Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Wellbeings podcast, Vital Conversations: Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Fowler: Thank you for joining us. Hello and welcome back. I'm Carolyn Cumpsty-Fowler, your host for today, and I'm delighted that you're joining us to listen to a conversation about how we live and work mindfully. Our guest today is Jennifer Salaverri, and she's a licensed clinical social worker who worked in healthcare for 15 years and specialized in working with people who have lived through trauma. But Jen is also a certified mindfulness and meditation teacher, a yoga teacher, and a certified life coach. At Johns Hopkins Medicine, Jennifer works as part of our office of Well-Being team and the Healthy at Hopkins program to support the workforce in lowering their stress. I hope that you will learn as much from Jen in this podcast as we have, having her part of our team. Jen, welcome.

Jennifer Salaverri Good morning. Thank you. I'm really glad to be here.

Fowler: Jen, before we explore the various ways in which we can live and work mindfully, can you start by telling us a little bit about your own personal journey?

Salaverri: Sure. As you said, I have been a clinician for over 15 years now. I like to joke that I started when I was three, and I really loved working with my clients and my patients and throughout my life, and certainly in my professional career, I've been really interested in the mind body connection. That led me to pursuing training in mindfulness, meditation and yoga. I would use those practices with my patients. It wasn't long into my career that I realized that in order to preserve my own health and well-being, not only as a practitioner, but another human going through this life, that I also needed to use the practices that I was teaching. Perhaps not surprisingly, it really helped. During the COVID pandemic, I really felt called to support my colleagues in healthcare because I saw how much we were all struggling under the weight of working in healthcare during such an intense time. I started to offer short yoga and mindfulness breaks during lunch or after work to my colleagues just in my immediate office, and they all shared how helpful it was. That really began to spur my interest in employee health and well-being, and a short while later I found my way here to Johns Hopkins. The rest, they say, is history.

Fowler: Well, we're profoundly grateful that you found your way to us at Johns Hopkins Medicine. Jen, there's such a lot out there right now about mindfulness. Perhaps before we go any further, could I ask you just to help us get on the same page about what you mean when you refer to mindfulness and how we live and work mindfully?

Salaverri: Sure. Very simply put, I think of mindfulness as bringing our attention or awareness to this present moment and not judging that. Another way to think about that is bringing attention or awareness to what is happening right now, not what has happened or not what might happen. There are really two different buckets that I think of this in. Then there's bringing attention to what is happening in my internal experience in this moment. How is my body feeling? How is my mood today? What are my thoughts like? For those of us that work in healthcare, that can be a little bit of a different practice because we're trained to attune to how everybody else is doing all day, how our patients are doing, how our clients are doing, how our family is doing. Really, the practice of bringing attention and awareness to our experience can be profoundly impactful. Then, of course, there's bringing attention and awareness to what is happening around me right now with a true quality of presence. I'm sure that I'm not the only person that's had the experience that you're driving along in your car, and you are so lost in thought that you drive right past the exit that you were supposed to get off at. Mindfulness really invites us to bring all of our attention and awareness to this moment. 

Fowler: I love that you describing it that way, because I think in one of our earlier podcasts, we really have talked about the gift of presence. In healthcare, we have to be so present with our patients, with the families, with each other. It's hard to do that when our brains are somewhere else.

Salaverri: Exactly. There's also the invitation to notice how you are relating in the present moment, how you're relating to yourself, is that from a place of kindness, and care, and compassion, or are you relating to yourself coming from a place of self-judgment, criticism, pushing, and striving? Then how are you relating to the people around you? Are you truly present with your patients, or your family members, or your spouse, or your neighbor? Really, considering how you're showing up and noticing that in any moment and again, not judging it, just being curious, what is the quality of my presence in this moment?

Fowler: Also, maybe we could dig a little deeper into this because we have talked before, and I think we've also mentioned in this podcast that we really believe that healthcare is a deeply relational business, and that everything that we achieve in healthcare depends on the quality of our relationships. Perhaps we could explore a little bit those different types of relationships we have at work, and how mindfulness or being able to live and be fully present in those relationships supports both the relationships and then the work that we do together.

Salaverri: Sure. I think that's great because often, I think most often, we hear about the individual benefit of practicing mindfulness, things like lowering stress levels, improving focus, improving performance, decreasing anxiety. I could go on, but it can also really profoundly impact our relationships when we're able to bring a mindful quality into all of our interactions. The first place that I think about this, perhaps obviously at work is with our colleagues. One of the things that we've worked really hard to do, as we've been bringing mindfulness to the employees of Johns Hopkins, is to teach teams to practice mindfulness together, because while it's great to have individual people practicing, if a team is practicing as a whole, we're really creating and establishing a new norm for the team, for the department. Then that spills out into the larger organization. There's a lot of research to show that when we practice mindfulness, we have increased capacity to regulate our emotions, our coping responses improve, and we have an enhanced sense of psychological safety, which on the team level is really important because then this contributes to things like an improved sense of trust, openness, and connection with our teammates. When the quality of our relationships with our teammates improves, this also positively impacts the quality of care that we're able to provide for our patients and the quality of work that we're able to do because we feel this sense of safety, openness and trust with the people that we spend our days with.

Fowler: I've heard so many people on the unit say to me, sometimes I'm so distracted that I'm having a hard time making decisions. Obviously they're self-aware, so they do something about it, so that they're able to provide the care that they need. But it's interesting, given how rapidly healthcare is changing right now, it feels that we're spinning sometimes, and I can imagine that teams that are able to recognize that perhaps they're spinning and able to bring themselves fully back into non-judgmental presence are really supported.

Salaverri: They are. I get feedback often from employees about how these very seemingly small, simple practices have had profound impact, not only on the relationships that they're having with their colleagues, but on their ability to move through the day differently. When you are able to notice that you are in a place of frustration or a place of overwhelm, then you're able to take steps to manage that. But if you're completely unaware, it's hard to know then how to move forward. Now, the other place that practicing mindfulness can really have profound impact at work, especially in healthcare, is with the clients, the patients, and the families that we're serving. When I think about this, I think the invitation here is to really consider how do I bring my whole self to this interaction, knowing that I have all of these notes to do? I have all of these other tasks, all of these other meetings. Right now my role is to be here with this person. How am I showing up for them? Where is my attention? A lot of the practices that I teach really train us to be present in this moment rather than lost in thought with all of the things that we know that we have to get done. But right now, my role is to be here with this person and then notice not only how I am showing up, but how are they showing up, so that I can relate to them the way that they need and are asking for in this moment. Then the last place that I think about how this spills over is with our families, and our children, and our partners, and our friends that we then go home to after we leave work. It's really the same thing there. The invitation is to notice the quality of presence. You've just left your work day, and you're trying to have dinner with your family, but you're still lost in thought about the meeting that you had earlier, or the interaction that you had with your patients. Of course, it's normal to be thinking about those things. But one of the things that we've been working really hard on here at Johns Hopkins Medicine is helping our employees create work life balance. Learning how to practice mindfulness can really teach you how to train your attention to be where you want it. If you're having dinner with your family tonight, your presence is there. I'll share that. I've had a few significant losses in my personal life over the last year and a half, and one thing that I'm keenly aware of is that this life is short and we don't want to miss it, and we're so distracted with our thoughts and our phones and our phones and our thoughts. I like to joke that those are the two things that are really taking us out of the everyday moments in our lives. Learning how to practice really being at dinner with your family, really being in the conversation with your patients, really being with yourself, it's hugely impactful.

Fowler: This is just so kind. I've heard so many people either talking to me obviously, or in groups about how at the end of a shift they find themselves going down the checklist of everything they didn't get done or everything they were not able to be for a patient or a colleague. That's such a heavy, judgmental load to carry after several hours of being fully present to then feel that you're beating yourself up about the fact that you couldn't deliver 150 percent of effort. Maybe I could ask you just to reinforce a little bit the connection between these mindful practices and self-compassion.

Salaverri: Sure. I think that goes back to what we spoke about a few minutes ago, in terms of being aware of how you are in this moment, and that may be how you are feeling physically, how you're feeling emotionally and mentally, and then noticing how you're relating to yourself. One of the things that I teach is that most of us that work here at Johns Hopkins Medicine, I'm going to say all of us that work here got here by working really hard. We have an amazing enterprise full of really committed employees. There tends to be this striving not just in our culture, but I think in the larger culture where we feel like we always need to be doing more, pushing harder, going faster. That is what we think leads us to where we're trying to go. But what often happens is that that is also what's contributing to our feeling of burning out of not being enough. Our feeling of falling short. We almost end up like a dog chasing its tail, because we feel like we need to be doing more all of the time. The first step, though, is to really notice when you're in that space. The way that I encourage people to practice this is to really turn to yourself, just like someone that you love or care about who is working really hard and serving a lot of patients and also taking care of a family at home. All of the things that so many of us are juggling and speak or relate to yourself like you would that person that you love or care about. Now, to be very honest, this is a challenge for most people, and I know that because when I teach it, I'm fortunate to have employees that will reach out to me and say that workshop was really helpful and it was really hard. This is why we call these things a practice. Because for most of us, we haven't been taught how to relate to ourselves, coming from a place of kindness and compassion. We really have grown up in this culture of you need to push harder, go faster and do more, so it can be a huge shift for a lot of us. It does take practice over time. But the other piece of that is that it is totally possible. It's the analogy that I often use is if you want to start lifting weights, you start with a small amount and build up over time. It's the same thing with learning how to practice compassion with yourself. You may not be able to do that all of the time every day at the outset. But you can begin to practice in small moments. Maybe noticing when you made a mistake and instead of going back to the old pattern of beating yourself up, just coming with curiosity about any story you may be telling yourself in that moment, and then see if you can offer yourself even two percent more kindness than you would have before. There are lots of different self-compassion practices that people can lean into. But the first piece is noticing how you're relating to yourself, and then considering that there may be a different way.

