Author: Stephen Swensen, MD
Health Care Leadership
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Steven Swensen and Don Berwick, both physicians and senior fellows focused on efforts to build trust by better integration of systems.
Steve Swensen: Don, I’m Steve Swensen. We’re longtime friends and colleagues. It was good to spend some time with you here.
Don Berwick: Indeed. I’m Don Berwick President of Emeritus and senior fellow at the Institute for Healthcare Improvement. Great to see you.
Steve Swensen: When I think of trust, I think of you and IHI and I’d love to hear your thoughts about the last three decades at IHI. It started with this cool vision and about that much capital and in one city and 30 years later, you’re a global behemoth that you’ve made your power by influence and change and impact and in that probably had a little bit of charisma or maybe a lot of charisma behind it in a beautiful vision, but trust had to play a role with your staff and the partnerships with patients and colleagues and medical centers in every culture on the planet.
Don Berwick: Well, thanks for the question and for the kind comments. You know, I’m really, I feel lucky to have been associated with IHI and it has grown, but it’s always felt to me to be kind of part of a very big community of effort that you’re in, Steve. And it’s never felt to me like one thing that’s grown, but rather a collective effort that’s just, it’s thrived. To the extent that there’s something in IHI’s genetic code around that makes it successful. And I’ve always felt it’s friendship. The origins of IHI, which go back to the mid-1980s, was actually in a group of about seven or eight friends. We independently had discovered the work of the great scholars of improvement, Deming and Duran and others. We were independently interested in healthcare quality and we found each other.
There was a center point that was Paul Batalden who was cofounder of IHI, and Paul convened us, some of us strangers to each other, as a learning circle. And for a period of a few years, we studied together, we learned together, we wind together when we ran into obstacles. Each of us was in place in an organization, but a little bit lonely there. But we all believed it was possible to improve healthcare, and if we learned the right methods. The glue was affection and I think, I think it was the source of trust also. So we weren’t competing with each other. We’re helping each other and that ethos, it’s really stayed through even to today.
Steve Swensen: Yeah. It’s beautiful. And you probably, can you have friendship without trust?
Don Berwick: Very hard to do. No. I guess you can’t. Once trust is betrayed, a relationship severed. But that idea of relationship, which you’ve written so eloquently about, I think, I think it’s core. If we treat what we’re doing as transactional, it doesn’t work. It just doesn’t work. It’s not sustainable, really. It looks sustainable. It looks clever. It looks macho, but it’s not right. And yeah, just knowing we’re going to help each other and can count on each other, that was, that was really key. It’s still there now and now, I think it’s a global community.
Steve Swensen: Yeah. What a great story. So in its core is quality improvement about trust where the leaders in organizations or systems or clinics or groups say you’re doing the real work and we, instead of giving you the answer, we trust you to figure it out.
Don Berwick: Yeah. Yeah, of course. [Indiscernible] [04:02] famous in one of his last interviews, said qualities about love with we try preferably believe so. I think that there’s a technical side of this that actually roots it for me intellectually because improvement of the type we’re invested in is about, it’s about systems, about interdependencies, complex endeavors where what you do affects me and what I do affects you. When we understand that and we’re going to work together to create a better result for the people we’re trying to help. The core asset is cooperation. Tom Nolan, who sadly died this year, my most important mentor, Tom was interested in change concepts, things that actually make a difference. He said the premiere change concept, the real, when at bottom, the one that matters the most is cooperation. So, which means we help each other because we want to get something done for someone else and how it’s not going to happen without trust. Otherwise, I’ll be afraid you’re gonna take something from me in instead of share something with me.
Steve Swensen: It’s fascinating. We were talking about love and Demi talked about joy in work and cooperation and trust as attributes of some of the most successful businesses.
Don Berwick: Yeah.
Steve Swensen: These are lovely, but soft, psychological, sociological terms is not—
Don Berwick: It’s a contest. Do you think it’s naive? Do you think that you’re being a, you’re going to be taken? Because the world’s mean and you know, there’s a lot of bad stuff out there in the world can be mean and there is a lot of bad stuff out there. So it’s, you know, it’s understandable for people to listen to this conversation and say, boy, what are you guys smoking? But I’ll tell you, I’ve been there, done that. And without that form of bonding, I don’t know how you’d get complicated things done in a sustainable way. It’s not through accountability. It’s not through incentive. It’s not through yelling loud enough. It’s not through trickery. So show me something better. And I think your earlier concept at IHI is that manifestly, it works. I’m gonna say, Steve, you added something big to this because you’ve clarified for me more than any other scholar right now, the relationship between what we just are talking about and meaning because I think the why, why should I trust you? What’s the reason? And the answer is because we’re both want to get done with our lives something that matters to us. And if you don’t connect to that, you’re going to lose heart pretty fast.
Steve Swensen: Yeah. And leaders play a central role and have that happen. Whether you’re the founder, president, CEO of IHI, or whether you’re a nurse manager, the relationships you have with the people on your team are fundamental and the behaviors that you have as a leader make a difference in the wellbeing of your staff. And that then translates into better care for patients. You know, Marine taught us that you cannot give what you do not have and if you’re distressed in some way then patients suffer from experience and outcome and higher costs and less safe environments.
