the knowledge that any improvement contributes to the bigger picture and is connected to others’ learning. Joy builds confidence, and confidence builds intrinsic motivation for continuous learning. As Deming stated, “We are here to learn, to make a difference, and to have fun.” Test to Try: Have fun! (Really!)
All in all: It isn’t “joy in work”; joy is the work. Being an improvement leader who creates the conditions for joy means knowing it, being it, sharing it, and designing for it. For Deming, there was no doubt that the experience of joy in work was a prerequisite for any high-performing organization. Joy must be how we do business — within ourselves, together with others, and across our systems.
Sources and additional reading:
- Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ QualSaf. 2015;24:608-610.
- Sirota D, Klein D. The Enthusiastic Employee: How Companies Profit by Giving Workers What They Want (2nd edition). Pearson FT Press; 2013.
- Stress in America: Paying With Our Health
- Finding joy and meaning in work: In support of the Quadruple Aim
- Joy in Work is a featured topic track at the 2017 IHI National
The intents and desires of the heart: turning good intentions into purposeful action - Shaun Maher, Strategic Advisor for Person Centred Care and Improvement
20 April 2017
As health and social care professionals we are in an especially privileged position often spending time with people at some of the most momentous or traumatic times in their lives. A new life entering the world; facing up to serious illness; recovering from an injury or perhaps the loss of a cherished parent? These are the most memorable, meaningful and often challenging times in people’s lives and in our daily work we have the opportunity to support people, to encourage them and walk alongside them.
Yet all too often in the hustle and bustle of a busy day we forget about this unique privilege – the honour of being a visitor in someone’s life story. Not taking the time to find out what really matters to them; a hasty response or a word spoken a little more harshly than it should have been. These lapses pass quickly form our memory in the bustle of the day, but what about the person? Do they forget so readily? The daughter seeking information about her Mum at a time of crisis? The young Dad (or Dad to be) that just wants to be as close as he can to the most precious things in his life? Do they forget so readily? A careless response by us becomes an experience, even a trauma, carried by that person for the rest of their life.
The spirit is willing but the flesh is weak
So, how do we make sure that we stay connected to the deeper meaning and purpose in our work? How do we make sure that we always have to the opportunity to focus on what really matters to the person in front of us? How do we create processes and systems that recognise the value human connection and provide reliable opportunities to and reminders to help us in this endeavour? How do we improve?
Often we set out with good intentions: “I promise to….” I will always…” But what do these good intentions look like in action? Even with the best will in the world, do they always happen? I think if we reflect on our own experience we realise that despite our best intentions we are at best patchy – the spirit is willing, but the flesh is weak!
Transforming good intentions into actions and making these behaviours part of our daily routine is probably the single biggest challenge. The reality for most of us is that the scale, pace and technicality of the modern world, and especially the health and care system, means that we can’t take it for granted that we will always remember to do the right thing, to say the right thing and treat people as they should be treated. We need prompts and reminders to help us. We need to design a more person-centred system to support the growth of a truly person-centred culture.
Purpose, Measures, Method
To turn our good intentions into reality we need to start by focusing on purpose. Once we are clear about our purpose or aim at work we can then start to think about the question: “have I achieved the aim that I set out to achieve?” To get answer to this question we need to measure something – DON’T stop reading just because I said measures!!
By starting with purpose measurement is made much easier and much more meaningful. In this context measurement can be as simple as observing (or reflecting on) whether the thing you wanted to do actually occured? Keep a tally or watch what goes on around you for 5 minutes. For example: “did I always ask every person about the things that are really important to them at this time?” Yes or No? If not, why not? And what could I do to remind myself to do it?
Your chances of success are much increased if alongside purpose and measures you have an improvement method. There are lots of methods out there – pick one and stick with it! We have widely used the Model for Improvement (MfI) in Scotland and I think it is probably one of the simplest and most adaptable methods out there. It starts with three simple questions:
- What’s the thing you want to improve? (your aim: how good do you want to be? and by when?)