Fowler: Could we perhaps transition now to talk a little bit about some of the programs that you offer? Because even though we're talking about things you've offered at Johns Hopkins Medicine, I hope that listeners to the podcast will be able to imagine how these practices might be relevant to them, wherever they are working.

Salaverri: Sure. I'm happy to share that there are lots of opportunities to practice mindfulness here at Johns Hopkins Medicine. The flagship offering that I've created is a four week series called Live and Work Mindfully. I mentioned earlier that we've really focused on teaching teams how to practice mindfulness together so that we are creating a norm within the organization. The Live and Work Mindfully program is a four week series where teams learn the basic principles and practices of mindfulness, and then, of course, there's some opportunity to practice outside of those sessions so that they are learning how to apply the skills in real time. It's great to learn these things, but then we also need to take them outside of the sessions and bring them into our real lives, both at work and at home. Live and Work Mindfully is our flagship offering, and it's been really, really well received. There are a couple of other options as well. We have something here called our Worksite Wellness menu, which is literally a menu of wellness offerings that employees and managers can go to to request for their teams. We have several mindfulness specific offerings there. Additionally, we have something called Mindful Monday. Every Monday from 12:00-12:15, I lead a mindfulness practice open to everyone in the enterprise. Truthfully, this is the highlight of my week because we have hundreds of employees who log on to that call from all across the organization, and there is such a sense of community, there is enthusiasm, and there is a lot of compassion there. If you have not joined, the information for that can be found on the Healthy Hopkins Portal and the Office of Well-Being website. Outside of that, we had a lot of employees request support for when they cannot attend live programming, and we've created something called the Stress Less video series. This is a series of five videos that are five minutes or less with short mindfulness practices. Those can be found on the Office of Well-Being website, the Office of Well-Being YouTube channel, and the Healthy at Hopkins portal. Outside of all of those structured things, there is the opportunity to take advantage of the Calm app. All Hopkins employees can access the premium version of the Calm app for free. It's a really great resource. The app that I use personally, that I've used for years, is called Insight Timer. I just never made the change when I came here to Hopkins, but I think encouraging people to lean into the resources that feel most resonant for them. The other piece of this is if you don't want to download another app or have to navigate another thing, there are lots of ways to practice mindfulness without any of that. I really tried to teach our managers, our teams, and our employees that it can be as simple as taking 10 seconds to notice your breath between tasks, or starting every team meeting with a short breathing practice. Then there are also opportunities throughout our workday to bring little mindful moments in. In healthcare we are constantly washing our hands. As you're washing your hands, take that opportunity to make it a mindful practice. If you have no idea what that means, it's really inviting yourself to bring, again, all of your presence to that moment, noticing what the water feels like on your skin, maybe noticing what the soap smells like, bringing awareness to the temperature that you're feeling, rather than washing your hands, going through your to do list with the 427 items in your head as you're trying to wash your hands. There's also mindful eating can be a really great practice. I get a lot of questions about this from employees, I think because in our larger culture, we are rushing all the time and certainly working in healthcare we are short on time. Bringing mindfulness to our meals can be really, really helpful in slowing us down and really encouraging us to take the time to nourish ourselves. Now, one of my favorite mindfulness practices to incorporate into my workday is mindful walking. I find this helpful for a few different reasons. One, because I spend a lot of time, like most of us, looking at a screen. Mindful walking invites me to take a break from that, and if I can, I like to go outside, even if it's for five minutes, just to give my brain an opportunity to have some different scenery. I don't plug in my earbuds or look at my phone, I really use the opportunity to connect with the world around me, and again, give my brain a break from all of the stimulation that is a part of our work world. A lot of our employees really enjoy doing this as well. Even if you feel like you're walking around all day, there's a different quality to mindful walking where you are very intentional about noticing. What does the Earth feel like under my feet? What does the air feel like on my skin? What is the light in this place? That in and of itself, can really help shift our systems out of this, again, place of overstimulation and rushing into a place of true presence if we allow it to.

Fowler: I love the way that you describe these mindful moments and these mindful practices, and I'm actually reminded of one of our colleagues here at Hopkins who talked once about mindful transitions. When I asked her what she meant by that, she was like, well, when I'm walking between one patient's room and another patient's room, I have to become fully aware that I need to leave that patient I've just seen behind. As I'm walking to the next room, I'm actively transitioning to be fully present with my next patient. She uses a combination of noticing the movement between the rooms and then when she does her hand sanitizing, she uses that as a mindful practice to focus on her intention for her patient. I hadn't really thought of it as being a combination of mindful practices, but that's exactly what it is, so that she's able to be fully present and intentional when she walks to that next patient's bedside.

Salaverri: I also really like that because she's bringing it into her everyday experience. One of the biggest things that I hear from people is that they don't have time to practice mindfulness, and I definitely appreciate that. We are all juggling a lot, but I know when I was still practicing as a clinician, I would do something similar to what you just described, where as I was walking to get my next patient, I would be doing a breathing practice and I would be checking in with how am I in this moment, and then how can I most fully show up for this next person that I'm about to see? But these are all things that we can make a part of our everyday experience. We don't necessarily have to set aside 10 or 15 minutes to do a seated practice. It is great when we can, and I am fully encouraging all of us to do that when we can, but it doesn't need to be all or nothing. It can be both when we're able to.

Fowler: Thanks, Jen. Just as we begin to wind up, we're obviously going to connect to the resources that you mentioned on the podcast page. But if our listeners are interested in practicing how to live and work mindfully, are there specific resources you'd encourage them to look at first?

Salaverri: I think that, again, it's important for people to start where they are and with what is most resonant with them. For our Hopkins employees, I would really encourage, and I am smiling as I say this, I hope that is coming through in this podcast, to join us on Mindful Monday, because that is such a wonderful community of people who are really excited about practicing mindfulness together. If that is not ever going to be possible for your schedule, that's okay. That's why we also have things like the Stress Less videos and the Calm app. Start with what feels most accessible to you. Again, if you don't want to do any of that, or you don't want to have an app or the schedule feels overwhelming, maybe just invite yourself to start with some mindful walking, mindful handwashing, or mindful eating.

Fowler: This is the last thoughts question that I always ask our guests. Would you mind sharing one of your real aha moments, or one practice that you would consider to be an absolute cornerstone or anchor practice for mindful living and mindful working?

Salaverri: Yes, I would be happy to do that. The first practice that I teach when I work with groups over the four weeks is bringing your awareness to your experience. This is something that I feel so passionately about for people that work in healthcare. Again, because we are trained and we spend our days attuning to how everybody else is, and then what happens is, when we are not also attuning to how we are, we can become completely disconnected and burnt out. We also need to be taking care of our needs. The first place that that begins is with noticing where we are and how we are. The very simple practice of pausing and noticing how is my body in this moment? What sensations am I noticing? Is there tightness? Is there tension? Am I cold? Am I hot, am I hungry, am I tired, etc? Then also inviting yourself to notice how your emotional state is. What is your mood like right now? Again, there's no need to judge it or try to fix it or change it in that moment, but just noticing. Then lastly, inviting yourself to be curious about the quality of your thinking. This can take as little as 30s. You don't need to set aside a lot of time to do this. This can happen as you are waking up in the morning, or as you are on your way to work in the car, or on the train or the subway, but taking at least 30 seconds once in your day to bring your awareness to your experience, because then you can learn how to meet your needs so that you can be meeting the needs of your patients and your clients.

Fowler: Thank you, Jen. It's been lovely to talk with you about this, and I hope to our listeners, this has been valuable. We invite your comments on our podcast page, and please let us know if you've tried some of these practices that Jen has offered today. Jen, thanks again.

Salaverri: Thank you for having me. It's been really nice to be here.

Fowler: Thank you once again to our listeners for the gift of your time today. That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Jennifer Salaverri, LCSW-C 
Health Promotion Specialist-Mindfulness
Johns Hopkins Health System 

1. A helpful way to define mindfulness is: bringing awareness to the present moment without judgment. This includes being aware of your internal experience as well as what is happening externally.
2. Mindfulness can have a profound impact on how we deliver health care. A mindfulness practice helps focus attention on the present moment, positively supporting our interactions with patients and families. It can even improve our relationship with ourselves.
3. It is common for health care professionals to ruminate on the ways they could have done better, and this habit can negatively affect well-being. Mindfulness can help us recognize the physical and emotional impact of self-criticism and support self-compassion.
4. Mindfulness can be integrated into our daily routines without requiring extra time. Try mindful handwashing, or incorporating a mindful transition in between patient encounters.

Johns Hopkins is making mindfulness programs accessible to all employees:

• Live and Work Mindfully. During this four-week series, teams learn mindfulness techniques and apply skills together.
• Mindful Monday is a weekly 15-minute virtual drop-in mindfulness session with wide participation across the Johns Hopkins community.
• The Worksite Wellness Menu provides information about mindfulness offerings available for teams.
• Stress Less is a series of five-minute videos on mindfulness practices.

Johns Hopkins Medicine employees can link to all programs offered through Healthy at Hopkins.

Mindfulness videos, somatic practices and guided meditations created by Johns Hopkins faculty and staff are compiled here. 

All Johns Hopkins students and employees with a JHED ID have premium access to Calm. See instructions.

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Wellbeings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Fowler: Thank you for joining us. Hello and welcome to another episode in our podcast series. I'm Carolyn Fowler, and my guest today is Carolyn Carpenter, who is president of the National Capital Region for the Johns Hopkins Health System. In this role, Carolyn is responsible for the strategic growth and operational performance of all current and future Johns Hopkins Medicine entities and initiatives within the National Capital Region, which encompasses Washington, D.C., and the adjacent counties in Maryland and Northern Virginia. I've been inspired by Carolyn's commitment to practicing and encouraging work life integration, and by her engaging and relational leadership style. I hope you get to enjoy knowing Carolyn the way that I do. Carolyn, welcome.