Don Berwick: Yeah. You know, ask you a question because I think one verge of vision of leadership is that you get other people to do things that, you know, you’re smart enough and good enough at using the levers that you can kind of make people do stuff so that you align efforts and things like that. But you know, I don’t, I’m not so sure. I think that leadership is much more about releasing people to do what they want to do. Again, that sounds a little naive, but I think—well, Demi used to say all people want us to be proud and joyous in their work, as you said, and the smart leader makes it possible for that. It doesn’t command it.
Steve Swensen: Yeah. It’s a social process to engage colleagues and teams of colleagues to meet challenges together. And the leader behaviors that are fundamental for this are basically are participatory management where it’s not the sage coming in with the answers, it’s he or she humbly listening and inquiring and engaging the team so that everyone collectively configured out together. And then that engages them, and you see higher levels of fulfillment and meaning and purpose because now, you’re a respected and trusted part of the team and then you don’t care about your job description anymore because you come to work because you can’t wait to work with people to get something done.
Don Berwick: Yeah. I once called a friend of mine who had been promoted to a much more senior job and say congratulations in being the boss and he said, you’re never the boss.
Steve Swensen: You’re never the boss.
Don Berwick: And I think that’s take home.
Steve Swensen: Yeah. And if you think you’re the boss, then you failed because then you’re being more impressed with a number of the back, the name of the back of your jersey instead of the name of the front of your jersey. And you’re, you made the title, you made the salary, but you won’t have the results.
Don Berwick: So one of the things I admire so much about your work at Mayo was you were able to take rather area ideas about leadership and converted into a leadership index and really discover some strong relationships quite formally. What spurred you to do that?
Steve Swensen: It’s a decade ago now that we started working on this. I was, that year I was appointed to head up organization and leadership development. And we look, we’ve been serving all 60 some thousands of our staff every year since 1981. And that year when I started in that role, we saw that there was a huge variation among physicians in their levels of satisfaction, fulfillment, and professional burnout. And so we said, well, why is this such a variation?
Don Berwick: And you could measure those things.
Steve Swensen: We could measure those things. So we measured those down to the unit level. We also measured leader behaviors, but we never did anything with them. And then we talked about this among all the chairs one morning, every Wednesday, all the chairs would meet with our CEO. John knows where the time and we all have had a cardiologist, said, well, let’s look for the positive deviance. So what were the departments and growth groups that had the highest levels of fulfillment and satisfaction and the lowest burnout? And then we ended up linking that to the behaviors. It turns out we did a deep dive, 130 different units and found that 47% of the variation was due to the leader behaviors.
Don Berwick: How much variation was there?
Steve Swensen: It was staggering. We had a twofold difference of professional burnout between the highest and lowest areas. And then so on the 60-point scale, the staff would answer questions about their leader. And for every one point up, single point up, there was a 9% higher level of professional fulfillment satisfaction. And for every single point upwards, there was 3.3% lower rates of burnout. So we knew we were, and it was statistically significant. And so we started managing that.
Don Berwick: So what were the elements of the index?
Speaker2: Index are, Don, the behaviors are common sense. They’re not rocket science. They’re just not, they’re just not common practice. Appreciation. Thank you for what you did with the team today for this family. It made a difference. It wasn’t your job description but thank you. I’m interested ideas. I communicate transparently. What do you want to be doing five years from now and how can we help your dream come true? And no, we should invite her. Everybody on the team should be welcome and comfortable and respected. So basically, inclusion and appreciation and transparency, those simple behaviors. If the staff thought their chair live those authentically, they thrived.
Don Berwick: Did you ever worry that you were being too soft, that this stuff is too nice and that there’s an edge to leadership where you have to really, you know, be strong and commanding? Or is it, is this really the heart of it?
Steve Swensen: Well, when we got criticized by a board member when we went with our results and our plan saying this is soft science. And I said, no, it’s not soft science. It’s rigorous science with controlled studies and key values. But it’s about social scientists, about psychology. It’s about sociology and people and behaviors. But it matters. And look what we’ve shown. When we work on those leader behaviors, burnout rates plummeted over a three-year period while the national rate went up nine points.
Don Berwick: Yeah. I remember reading your first quantitative paper on this and the relationship between the variables you talked about and the burnout levels was stunning. I mean, really, really strong correlation.
Steve Swensen: So rigorous science of randomized controlled trials with, you know, common salady in meals. It’s a soft science, but that we’re people—we have, that’s the nature or not.
Don Berwick: So what’s the—explain this common salady concept, which I first learned from you.
Steve Swensen: It is a great word and it means a precious thing for human beings. It’s sharing a meal with someone and it makes a difference in our wellbeing and our ability to take care of patients in a better way. In the randomized controlled trials, you know, one of them we showed our cortisol levels went down.
Don Berwick: Which is a measure of stress.