- How will I know I’ve improved? (what are you going to measure?)
- What’s the first step towards making this happen? (your ideas about things you could try to make this improvement happen)
Once you’ve answered these three questions the second part of the MfI is to move to action – using a simple framework called the Plan. Do, Study, Act (PDSA) cycle. This structure can help you test your idea in a very small way to see if it works. Try it with one person on one day. Tweak it and try it again. Try it with two people, and so on. Once you’ve run a few tests you’ll be amazed at what you learn AND most importantly – your good intentions are turning into actions!
So, let’s maintain that strong sense of purpose, but don’t stop there. Think about what your good intention would look like in practice and then measure whether it actually happens. Being fallible human beings we inevitably realise we’re not quite as good as we’d like to think we are – there’s always room for improvement!
Then move to the final step and think about the thing you can do to make yourself more reliable – focusing on what matters for every person, every time. A prompt in the notes, a personal “what matters to you?” board above every bed in a hospital, a reliable framework, such as Talking Points, to help you understand what matters most to the person in front of you.
Take good care of yourself!
This isn’t just about you changing the world. There are all sorts of other things that need to change in the wider system around us, but these things are outside the sphere of influence for most of us. In light of this reality we need to maintain good self-care and set our sights on the long view as we work on our small wins each day. Sometimes we will have set-backs and this type of work can feel difficult and challenging in the prevailing climate and culture. But don’t lose heart! The overall momentum is in the right direction. Maintain your strong sense of purpose, think about how you will measure your progress and then move to action.
It’s also important to find some like-minded folks so you can support and encourage one another. Start small and begin by designing some prompts and processes into your daily routine that will support you to turn the desires of your heart into your daily reality.
Why communication key - Claire Chue Hong, Disabled Peoples Housing Service Fife (DPHS
16 March 2017
With spring in the air and thoughts now starting to stray towards the long summer nights and been able to stray from the cosy fireside to the garden and planting new seeds, though this is Scotland so with the recommend wellies and waterproofs in tow. I can’t help but wonder if I’m choosing the right seeds to sow, should I start from scratch with the seeds or should I just go to the shop and buy any plants I can find? Who do I go to for information and advice, as a total novice at gardening there is more chance of me going to the local bakers and asking for gardening sheers than going to the local garden centre? Why does this even matter I hear you ask, well for service users this is very much the point, they need to have someone who they can have a good quality conversation with to help them understand the very detailed process of accessing social care.
We are a disabled people’s organisation in Fife who are offering this service, with the approach very much centred on the person and their families/carers and helping them to understand self-directed support (SDS). This gives them the confidence that when they see a social worker for an SDS assessment they know what they are talking about, what to highlight and what to expect. Very much like myself I have the seeds and the knowledge and now the confidence to sow them.
An example of this was I was working with a lady who had a risk of falls and has dementia but wants to stay in her own home. I met with her and her daughter to have a conversation to find out what she wanted in terms of help, what her needs were and how she wanted to receive her support, this meant her daughter was able to liaise with social work to get in the care she needs because she had the confidence to put across her mum's choices over her support. This really shows the value of what a small thing like having a good quality conversation can have on individuals and asking them what they want and what matters to them.
However, what happens when you bought the wrong seeds, you have a hole in your wellie and it just seems to be constantly pouring with rain, we are in Scotland after all. There is still hope of that seed coming through the surface with the right support and May does seem to be the month of sun breaking through those dreary days and flowers coming into bloom.
Another service we provide is assisting people at meetings with social work where communication has broken down. A person who I supported on such an issue is bedbound and receives 3 hours support a day in the evening but needs more help. Unfortunately communication had completely broken down between her and her social worker so she was reluctant to see her social worker again. I went to visit her to have a conversation to find out more about what help she needed, what her personal assistants were doing when they came out, what extra help would benefit her and how much time she needed to do different personal care tasks.