Carolyn Carpenter: Thank you. I'm really delighted to spend this time with you today.

Fowler: Well, I'm thrilled that you're here and we're going to break from our current pattern of me giving a long bio or a longer bio. I'd like to invite you to share with us maybe some of the highlights or the [inaudible 00:01:30] that you've gleaned from 30 years as a leader in the healthcare industry.

Carpenter: Absolutely. Well, I often start with reminding folks of how long I've been at this, and that's for a few reasons. Number 1, you learn a lot over time. One of my favorite leaders actually said to me when we were talking about positions many years ago, she said, I like to hire people who've been in organizations long enough, or in fields long enough that they have to clean up their own messes that they've made. I think the longevity in the field for me, which is [inaudible 00:02:10] doing my calculations, technically, 33 years of having the privilege, and that's how I see it, the privilege of working in healthcare and healthcare administration is core to how I come to leadership every day, because I've probably made many mistakes before that I have learned from. As I have the opportunity to see what I think of as constant reinvention and constant learning, as in many ways the foundation of how I work and lead. I've been at this for more than 30 years. I've spent more than 90 percent of my time in academic medical center environments, the remaining in community hospital and healthcare environments, and that has very much influenced my passion for what I call bringing life changing care to individuals and communities. It's because I have seen the power of the intellect and the discovery and the multidisciplinary teamwork of the academic environment. I've seen the power of the scale that allows for compassion and excellence and service in a community environment. Have said this multiple times over the last four years I've been at Hopkins. Four years I have the best job because I get to spend my time working on what are those synergies across community care and academic medical center environments that can really, distribute and grow life changing care. Today I'm in the NCR, before that, three years in Virginia hospital and health systems before that 20 years in an academic environment at Duke and before that, two other academic environments as well. And probably the last thing I'll mention is when I was in college, I helped start a dance company, and I shared that with you because I think in many ways it was my initial set of leadership lessons around how do you take a passion that you have? For me, it was dancing and create something that brings people together to move down a common path. In that case, it was both recreation and performance. How do you understand developing functions and systems and processes? I will tell you, college kids are pretty unruly, in a way that motivates people for a common purpose. I didn't know that then, but I look back on that now and say, that was really an incredible opportunity for me that started my leadership journey.

Fowler: What a lovely story and I can just hear your energy around it as you share it. The picture that's coming to mind for me is almost this beautiful mosaic pathway, with all these different little pieces that have contributed to the path you've walked in leadership. As you think back over these 33 years, Carolyn, what are the most important influences, do you think in your current leadership style?

Carpenter: Truly, the most important influences for me have been tremendous examples of leaders, which was luck. That is definitely the opportunity of having been in some extraordinary organizations and learning by watching, learning by being taught. I am a product of what I call an apprenticeship model of learning in healthcare administration, which is not as common today as it was then. That has given me a lot of food for thought as both watching how people were extraordinary in making change, being literally at the elbow of people who were doing that, and then also being stretched and being given opportunities to do that. Extraordinary examples, I would say is one category, and then the other is really the very talented people on the teams that I've been with. I really believe that the job of a leader is to listen to what their teammates are saying and what they want to get out of life. Not just work, but what they want to get out of life and find a way to link that sense of purpose they have to what you're doing in the organization and what you're doing as a broader team. When I think of some of my best leadership lessons, they are not always easy things that were said to me, but things that were said to me by teammates. I was just talking with one of our board chairs recently about how when I reflect on some of the best lessons for me, I remember bumping my head against the wall and not making progress with the team and two of my at that time, formal leaders. They weren't even informal, and often it is the informal. I sat down with them and said, why is this not working? They looked at me and they said, you need to not be there. It was an issue that had great interest and passion and importance to me. But the way I was working with the group and the role I had in the group was not allowing them to be successful. First of all, we built the trust that they could say that, and I said thank you and left the group and they did an incredible job. I watched the results to exactly what I had hoped from the beginning. But it goes back to who are those influences? It is often those trusted teammates who put the mirror in front of you and say, look at how your behaviors and your statements and your approach are not supporting the successes for everyone in the room.

Fowler: They care about you and your success enough to tell you the truth, even when the truth is sometimes hard to hear.

Carpenter: You got it. That's exactly right, and creating those environments where people will do that and can do that has been a focus for me in my career.

Fowler: Wonderful. Well, you are known throughout our health system as someone who's a deeply relational leader, and you've begun to describe it, but can you tell me why this is so important to you. I know you've said to me, you absolutely prioritize relationships. Can you help us understand the power of these relationships a little more?

Carpenter: Absolutely. The way I view it is the connections we make with the members of our team teaches us how to best support them and set them up for success. In those relationships and in those connections, you have the benefit of setting the different team members up for success, understanding what their strengths are. You build across a team on the strengths, not on the weaknesses, and you allow the diversity of those strengths to really flourish. For me, really great teams are about developing this Trusting relationship with members who have those different skills and approaches. One of my new favorite phrases over the last couple of years is generous listening. I heard a woman, Anna Leotta, describe that, but to do the generous listening that allows you to connect and understand those strengths so that you can help set those people up for success, that then allows the teams. Because we all know, like empirically, we know teams do better work than individuals better. You could define 100 different ways, but teams do better work. How do you create those teams is absolutely about understanding the individuals and then their strengths, and then the path to setting them up for success and allowing the team to do that.

Fowler: This is so interesting because from one perspective we could hear you describing something that's about organizational success, productivity, all those quantifiable metrics that help us see that we're creating the outcomes or achieving the outcomes that we care about in healthcare. Then as I listen to you from the perspective of wellbeing leadership, I'm hearing you describe something that's about really creating a sense of belonging. That sense that I'm seen, I'm known, I'm respected and I belong to this team. How do you think about that interpretation that I'm offering you?

Carpenter: I really support that. In particular, I often think about how do I interact with individuals that lets them know they are heard. Because I do believe the requisite for belonging, is to be heard and seen. More often than not I can do a track to seen, but are people being heard for their individual gifts. The sum total of what their life experiences are bringing to the situation, or the problem, or the environment. I really believe that that is a sense of belonging. When you are heard for the total of who you are at work, not just who you are as a worker.

Fowler: Well, and we know that that deep sense of belonging is something that is an important prerequisite for wellbeing. If we think about resiliency, knowing that you have support and connection, that someone has your back and that you are safe and heard and included, is a major factor in in your in our well-being and not just our well-being, but our sense of professional fulfillment.

Carpenter: Absolutely. I think of how well do we each understand our own sense of purpose and how well, when we're in different environments, does that connect with others? Knowing our purpose and knowing what someone else's purpose is, that helps create that milieu of belonging is critical in my mind to all the advancements that we can make, particularly honestly if it requires creativity. One of the fun parts of healthcare is it's a bit of chaos every day. Something in our industry throws us for a loop. But the positive of that is it reinforces the demand for creative problem solving and thinking.

Fowler: Which, of course, requires that psychological safety.

Carpenter: Yes, exactly.

Fowler: We have a lot of listeners who are different levels of leadership, so they might be at frontline leadership right now, clinical frontline or non-clinical frontline. Then some may actually be running organizations like you are. What would you say to them about how relational leadership supports individual well-being, collective well-being, and professional fulfillment within a healthcare organization?

Carpenter: That's a great question. What comes to mind first is, is relational leadership makes the shift from followers to participants. Certainly earlier in my career, a lot of the leadership lessons and dialogue was around how do you create followership? I've never really resonated with that. For me, relational leadership has helped me because it isn't about followership. It's about participants. I love when we talk about employee engagement because that's what it is. It's engagement that is at any level in any role in an organization. That is what we need to aspire to. Relational leadership has helped me with that concept of while people want, team members want folks in, in senior roles to be committed to developing them and having experience and caring about them, and maybe even lucky enough to have some wisdom that in specific roles, that is needed. What relational leadership really does is it says what it's about is the participation and the contribution of everyone matters at different points and in different ways, with different problems.

Fowler: So inspiring. But let's get a little practical here. Given the complexity and the pace and the level of change in today's healthcare organizations, we can so easily become task focused and just transactional. How do you incorporate these relational touchpoints throughout the craziness and unpredictability of every day?

Carpenter: Well, I think there are points that we have to be intentional with our teams. One very simple and maybe rudimentary example is when we come together in the National Capital Region as a leadership team, I strive to always have a moment where we share. It may be something very mundane. It may be something very personal and touching, but teen time, as I call it, because I like alliteration, is a part of our agenda every time and often it is a question. If it's a deep question, I give it to people in advance. If it's just a what's your favorite movie question? I don't give that to people in advance, but to take a moment to be a person on a team does require intentional tactics sometimes. That's a very specific just tactic that we use in everyday life. I think the other tactic that I've learned along the the way that is so important is when we meet with people and we meet with our team members for all different reasons and it is an environment where it allows for dialogue. It's not 50 people, it's two or three. Always begin the conversation with that person as a person, even if it's just how was your weekend? Or has this week have a challenging time because of this or that? How is your dog? How is your son? The initial interaction that you have with your team members matters that it be as a person, not again, just as a worker or employee. I strive to do that all the time when I meet with people and I even strive, though I'm not as good as it as I used to do it on e-mail. Because e-mail I think is a little bit aggravating. I'll use that word because it's a deluge, but I try to not say when I write a note to someone very first, will you do blank? I try to say, I hope you're well, or I hope you're having a good day. Or it was good to see you recently. Honestly, those are throwaway words. But what they are intended to communicate is I'm thinking about you first and then the task at hand.

Fowler: Right. You're checking in with them essentially in a spirit of curiosity and that's establishing then that personal connection, which is your conduit for getting anything else done.

Carpenter: Well said.

Fowler: Well, I think you put the words into my mouth, I just summarized. All right. I hear the passion in your voice about this. Obviously you're very skilled at it, but if you were talking to leaders who feel uncomfortable with this more authentic or relational leadership style, what suggestions would you offer to them?