Steve Swensen: And we measure stress and we saw that demotion, that social isolation went down and emotional exhaustion went down and cynicism about the organization went down all by having professionals and colleagues have a view of someone in a conversation. And that, is that soft science? Well great, bring it on. Because we know that that makes a difference for patients. And that’s so.
Don Berwick: So you said earlier that the science is clear, the results are strong, it makes sense. And yet it’s not, these behaviors are not as widespread as you wish they were. Why not? What’s in the way? It seems so obvious.
Steve Swensen: They aren’t. And I think it’s starting to spread that there are people that are measuring it. So many of our healthcare organizations on their planet have a razor thin margin and there is an inducible rock solid return on investment for patient-centered quality improvement and for working on engagement of professional burnout and joy of work. But it doesn’t show up on the balance sheet tomorrow or next week or next month. It shows up next quarter and next year.
Don Berwick: They’re alongside.
Steve Swensen: You do. And so that’s where, that’s part of the problem.
Don Berwick: You think it’s harder to be nice?
Steve Swensen: You know, I think it’s everybody has more fun and there’s more joy in work, in collegiality if you do that, but it’s not the last generation of what bosses did. You know, you’re not, the reason we pay you is if you’re not supposed to have fun at work.
Don Berwick: Yeah. I remember going to a group suggesting that joy in work become a goal and that group laughed me out of the room. You gotta be kidding. And I, you know, made me sad. You know, you were asking earlier about IHI’s successes. You know, one of the most satisfying eras was the campaigns we ran, the 100,000 Lives campaign, you remember? That was I think 2004 to 2006 or something like that. And it was an amazing experience. We had our board and the staff had looked at our results. We were a little impatient with spread. And so we, and we had some changes that we thought would make a difference in survival in the American hospitals. And so we just called it out. We said, how about, hey, would you like to join? Would like to save, you know, tens of thousands of lives through adopting some changes?
And that one of the lessons I learned through that period that always comes back to me when I read your work, is we had no power. There was nothing that that little organization could have done to order anybody to do anything. We couldn’t pay them. We couldn’t create contingencies. We couldn’t reward them or punish them. All we do is invite them. And that idea of invitation to do something that your heart wants you to do, it was so powerful, Steve. We had 3,100 hospitals. We had, every meeting I remember going to all over the country was like, it was like I don’t know, a festival of commitment to something really important.
Steve Swensen: And you saved countless lives and as important or more important, you engaged thousands and thousands and thousands of healthcare professionals in a long-term passionate need. I remember going home from that meeting with Dave Herman that was just new in the quality leadership to Mayo said, we’re doing this and we’re starting tomorrow, and we can’t wait to get going. And Mayo that, you always make decisions and committees and groups, and we said, we’re not waiting. This is so important. We have to do this right now. And we did. And no one objected. And because it was, because you inspired us, and we trusted you and it made a difference.
Don Berwick: Yeah. I mean, of course, they who saved the lives of watching these hundreds and hundreds of people around the country dig in and try to do this. It was, it was amazing. We released something and I wish we could hold onto that and build on that.
Steve Swensen: With the power of the spirit and passion, it unleashes so much good. And I think that’s, that doesn’t happen unless people trust leaders. And that’s a wonderful case study for now that can work.
Don Berwick: I know we’re almost out of time, but I gotta ask you one question on top of it. Is your experience with the work you’ve done at Mayo on burnout and the leadership index, is this a globally useful, that have you gone to other countries and found the same dynamics at work, or is this pretty much an American model right now?
Steve Swensen: I think the two core improvement efforts which one is a quality improvement, you know, core that the IHI’s white paper. The two core strategies for addressing professional burnout are universal as long as you have human beings working. It’s basically identifying frustrations as a team and then fixing the processes or helping leaders be more humane and sensitive and participative at the end. I think that no matter what the language or culture, it’s that’s universal, like the language of quality improvement.
Don Berwick: And it probably goes way beyond healthcare for sure.
Steve Swensen: It does, yeah.
Don Berwick: So does your use of and teaching about the leadership index itself build trust? And if so, how does it do that?
Steve Swensen: You know, I think it does. So imagine if you had a leader who authentically appreciated you, was genuinely interested in your ideas, opened the books for you to see all of the information, all the data, all the blemishes and warts, had a special interest in your career and worked with you to become better and included everybody, regardless of genome or phenome or creed, how could you not trust someone like that?
Don Berwick: The other thing is it strikes me, maybe, maybe I’m wrong, that the leader who believes your science has to trust the workforce. You’re going to be seeding quite a bit of control or the illusion of control and you better trust them or that’s not going to go well.
Steve Swensen: All right. So if you’re looking at really interested in their ideas, communicating transparently and doing this together, that is a surrogate for I trust you.
Don Berwick: One of my early teachers in the field of improvement was a guy named John Dowd, who was a protege of Dr. Deming’s, and he was, he taught me so much, and I remember one of the things Dowd told me once was, if you’re a leader and you don’t trust your workforce, don’t even start. He viewed it as a precondition for improvement.
Don Berwick: Profound. Don, it’s great to visit.
Steve Swensen: Great to visit. Thanks.
Narrator: Visit buildingtrust.org to learn more.