From this visit I then arranged a joint visit with social work to support her to communicate with her social worker. Both were firm about their views which made it hard for each to understand where the other was coming from. Previous requests for extra support were turned down but we managed to agree that if her PA kept a record of how long it took to do each of the tasks during their 3 hour visit for 4 weeks. If all the time was taken up on personal care tasks only then would her social worker have evidence to take to her manager to request extra hours so that a visit earlier could happen for someone to come and help her with lunch and any personal care tasks needed. Without my involvement it is unlikely that things would have moved forward.
Thinking of different ways to evidence the need for care and having good conversations makes all the difference. Also having someone to explain that the social worker is hearing how bad things are but that they can't make a case for extra care without evidence to prove it's needed, that decisions are made higher up and funding is stretched. Communication is key and it has to be in a way that the person you're working with understands so re-wording jargon and explaining things in a different way makes a huge difference.
Very much like my gardening skills if they are encouraged, given the right support and confidence and the opportunity to flourish the outcome can be a garden full of roses.
For further information on Disabled Peoples Housing Service (Fife) Self Directed Support Options Project please get in touch via the below methods.
Website – www.sdsoptionsfife.org.uk
Telephone – 01592 803 280
Twitter - @SDSOptions
Email – firstname.lastname@example.org
'What matters?' - Shaun Maher, Strategic Advisor for Person Centred Care and Improvement
15 February 2017
It might seem strange to some people that we have to remind people working in health and social care to focus on what really matters to the people they are supporting or caring for. If they aren’t focused on the things that really matter to the person they are speaking to, you might ask, what are they focused on? That’s a good question.
Health and social care services have developed in the modern era from a time, less than a hundred years ago, when there was little or no state support for anyone. In those times the only support, care or treatment that was provided was based either on your ability to pay or the good hearted generosity of charitable organisations and individuals. Over the last 100 years or so, state-funded health and social care services have gradually developed into what we see around us in Scotland today.
These services have their origins in a time when “doctor knew best” and things were done “to you” without too much recourse to your personal preferences or inherent strengths or capabilities. This paternalistic “we know best” culture has survived down to the present day and means that often decisions are still made on the basis of what someone else thinks is best for you, without very much knowledge about you as a person and what makes you tick. Of course the health and social care system today is focused on people, but is it truly focused on what matters to those people? I would argue that the perspective is still predominantly one which is all about doing things “to” people or “for” people. This way of thinking can only get us so far. The signs around us indicate that we need to do something different for the 21st century.
So, when we talk about “what matters to you?” or person-centred care, we aren’t just talking about being nice to people, important though that is. Neither are we are implying that the current activity of the health and social care system isn’t focused on people; it very much is. But the current perspective is still too much in the “we know what’s best for you” mode of thinking. Not enough attention is paid to the personal preferences and values of the people we serve, the inherent strengths and capabilities that every person has, and the relationships (or lack of) that surround them in their life. This is what we mean when we talk about “what matters to you?” and person-centred care.
The impact of this shift in perspective has the potential to be very significant in helping us to develop health and social care (and other areas of public service) in new and creative directions, but the scale of the task should not be underestimated. This different way of interacting with people and understanding what truly matters to them in the context of their life, requires new skills, new and creative ways to measure, a much stronger focus on people and relationships and new ways of working. This is a generational shift and it will perhaps feel challenging and uncomfortable at times, but these feelings of difficulty and discomfort are a good sign and indicate that we are moving out of our comfort zone into new ways of doing things. We need to lean in to the discomfort!
The Scottish Government has a dedicated Person-centred and Quality team. This team supports “What matters to you?” day along with a range of other work that is underway with health and social care services, the charitable sector and other partners across Scotland. Our aim is to support and develop new ways of thinking about and delivering truly person-centred care and support for those who need it.
We hope that you will be excited by the opportunity to think and work in a way which feels much more meaningful and is strongly focused on people and relationships and the things that really matter. “What matters to you?” day 2017 will be a wonderful opportunity to join in with thousands of people around the world who, together, are working and learning how to create a health and system that starts with a “what matters to you? conversation for every person, every time.