Carpenter: My initial thought with that question is to reinforce that the job of a leader is to listen. Therefore, if you're uncomfortable with it, come to the table with your questions prepared. Come to the table with that curiosity that you just mentioned. Come to the table with that sense of I'm here to hear. I am not here to tell. That will shift everything in a direction that sometimes gets unwieldy. Rabbit holes certainly exist, but will really set you up for success in understanding where people are in the process that you're trying to engage in.

Fowler: Yes, I think you and I have had conversations before, and I know that you've heard me almost obsessing about the importance of listening and building listening cultures and organizations to support well-being.

Carpenter: Yeah.

Fowler: Carolyn, before we started recording this podcast, we had been talking a little bit about that, an assessment that I did at Hopkins when I first came into this role that you were part of. I had shared with you that the thing that was so fascinating to me was that when I asked leaders how they thought leaders in organizations influence well-being, with very few exceptions, what I heard from them was, you have to role model your own wellbeing well-being practices. While I love the idea of somebody modeling well-being practices, including maybe having some balance in their life, it was fascinating to me that they didn't truly understand how, because of this position that they're in and this privilege that you said you have of being a leader, with that comes the ability to so positively organize or so positively influence organizational culture and well-being. You've been very vocal about the importance of wellbeing and work life integration and relationships after that long winded question. What would you say about how leaders truly influence well-being at the organizational level through the work they do each day?

Carpenter: I think leaders influence and create environments by truly understanding this concept of excellence and progress to the results we aspire and plan for requires people bringing their best selves to these problems. We, I believe, generally recognize that these are complex situations and problems. I believe we generally recognize that this is a human industry, which means there's a lot of emotional content that is part of our environment, but I'm not sure we recognize often enough what it means to be bringing a best self to the table. Because as often as it is a skill set that we're looking at in our work environments. As often as it is that we are assessing that skill set, we also need to be assessing our people outside of work. Are they here with energy? Are they here with positivity? Are they here with the brain and brain space came to mind? But it's even more than that. It's a wellness enough to actually hear each other. Those assessments of what's going on are a constant process that we should be having with our teams, a constant testing of what will help them and learning what works in that regard and knowing that it is not the same for each person. As we learn what those things are, continue to push and influence. I'd love to say role model, but I'll be honest with you, more often than not, I tell my team members where I've failed and don't do what I do and let me support them and let me tell them the not well-being implications of doing what I do sometimes. I can recall one of my most one of my most influential mentors and people on this podcast will likely know him. That is Kevin Sowers. When I was a baby administrator and I was and I had the privilege to work with him, he would, with some regularity call me and say, go home. It was generally after 730 or 8:00 at night. He was very clear on my pathology of working too much, and he was my boss. He would on occasion pick up the phone and say, go home. That taught me a lot. Generally he was calling me either on the way home or he was home. There was some role modeling there, but it was the intervention on the individual level of understanding and assessing what was impacting wellness for me. It wasn't a complex issue, but understanding that and then stepping in and doing that each and every time, because I think we owe that to our team members when we ask them to be accountable for results.

Fowler: Right. For him giving you permission to disconnect from work and to not feel guilty or less than because you're doing it.

Carpenter: I pass that on. I do that now. I walk in people's offices and say, go home. Let me stand over you. I'm not always successful, but let me stand over you till you pack your stuff up.

Fowler: Yeah, sometimes I just go for a walk while we have this meeting.

Carpenter: Yes. Or have you put that day on your calendar? One day, a quarter. I was talking with one of my teammates recently and said, you need to put one day a quarter that is unscheduled, that's your day. Is it on your calendar yet? Have you picked that day? Pick that day.

Fowler: That's wonderful. Well, there are so many other things that we could discuss in our time together, but I think I'm going to just offer you an opportunity to tell our listeners whatever else you would like to tell them about your journey, about relational leadership and about well-being.

Carpenter: Well, as usual, two things come to mind, which is a little bit of my brain space issue. One thing I'd like to share is the intrinsic reward that comes from creating the conditions where your team members produce extraordinary results. Is just phenomenal, and I would love to be the billboard for, you can only know how good this feels when you do this. That's one message. The other message that maybe simplifies out of it is I'm a gift giver, particularly in my personal life. I'm one of those folks that starts the Christmas gift list in July. I give gifts whenever I can, and I firmly believe that the point of relational leadership is gift giving. It's the gifts that you give people by giving them the environment. It's the gifts that you give people by hearing them. It's the gift that you give people, by giving them an opportunity that they may not have seen for themselves, that they then sail and just have incredible positive impact on others and patients and reduce the suffering that we spend every day. The billboard of be a gift giver in this way is one thing that came to mind. The other thing that came to mind is, at least for me, I go in and out of environments at Hopkins right now that are struggling for all different reasons. I do believe that there are moments in an organization where we need to be reminded of something that I have on my wall in one of my offices, and it says, you can always do the unthinkable. It just takes time. A mentor of mine said that to me, and I want to remind people that it's truly possible if you use that time to develop the relationships you have with your team members.

Fowler: You have described so eloquently, there's not only that it's a gift, but it's a gift that keeps on giving, and that you described it as giving a gift to the people that you lead or the people you work with. Yet, I know that you've also said to me that leading in this way also yields so many gifts for us as leaders that with everything burn.

Carpenter: Yeah, that's what I meant by that intrinsic reward. It can feel you particularly now when things may be difficult or you may be tired, or there may be some challenges that are hard to see the horizon. Those gifts Absolutely give back to your own sense of impact in a way that can be very energizing and reinforcing and positive to help resilience of you as a leader as well.

Fowler: Carolyn, it's been absolutely delightful to have you here with us, and for the gift of your presence and all of your insights. I hope that our listeners have enjoyed getting to know you and your leadership philosophy as much as I have. Thank you so much for being here.

Carpenter: Thank you.

Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Carolyn Carpenter, M.H.A., F.A.C.H.E.
President of the National Capital Region
Johns Hopkins Health System 

1. The job of a leader is to listen to what their team members want to get out of life, and create an environment in which they can align this with the organization’s purpose.
2. In a culture of “generous listening,” leaders seek to understand each team member’s strengths, aspirations and unique contributions. This enables leaders to make connections and allows diversity to flourish.
3. The following are two relational leadership activities to try: a) Incorporate intentional team building activities into meetings, such as sharing personal moments or answering thought-provoking questions. b) Start individual conversations by acknowledging the person first before discussing work-related tasks.
4. Are you unsure about relational leadership? Start with a mindset of listening and curiosity. Come to the table with a genuine desire to understand team members. This can shift the dynamic and create an environment that supports well-being and professional fulfillment.

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-being's podcast, Vital Conversations Influencing Workplace Well-being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Fowler: Thank you for joining us.

Fowler: Hello and welcome back to our podcast. I'm Carolyn Cumpsty Fowler, and I'll be hosting today. If you had an opportunity to listen to one of our earlier episodes, you heard Lee Biddison and I discuss the importance of fostering a culture of connection and support and how important that is for well-being. That's why I am so excited today to introduce our two guests, who are important and valuable colleagues to us, and also friends to us in the office of Well-being, Dr. Cheryl Connors and Dr. Matt Norvell. Matt is a board-certified chaplain. He's very well known in the world of pediatric chaplaincy, especially, and he is the Spiritual Care and Chaplaincy Department clinical manager at the Johns Hopkins Hospital. But Matt is also the RISE, which is the Resilience In Stressful Events program team manager at Johns Hopkins Hospital. Doctor Cheryl Connors, who is a nurse, works in the Armstrong Institute for Patient Safety at Johns Hopkins Medicine, but she is the RISE director for the Johns Hopkins Health System. Cheryl and Matt, together with Dr. Albert Wu, were the co-developers of the RISE program. I hope that you will find the story that they tell of the development of it, and also the importance of it, really interesting and inspiring for you, wherever you are today. Cheryl, can we start with you?

Dr. Cheryl Connors: Yes, please.

Fowler: Firstly, thank you so much for being here.

Connors: Thank you for having us.

Fowler: Could you describe the RISE program, please, for our listeners?

Connors: Yeah, I would be honored to. RISE stands for Resilience In Stressful Events, and it is a confidential peer support service that is available 24 hours a day, seven days a week, to anyone who serves Johns Hopkins Medicine. I say medicine because we have RISE teams expanded throughout our health system, but maybe I will mostly focus on the Johns Hopkins Hospital RISE program for the purposes of the podcast, since we have Matt here, who is our fearless leader at Johns Hopkins Hospital. RISE was created in 2010 when myself and Matt and colleagues, we had recognized that there was a need for something. We did some exploration to identify what exactly was the need and how could we strive to meet the need. What we found was that most of our colleagues were reporting that they were, by definition, at some point, a second victim, meaning that they were traumatized by either a medical error or adverse event as the caregiver in the position of the situation. The second victim is actually a term that our friend and colleague, Dr. Albert Wu, coined back in the year 2000. We had known quite a bit about it, and that's where we really targeted our exploration, and only to find out that, yes, people were in fact validating that this is a real thing. Most of our health care workers have experienced it. Then, when we asked them about support that they received after experiencing this second victim phenomenon, they basically claimed that they didn't receive support, or if they were going to receive support, maybe they went to their supervisor. Now, I myself at the time was a supervisor, and I remember staff coming to me to talk about such things, and I also recognized that I really wasn't trained or equipped to manage that type of support. It was also on the long list of other responsibilities that a manager or supervisor would have if there was an adverse event or medical error. Then the other option for support, like the opposite end of the spectrum, was essentially to seek out counseling or therapy. We fortunately do have access to an employee assistance program. What we found is that staff were underutilizing it. They weren't utilizing it for these types of situations. We further explored why, and what we heard from the healthcare workforce was that they didn't feel they needed a counselor or a therapist, that at the end of the day, when they experience something stressful, they really just needed to talk to somebody who could relate to that experience so they can unload the heaviness that came along with it and have somebody bear witness to their their pain, to their distress and then they can move on. They could go home from work, come back to work, and not feel plagued by this situation. We then further asked our healthcare workforce if we were going to create a support program, what features would this program have that would essentially fill this gap, fill this void, so that you could have support for those types of work-related experience or patient-related experiences? They told us that they wanted something that was timely. If it happened today that they might be able to pick up the phone and call somebody today, or if they weren't ready to process today, but maybe they were tomorrow, they can pick up the phone and not really need an appointment, not make it a formal process that they wanted it to be timely. When they were ready for it that it would be available to them. They also clearly indicated that they wanted it to be a peer, somebody who works here at Johns Hopkins Hospital, somebody who understands the culture of the organization, understands the types of situations that we encounter, and, more importantly, the impact that it has. Somebody who's trained, somebody who can effectively provide support. People would say that, I would go home, and I sometimes would try to talk to my family about this, but I didn't really want to burden my family and make them worry about the things that I endure when I go to work, and they, too, didn't know how to offer support. They were really interested in having somebody who knew how to provide support effectively. They also conveyed that it was important, since we're a 24/7 operation, that we have support 24 hours a day, seven days a week. Then lastly, the other feature that we learned about was that they thought it was very important that this support be confidential.

Fowler: Wow, thank you, Cheryl. To think that that has been going on 24/7, 365 for more than 13 years is truly extraordinary. Matt, can I maybe ask you to tell us a little bit about the value of RISE and the impact that you've seen RISE have over all these years?

Dr. Matt Norvell: Sure. It's great to be able to talk about this with you, Carolyn. When I think about both value and impact, I go in a few directions, and I think on maybe at least three different levels. I think about the value and the impact that there is for the individual employees who get support. I think about the value and the impact on the institution, and maybe even talk a little bit about culture there. Then I think about the value and the impact on the people that are on our team, the individual peer, we call them peer responders. When we think about the employees, it has been amazing to watch. We started building it in 2010, and then we went live in the fall of 2011. To watch the way that our employee workforce has embraced and come to appreciate and understand that when they need to talk about some impactful or stressful work-related event, that they have access to that anytime. A few minutes ago, just before we were meeting to get today, I was at an orientation to be able to talk to some new employees about the availability of this program to them. They're brand new, coming into the institution. When we talk about we want to provide this service because we're interested in them being whole, healthy people who also are good employees who work here. You can watch their faces change a little bit. People appreciate knowing that somebody is available to pay attention to them as a human, and to listen to their particular concerns as it relates to whatever work-related thing that they encountered. It's been a really fun journey to watch this unfold and become more and more engaged. When we first started out, we got about one call a month, and we were super happy that that one call came in every month. We got about one, and then we have an internal messaging system is the way that people reach out to us. With that, people would reach out, and when we would have one of our peer responders go and provide that support to them. It was so satisfying to know that, at a minimum, we gave that one person a safe space to talk about something that was really on their hearts that they had experienced. Today, the pandemic was a big blip as we look at usage. We went from, in January of 2020, I believe we were at about 12 to 15 calls a month. Then, in the spring of 2020, we did about 7,000 employee encounters between March and June of that year, so that was a blip. Today, we've leveled back out, and our usage has definitely increased. We're at about 30 of these different encounters a month now, being able to provide the support to people. I think about that helps me transition of thinking about the value or the impact for employees to be able to think about the value or the impact for institutions. As Cheryl mentioned, when she was a nurse manager, most of our nurse managers are really good at managing their units. They're really good at the business side of making sure there's enough people in the right places to be able to do their work. They're really good bedside nurses, and it varies on their own individual experience level about how good they are of providing that interpersonal support whenever somebody has had an impactful thing. They're in a tight spot, it's not just nurse managers, it's any leader because they want to provide support to the employee that's in front of them, because they know that's necessary and important, and they're trying to run whatever is their responsibility. It's a tough balance to take that time and to be that safe listening ear while they're also watching safety issues and they're also watching staffing issues. That really starts to speak to the impact on the institution. The existence of our program has offloaded a little bit of that real time emotional support responsibility, offloaded it off of that, those manager level folks, and off of our hospital leadership folks, because they know and they trust us that we're going to help take care of the people when they need it, and so they can pay attention to the rest of their jobs there and they know that we're going to be a part of it. That's been a really satisfying thing to watch about how it's impacted the institution is made up by a bunch of people, as we look at the different people with the different very serious jobs that they've got at every level, that corporately has come together to make a big difference, I think. Then, when I think about the impact specifically on the people on our team, the people that volunteer their effort, our peer responders on our team. We hear again and again how much they appreciate the opportunity to help in this way. All the people on our team have other very real, very serious jobs. They still volunteer a couple of times a month to be able to be the person that will show up and give an individual or a team space to talk. Not too long ago, we got a call from a nursing unit that had three deaths in a 36-hour run, and they don't normally have three deaths in a 36-hour run. They just wanted somebody to come in and sit with their team and give them a chance to talk about not an event debrief, but a chance to be able to talk about it. Our people find a lot of satisfaction in the opportunity to be able to provide support in that way. I think that it impacts the life and job satisfaction of the individual peer responders on our team, also.

Fowler: Thank you, Matt. I was going to mention this later, but I should disclose right now that I'm the RISE responder. I have been trained by you, and I would absolutely agree. It's one of the most rewarding things that we get to do for each other.

Norvell: It's always great to be interviewed by an insider. Thank you, Carolyn.

Fowler: The insider track friends. Cheryl, as you think about getting the Rise program started and sustaining it over all these years, what do you think has been essential to its success?

Connors: Yeah, I'm going to emphasize some of the things that Matt had already said, and maybe that I already said too, when I talked about what Rise is but, there's two ingredients, I think, that really are essential to the success of a program like rise and the first is, leadership support. I'll start from the very beginning. This program, like any other program or project that somebody tries to get off the ground in a healthcare environment, you would anticipate there to be some challenges, some barriers, and that it might actually be quite difficult and I would say that none of that was true really for us when we were implementing Rise because we had leadership support from the very top, our president, our VPMA, our director for safety and quality, they were all very much executive champions from the beginning. They sat at the table as we were talking about some of the special features of a program like Rise, and I'll start referring to it right now as a culture changing program. The features that we were talking about that really needed leadership support behind us, behind the program was features like the confidentiality aspect. We had to work very closely with our chief legal counsel to make sure that we understood those, you know, boundaries around confidentiality and how peer support was unique compared to anything else that we're doing as we were serving as peer to peer. It wasn't a provider to patient type of relationship that really helped support the confidential aspect of the program. Leaders also needed to stand behind us and, and be the champion so they were helping us to campaign for the program, advocating for the program. They had a voice in helping us to design the program and then I think what was important from the beginning and continues to be incredibly important, is that our leaders are the people who endorse the volunteers who say, I want to be a peer responder and so, Carolyn, I'll use you as an example. If you were going to apply to sign up to be on the Rise team, we would need you to have your director sign off on that and we ask that of every person that volunteers. It's really important for our leaders to understand what we're asking of these volunteers and that we look to them to make sure that we are onboarding people who are qualified to do this. Maybe they have innate skills, and maybe they're also willing to learn more about how to do this. Well and it's both. You can come to this with some natural skill, but we also do training that helps people understand what those principles are to provide effective peer support. Then I think another part of leadership that we learned so much about was in 2017. Around then we realized that our utilization, our activations were mainly coming from our leaders or managers and we wanted to understand that a little bit better. This is where I'm going to emphasize some of what Matt said. Our leaders saw Rise as an incredible resource that helped them offload some of their already very demanding role. They found it as a way to be more of a support to their staff and the other thing about that is the lead by the leaders activating the program. They're acting as models and they're saying, this is really important. It's important enough for us to take the time to receive support and so they are very much instrumental in that culture change that I had mentioned. On the second part of this is that we have skilled peer responders. That's the other essential ingredient and I say that because they are the life of the program, actually. These are people who are, as Matt said, they're willing to do this work. They're actually very excited to do to do this work. We had a chance to interview some of them, and at the end of the week, they'll say the thing that was most meaningful for me this week was the Rise encounter that I had, the support that I was able to provide. These are people who are willing to go through training, and they're willing to become a part of another team and they are multi-disciplined. It's really nice to build these connections across the organization, but I can't say enough that they are the life of the program.

Fowler: Thank you. Cheryl. Maybe Matt, could I just toss it back to you to just give us a brief overview of the peer responder recruitment and training?

Norvell: Sure thing. When we first started, we were starting from zero and so we went to and a lot of institutions, when they're doing this today, they, they go to their leaders around the hospital and say, hey, who on your unit and your department do people already talk to? We started with, I think, our original number, there was 18 of us on on the team, and we quickly learned that was not enough people to be able to provide 24/7 support like this on a volunteer basis and so we recruited some more folks. Then today, all this time later, the way that we do our recruitment it's pretty passive, like people find out about us and they find out about the mission of the the work that we do in our program and they reach out to us and they say, hey, I think I might want to be a part of that. I've also onboarded some people onto our team recently who their managers identified in them that they have a natural skill set that might be valuable and might fit with our team methodology and planning. The other thing that I've recently been able to catch on to is managers have recognized, hey, wait a second. It would be valuable to have people in my unit that already belong to our area, trained in this approach, and so they're willing to let them have a little bit of flexibility to do the rising calendars, because they know that there's an internal benefit to their unit. That's a little bit of the recruitment we do. We the peer responder training now is it's about six or seven hours depending on how much the group talks but it's about six or seven hours. It's a full day and Cheryl and I usually do that together. We do that now at our hospital. We do that three times a year and people, anybody in our system that wants to is able to take the training and sometimes they take it just because they are looking for some personal enrichment on their own sort of listening and communication skills, because that's really the focus of the day, is helping people, pay attention to the baseline challenges that are in a health care system and sort of the emotional impact of it. Then what are the ways that we can be a non-judgmental, listening, compassionate support to our colleagues? Some people take that just for themselves to be a better person. Then some people take it knowing that they want to be a part of our team and so the we have our own onboarding process like everybody else does, but they take the training and then we do an interview, and then we sort of do some onboarding training for them to make sure that they're ready to be able to provide the support that they need to. It can be intimidating for people the first time, because sometimes when we get a request for support, it's just a phone number, like somebody has reached out to us through our messaging system. They just gave us a phone number. For some that have never, called somebody that they didn't know who might be in distress, that can be an intimidating first hump of the roller coaster to go over. But most folks find that once you can make that connection and and the person knows that you're there to provide support. It really the natural caring skills take over and people find that it's really easy and satisfying for them to be able to do.

Fowler: Thanks. I really appreciated that you offered opportunities for us to shadow experienced peer responders before we had to go solo or leader-leader response.

Norvell: Yeah. As the leader of our team, I find that it's my job to make it as easy as possible for our peer responders to be able to provide that support and get sort of the positive endorphin hit of helping somebody and so I do, I try to control the organization portion of it as much as I can, so that it's easy for them to be able to do that. Similarly, people when they apply to be on the team, they say, how long is the onboarding process? Or how many people should I shadow? Because that's so much of the of the medical approach is, you know, see one, do one, teach one, or, you know, you need to shadow X number of hours before you can go do one of these things. I tell people, I want you to shadow until you are comfortable and confident to be able to go do this on your own. Some people, maybe they come from a background where they've done this helping before, and they jump in pretty quick and some people, it takes a little bit of time to be able to feel confident to do it, but everybody gets there eventually.

Fowler: Perhaps can I ask you just to once again, maybe briefly talk about the importance of how you care for the resiliency and the well-being of the peer responders themselves?

Norvell: Well, the two things that I think about for my perspective that I do on that is, as I just mentioned, I try to make it as easy as possible for them to do it. I don't want this to be too much of an extra burden on their time and we we asked them to be on call a couple times a month, which can be a burden for people and so we really try to work to make the process, the logistics of it as easy as possible so I care for them in that way. Another important way that we do it is we really, regularly checking in with people, especially after they've had an encounter. We debrief every one of those encounters to be able to make sure that, that person is cared for, because maybe they heard a story that is way outside their experience, their normal experience, and they need somebody to process that experience with. We want to make sure that they're cared for and they're not left out there. In fact, I just had this the other night. A call came through and it was later in the day, and I just reached out by text to our peer responder who was taking that call and said, hey, if you want to talk afterwards, I'm available and she called me back at ten o'clock at night and said, I really need to process this because that was a really wild thing I just heard. Because it's in hospital, you hear stories that we don't normally experience and so just being able to give that person a chance to process that and not be stuck with the emotion for themselves. Then the last thing that I'll mention about how I really focus on caring for our peer responders is, I try through weekly e-mails, through different conversations to help them understand the importance of the work that they're doing and the take home value that they're doing and we get positive feedback from somebody, it was so great that your team came and did this, I try to pass that on to the individuals that were involved, because I want them to know it's not just your effort and your personal thing that you're getting out of this. It is rippling out and helping other people and I think all of us get a really positive, it's a positive feedback loop to know that what we have done helps. When we can do that for when we can make sure that people see that. I think it feeds everybody, helps everybody feel a little bit higher.

Fowler: Yeah. This is such a powerful example of what happens when people know that they're working in an environment where somebody is going to be there for them, that they feel that they're connected, meaningfully connected and supported so I want to thank both of you for your leadership of this. It's been a fascinating journey, and you've expanded it well beyond our health system across the country so thank you to both of you. Cheryl, I'm going to turn to you for the last question, and that is if any of our listeners today were interested in learning more, either about Rise as it is now or perhaps even how to start a peer responder program in their own organization, where can they find more information?

Connors: Yeah. Thanks, Carolyn. We're very excited to share with the world how to get more information on Rise. Maybe I'll start with our internal folks, so if you are a part of Johns Hopkins Medicine, we want you to know that we have an intranet site that's easily accessible where you can find out all of the information, how to use the program, how to become a part of the program, why you might use the program, and that could be found on my.jh.edu and we have a Rise title so all you have to do is type in Rise under apps and it should pop up for you. You can get all the information that you need if you're a part of Johns Hopkins Medicine. For the external folks who are not a part of Johns Hopkins Medicine, I am happy to share that the Maryland Patient Safety Center, they found out about us around, you know, 2015 and asked us to be their partners. They felt very passionate that this was a good model for peer support and they wanted to help promote peer support programs in other organizations external of Johns Hopkins so they sponsored us to create this curriculum that we could use to help other organizations get a program off the ground. The program, through the Maryland Patient Safety Center, is known as the caring for the Caregivers Implementing Rise program and if anyone just goes to a internet site and you type in the Armstrong Institute, and then you look for caring for the caregiver, implementing Rise, it'll bring you to the page that also has the link on there for the Maryland Patient Safety Center. You get connected with our business partner. We also have some resources on there so if an organization thought they might want to try to implement a program without our support, there are some tools on there that they can absolutely use to guide them through some of the steps that are really essential in setting you up for success.

Fowler: Thank you so much for that, Cheryl, and for everybody listening. We will link to those sites that Cheryl mentioned on the episode page for this podcast. Friends, thank you so much for being here. Thank you for everything that you do. We are so delighted to partner with you in the Office of Well-being, and I hope that what you've shared today will be really meaningful and potentially impactful in future for those people listening to our podcast. Thanks everyone, and thank you for listening.

Fowler: Thanks for all you do Carolyn.

Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague and as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [inaudible 00:31:11].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Cheryl Connors, D.N.P.
Program Director of Organizational Resilience
Johns Hopkins Armstrong Institute for Patient Safety and Quality

Matt Norvell, D.Min., M.S.
RISE Team Manager
Spiritual Care and Chaplaincy Department Clinical Manager
The Johns Hopkins Hospital

1. A culture of connection and support is essential to improving the well-being of individuals and health care teams. Offering a peer support program, which provide a safe space to talk, is a key strategy.
2. Talking to someone who can relate and bear witness regarding the distress we face in health care can help us feel less alone and enable us to return to work and to our families without carrying the weight in silence.
3. Leaders, managers and supervisors can’t be all things to all people and need to focus on areas like safety and staffing. A peer support program, such as RISE, can impact the institution by off-loading some of the emotional support responsibility from managers.
4. Key drivers of success include:
   1. a training curriculum and onboarding program for peer responders
   2. endorsement from leaders so staff feel they have permission to take time to receive support and so volunteer peer responders can help their colleagues in a rewarding way, and
   3. care for the peer responders themselves. RISE offers a debriefing so volunteers can process difficult responses.

• RISE Internal Link for the Johns Hopkins Medicine Community
• Caring for the Caregiver Program
• Helping Without Harm: Providing Emotional Support to Health Care Workers in 2023
• Confronting the Inevitable: When a Urologist Feels like a Second Victim

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Beings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare. 

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share what we're learning.

Fowler: Thank you for joining us. Hello, and welcome. Today, we're joined by Dr. Richard Safeer, who is our colleague in the Office of Well-being. Rich is the Chief Medical Director of Employee Health and Well-Being for Johns Hopkins Medicine, where he leads the Healthy at Hopkins Employee and Well-Being Strategy. He's also the author of A Cure for the Common Company: A Well-Being Prescription for a Happier, Healthier, and More Resilient Workplace. But as people who work closely with Rich, we greatly appreciate not only his commitment to building a workplace culture that supports well-being, but his commitment to living this lifestyle too. Welcome, Rich.

Dr. Richard Safeer: Thanks for having me. Good to see you again.

Biddison: Rich, so excited to have you on the podcast today. I get to ask the first question. That is, you've been in this business, as we say, employee health and well-being for quite a while now. How did you come to focus on workplace culture and make that really central to all your efforts?

Safeer: Yeah, it's not what I thought I'd be doing. When I went to medical school, I trained in family medicine. After a year of practice in realizing, boy, it's pretty hard to make a big difference in 15-minute visits, I knew I had to go a different direction. In my second job at George Washington University on faculty, I was reading a paper about Johnson and Johnson, the company, and what they were doing to help increase physical fitness for their employees, and that got me interested and I kept reading other journal articles, ultimately coming to the conclusion that I could make a big difference on or for thousands of people at a time. That started my journey to ultimately, Johns Hopkins.

Fowler: Rich, as you think about culture and how you influence culture, do you think of organizations as having one culture, or are there many cultures nested within one place?

Safeer: There are definitely many different cultures across an organization. A culture is the shared behaviors, beliefs, and attitudes of a group of people. When most people think about culture, they think, Hey, I'm about to travel to another country, and they think about that culture and that country. What are their foods? What is their music like? Do they have special dancing? But culture doesn't have to be just defined by geography, it's also defined by a company per se. Everybody within an organization shares many different cultural aspects. Now, within an organization, there can be multiple cultures. Sometimes, they're defined based on departments. Here at Johns Hopkins Medicine, there's a nursing department that may have a different culture than the accounting department. It can be based on department, but it could also be based on other attributes that aren't defined by the organization. For example, some organizations, they create special interest groups. If you want to find other employees who also like to go bowling, you might have that group with a shared interest. Then this bowling group has their own culture. It's hard to address every culture, but when you look at the culture that goes across the organization and then give the leaders within each area the tools to shape their own culture on their teams, you stand a much greater chance of making a positive impact.

Biddison: There's this question about navigating and managing multiple cultures at the same time is such an interesting one. If you had someone coming to you saying, "I want to set up a program, Rich, and how am I going to think about and understand these cultures and address that?" What would you say?

Safeer: Well, it's interesting, Lee, as we, the three of us share this privilege of leading the office of well-being, we ourselves are a case study in how our cultures or the groups that we support overlap. We have a culture across Johns Hopkins Medicine. Then we have a physician culture, and we have a nurse culture, and we also have a food services culture. Depending on the program, we have to make some adjustments. We might not even have the same program for every subculture. For example, let's just take a look at food. On one hand, we have clinicians who might take call and be in the hospital for an extended period of time, and we would want to make accommodations to help them. They have this culture of long hours for whatever interval that is. Then we have other subcultures who may live in neighborhoods where they don't have access to large grocery stores with fresh produce, so we may want to make accommodations to allow them the opportunity to maybe shop on our physical campus, so that they can go home with those fresh fruits and vegetables. That's the thinking, it's all in the category of food. But there's these nuances [OVERLAPPING].

Fowler: Different experiences. Very interesting.

Safeer: Carolyn, what subcultures of the nursing population do you think are are different than the, let's just say the physician population. This is not rehearsed for the audience. We may have a pause for a second. It's something that we grasp with a lot, but we don't usually talk in the context of cultures.

Fowler: Well, Rich, as I think about that, I hesitate to give you the traditional answer, which would be generational or certain specialties. I tend to think about the subcultures in terms of where are they in their lives, and what are the other challenges that they're facing. For people who are in management and leadership roles, although they officially work a certain number of hours a week, that is essentially a 24/7/365 expectation for many of them. They're people who are later in their careers pretty well established, but they maybe have elderly parents. They're trying to deal with kids in college. We have many of our younger colleagues coming in dealing with graduate school and children. All the different generational issues in terms of whether we're primarily digital or not. I think that idea of work being work and home being home is irrelevant now. We have to be asking the question, what shapes your work culture, but also what shapes your broader experience in life? Just what's possible for you in terms of looking [inaudible 00:08:01].

Safeer: I like that you brought up this generation idea because, look, if you have a subculture within your workforce that has small children at home, then perhaps the best well-being strategy for them is giving them greater flexibility in their work hours, whereas that may not be the case for people who either don't have children or who are empty nesters. We definitely, well-being in the workplace is pretty complicated, but the more we can nuance our approach, the more likely we are to help our employees feel as if they're supported. We know that when employees feel that they're cared for by their employer, it not only boosts their well-being, but it also boosts their engagement and they're more likely to stay with that employer.

Biddison: I love this area we're going into because I think it's so important. I know in thinking about how we impact well-being at Johns Hopkins, I have often gotten caught in the trap of what are the 1 or 2 big things we can do that will make a difference? What's the thing that if we can crack that nut, we'll get there. The answer is all all the things, and I think to your point, Rich, and maybe you can unpack this for us a little bit more that that really is a multi-pronged strategy and multi-pronged approach to try to meet these different constituencies in the spaces where they find themselves.

Safeer: Yeah. When I get asked that question, I'm always like, "Oh gosh, this is the hardest question." I actually have three different answers that I use for different audiences. It's a rotating one answer. Earlier this week, I met with our chief financial officers across Johns Hopkins Medicine. The answer to them was one meaningful conversation, which with each of the persons who report to them each week and a meaningful conversation would be between 10 and 15 minutes. The meaningful conversation would be of the context where the manager makes a connection with the employee beyond the deliverable. It might be a conversation that includes what that individual did well. It might be a conversation that includes some acknowledgment of the strength that that person brings to the team and Johns Hopkins Medicine. It might be a conversation that includes growth opportunities, something that helps the individual feel as if their manager is listening and cared for. That boosts well-being. That was my one answer. Very quickly, I'll give you the other two answer. Sometimes, depending on the audience, my one answer is breathe. Because most people are stressed during the workday and they're running around too fast. If people could just slow down long enough to take a good deep breath, which I just did, which amazingly still surprises me how much that's helpful, that would not only improve that individual's well-being, but we're better to be around when we're less stressed. The third one answer is put well-being on your team agenda. If you have a standing team meeting and you have well-being as a standing item, that means you will regularly return to that item and each time that you are approaching that meeting date, then you will prepare for what it is within the category of well-being. Will you be discussing or sharing with your team? That's going to keep you on track to growing that well-being culture for the people who are most immediate to you in the workplace.

Biddison: I love that. Right there ARE three different strategies for potentially three different cultures. That's awesome. Very cool. Well, I'd love to ask you a question about norms. This whole concept of norms has come up a lot in our internal conversations around transforming culture. But that may not be a term that's familiar to some of our listeners. Can you talk a little bit about what norms are and why they're important in this space?

Safeer: This is definitely something that doesn't get enough air time in the well-being community. Norms are the expected behaviors, expected and accepted. When you go into a workplace, there's certain expectations. Right now, the expectation in 2024 is that you do not smoke inside your work building, and that is a norm. We don't think of it that way. We think of it as like, of course you don't do that. But different industries and different workplaces have more nuanced approaches. In healthcare, one of the norms is that before you go to see a patient, you will wash your hands. That is a norm. It's not only expected, it's also accepted. It's what we expect that we're going to see. If you don't practice that norm, someone will probably call you out and say, "Hey, I think you forgot to wash your hands," as you're going into the patient room. Let's talk about the more subtle ones that don't really come with rules or the institution from behind. For example, lunch time. Most employers have some type of benefit where the employee has a written policy about how long is the lunch break and that's great. That's a nice start. But there is a difference between what's supposed to happen and what does happen. For many workers, the norm on their team is to just work through lunch or to maybe eat lunch. But you're on your computer or you're doing medical records while you're eating lunch. Those norms can make it really challenging if you're the one person who wants to take that break. Let me tell you how this looks. Imagine it's your first day of work, and it's 11:45 in the morning and you're like, "Hey, I wonder where everyone's going to go eat lunch," and no one's moving, and 12 o'clock comes around and you're like, no one's moving still. Maybe they eat at 12:30. So 12:30 comes around and you're still not seeing people break, but you have started to notice that on one person's workstation, there's a bite out of a sandwich, and on another person's workstation, there's a bowl with a fork in it, and some of the salad looks like it's gone. All of a sudden you start to realize, hey, people are eating while they work. Do I want to be the new person on the team who just leaves? The potential that people think that I'm a slacker, that I'm not going to hold my weight. It puts an enormous amount of pressure for an individual to make the choice that's healthy for them versus what they perceive as the expectation of their team on them. That's the power of norms.

Fowler: Well, Rich, as I hear you talk, I'm thinking about the norms that we have that really contradict what we know to be correct or what we know is desirable. This idea of it's normal to self-sacrifice. It's normal to not eat. It's normal to not drink water in case you can't get away, that thing. That brings me to a question which would be about how then do our colleagues or our fellow employees support our healthy lifestyle behaviors or support these healthy norms in our workplaces.

Safeer: Sometimes, it's easy to see how people support our healthy behaviors through norms. Because just as easily can you be in a work team where the norm is unhealthy, like not taking a lunch break if it's your first day of work and three of your teammates come over to you at 11:59, say, hey, we like to take a walk for the first 15 minutes of our lunch break. Would you want to go with us? All of a sudden, you're now drawn into this healthy behavior, but most of the time things aren't so obvious. First of all, we're usually not thinking about norms. But I would ask our listeners to just pause and ask themselves, what healthy behaviors am I trying to build, and how does the team I work amongst either support that healthy behavior or actually make it more difficult for me to achieve that healthy behavior and then make a decision? If you recognize the forces that are either working for you or against you, you're more likely to make a conscious decision now that you understand what's influencing you, you're more likely to make the conscious decision. You know what? I'm going to go eat lunch even though nobody else is leaving their workstation. If someone asks me later, I can just feel confident that I thought through this and this is the right thing to do. Carolyn, I would strongly suggest that teams and teammates start to have these discussions because we do not live in a vacuum. We're all impacted by the health and well-being of those around us. If we really want to achieve healthier habits during the work day, we're going to need to do that with one or more other people. Do either of you have a story or have acknowledged like, hey, this is a healthy habit I've been trying to work on, and it's working because of a coworker, or hey, it's not working so great because of these other influences

Fowler: Well, there's one that I think we're getting better at in our office, Rich, and that is not scheduling one hour meetings. It's 50 minutes or 5 minute meetings. We acknowledge that we have biological needs or just simply the need to stretch. As we're recording, our listeners can't see it. But I'm looking at Lee's bike behind her, and I have my weights here, and we support each other and trying to be active. But, Lee, do you have something?

Biddison: I love all the things that you've mentioned. I also think one of the things that we have done in the past is support or stock the wellness carts, and have tried to be really focused on being sure we choose healthy snacks, but what that means is they're also healthy snacks around the office that promote good choices because we make them together. The other thing which I was just going to say, as I was thinking, as you were talking about when we first started working together as part of the office, your team had outside of their offices or cubicles, a little note of here's something I'm working on, help me. I think that other piece of putting ourselves out there to sometimes we don't like to do that because we want to be seen as having it together, but putting ourselves out there to say, this is what I'm working on, would you help me, please, in some very simple way to do that. Ask me if I went for a walk. Encourage me to do whatever.

Safeer: I see a theme through each of those examples, and that is, hey, how can we make it easier to make a healthier choice? Specific call out to operational changes. Carolyn mentioned the 50-minute meeting instead of the hour meeting. That's very rarely thought of as a well-being strategy by most people. But boy, how important is that so that we're not rushing from one thing to the next? Would be great if the folks listening to this podcast not only thought about what operational changes they could make to support well-being, but if you've already made some, maybe you could write in the comment box where this is posted what you're doing now, so that other listeners can get a better idea.

Fowler: I love that idea.

Fowler: Rich, as we were talking again, I was thinking about the importance of environmental cues or environmental support. When you mentioned hand hygiene requiring people to wash their hands, we didn't just lecture them about it. We put hand sanitizer up. We thought about the positioning of our sinks. We made it easy to wash your hands correctly in the environment. Similarly, we've been fortunate enough in our space to be able to bring some exercise limited exercise support into our workspace. Then how does changing the environment or providing environmental cues make it easier for somebody to stick with wellbeing behaviors or even well-being practices? Not necessarily.

Safeer: Environmental cues are one of a dozen different what I call culture connection points. A culture connection point is any nudge that the employer can influence put in place, that makes it easier for an individual to either make a healthier choice or have a more positive emotion. An environmental cue is one of those cultural connection points. Carolyn, yes, having the hand sanitizer available, having a arrow pointing towards the stairwell, which is a nudge to take the stairs. These are all cues that just make it easier. We have to remember, by the time we get into the workforce, full time workforce. We're usually at least 18 years of age. We've had 18 years to develop habits. By that time, it could be challenging to change your habits. Anything that we can do to make it easier for the default to be the healthy choice. We've just lowered the barrier for an individual to develop a new, healthy habit. Now, some of that is driven by the employer. But we've mentioned a little bit about having exercise equipment, and each of you have purchased your own exercise equipment that fits in your work area, but you may not have done that had you not had the support of your coworkers. We have made it an acceptable conversation amongst us. If one of us is engaging in some physical movement during a zoom call, we're okay with that. We're accepting of that. Not every team has gotten to that point. Carolyn, I would say that environmental cues are great and they work even better when they're part of a team discussion about norms. Here we have these two different parts of the culture overlapping. We just previously talked about norms. Now we're talking about environmental cues, which is an example of a culture connection point. If we can get teams to start talking about what healthy norm they're trying to achieve and then give them ideas of what environmental cues and other connection points they can put in place to make those norms come to life. Then we'd really be accelerating our path towards a healthier workplace.

Fowler: That reminds me of all conversations both in the office and other podcasts that Lee and I have done, where we talk again and again about the importance of social support and social connection.

Safeer: We've talked about norms and we haven't yet talked about peer support. I'm not sure how much time we have, but just a quick note. There's one thing to be amongst a large group and be talking about norms. It's another thing to be working with one other person, a peer and in how they can either help or harm our health and well-being. Maybe that's another episode, but if the listeners haven't thought about a peer support strategy, I strongly recommend you. You do a little reading and think about how you can integrate that into your wellbeing culture plan.

Biddison: We've talked about peers and coworkers, maybe Rich, if you could comment on role of leaders in this space. But the manager, the leader, the boss, we all have a different name for that person we report to. But what their role is in this space.

Safeer: I subscribe to a model of shaping the workplace well-being culture with six building blocks. We've already mentioned a three of them; norms, culture, connection points, and peer support. A fourth is leadership engagement. It's not the same as leadership support. It's one thing for a leader to say they support what you're doing. It's another thing for a leader to be engaged. That is an entirely other conversation that could be that is the topic of symposiums and conferences.

>> We'll definitely have to return to that.

Fowler: Great. Rich, our time is winding up and I'm no doubt we'll be back and talking with you again. But I'd like to give you an opportunity to have the last word. If you wanted to tell our listeners anything you could about influencing workplace culture, what would it be?

Safeer: This is a variation of you could just do one thing.

Fowler: No, not one thing.

Safeer: I just think what I'd like the listener to take away from today is that a well-being strategy in the workplace has to be more than benefits and programs. We really need to be thinking about culture in its entirety. If you're not comfortable with the word culture or well-being culture, I strongly suggest you read about it because there are plenty of commercial enterprises, companies that want to sell you something that has the name culture in it. You don't want to be duped. What we're promoting here shouldn't be costing you a ton of money. Peer support norms. These things are free. We just have to know how to leverage these social sciences. I guess the takeaway, Carolyn is. I hope our listeners will want to learn more about how to build a well-being culture on their team and across their workplace.

Fowler: Rich, it has been delightful to talk to you today.

Safeer: It's been great.

Biddison: Thanks for being here, Rich.

Safeer: Yeah.

Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Rich Safeer, M.D. 
Chief Medical Director for Employee Health and Well-Being 
Johns Hopkins Medicine

1. Culture is defined as the shared behaviors, beliefs and attitudes of a group of people. Culture influences well-being at many levels — in the organization, in the discipline/field, in the department and on the team.
2. There is no one size fits all approach for well-being in the workplace. We need to adapt our approach to account for the lived experiences and needs of different groups.
3. Norms are defined as the expected and accepted behaviors of a group. To support well-being, teams can start by talking about norms and how they can support one another to create healthy behaviors and emotions.
4. There are many low-cost well-being interventions, including: listening, making time for meaningful conversation, putting the healthy choice first, peer support and leadership engagement.
5. Fostering employee well-being reaps benefits for the organization. When employees feel supported and cared for, they are more engaged with the mission and with one another, and more likely to stay with the organization.

Lee Daugherty Biddison: Welcome, I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we are your co-hosts for the Johns Hopkins Medicine Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share some of what we're learning.

Fowler: Thank you for joining us. Hello, I'm Carolyn Cumpsty Fowler, and I'm the host for our podcast today. It is my pleasure to introduce a colleague and friend, Dr. Karen Swartz. Karen is a psychiatrist and professor of psychiatry at Johns Hopkins School of Medicine. She's director of clinical services at the Johns Hopkins Mood Disorders Center, and director of the Johns Hopkins Adolescent Depression Awareness Program. Throughout the pandemic, Karen and I were part of a collaborative that worked together to support the mental health of our colleagues at Johns Hopkins Medicine. Karen, it's so good to have you here with me today.

Dr. Karen Swartz: Oh, it's my pleasure.

Fowler: We've talked quite often, you and I, Karen, about the fact that clinicians are not good patients. Could you tell us a little bit more about that?

Swartz: Well, Carolyn, it's startling. They have some data that only 35 percent of physicians have any regular source of health care. In general, I think all clinicians have enough knowledge that they think they can manage things, and tend to only get care when they feel that it has gotten to an urgent or emergent level, which obviously is problematic in all ways, but particularly problematic for psychiatric issues.

Fowler: Before we move into the mental health realm, are you saying that they're not getting much care in general across the spectrum of healthcare?

Swartz: Absolutely. They're not getting preventative care, they're not having regular check ins. They're not perhaps getting the screening tests that others get. We have knowledge clinicians do that allows us to recognize maybe when a new problem has started and then take action. But it is not a good thing when you take a group of highly educated people and you find that a third of them don't see anyone regularly, especially given those people age, obviously it's a part of your health to be able to get regular check ins and annual visits to make sure there aren't issues that need to be addressed.

Fowler: Wow. Absolutely. Then what's different when we're talking about clinicians receiving care for depression?

Swartz: There are a couple things that are different, Carolyn. But I think the one that people think of first is the stigma associated. It is not no one wants to be battling cancer or dealing with that, of course, but they're not embarrassed about it. I hope, in 2024, in the way that people remain very embarrassed about needing psychiatric treatment for depression, anxiety or other issues. Doctors don't want anyone to know that they're dealing with it, and there are enough societal discriminations that you worry too. I recently had someone who needs records to get insurance, and the fact that the person has responsibly had very successful treatment for depression could influence their ability to get life insurance or disability insurance, and that's just wrong. When people say there's discrimination, there is. But then on top of it, there's the view that this is something that people will think differently of me, or doubt my abilities or doubt my ability to function in a as a clinician if I am someone who's had depression or anxiety.

Fowler: When you say clinicians, Karen, are you referring only to physicians or to other clinicians.

Swartz: All clinicians, sadly, when you look at the people in the hospital who you would hope have seen people benefit from treatment and that would influence them. It's just not the case, because I think that people that are highly responsible and self-sufficient tend to become physicians and nurses and respiratory techs. You and I saw this during COVID across the board. So many different people that were in healthcare on the front lines of healthcare were not taking great care of themselves. They were sacrificing to take care of everyone else, but they were not great at taking care of themselves. They have this sense of I should be able to handle things, which is really problematic.

Fowler: If we were to dig a little deeper here and go beyond the stigma and beyond the reluctance to seek care for whatever reason, are there things about depression itself that we should be thinking of.

Swartz: There definitely are. One of the most important is depression itself changes your self-confidence. It changes your view of yourself. One of the symptoms of depression is that you start thinking that you're lazy or you're not talented, or you're not someone that people would want to be around or that people can count on. It could be that you're functioning just fine in your role as a nurse, as a doctor, as someone working on the unit. But you'll start doubting yourself in a different way. What happens is when people are depressed, they've shown in surveys of clinicians that when you're depressed, you're more likely to have these negative views of yourself than if you're not depressed. You start saying, oh, people are going to see me differently if I get care. The sense of I'm just a screw up and I just need to get my act together, that's part of depression. Many patients over the years have told me when they're depressed, I don't really think I'm depressed. I think I'm just being lazy. I'm not really depressed. I think I just need to work harder. Or maybe I'm just not applying myself. I'll talk with him and I say, you don't say any of these things if you're well. These are all the things you tell me when you're depressed. But imagine that with someone who is naturally high expectations, very hard working, they start believing themselves. Depression means that you lie to yourself, your thoughts get distorted, and so why would you not trust your brain? We have highly educated people in clinical roles. They're used to trusting what their brain tells them. When your brain starts saying you're just lazy and really no one wants to be bothered with you, then you start believing that which is which is painful.

Fowler: It must feel very lonely.

Swartz: I think that is a perfect word for it because it is so isolating. People feel that, well, first they feel that others cannot understand them, unless you've gone through it yourself, that might be true. But they also feel that they're not worthy of other people's attention or their love or their concern. It's that sense of, I'm just going to go and and hide in a hole, so to speak. If people are already feeling like they're different or they're less than, and I think it's tremendously lonely, and I think it's incredibly painful. Because people look okay, and sometimes even at work, they can function at a high level. It often gets missed, which is terrible.

Fowler: To what extent does the diminished motivation influence the likelihood that they'll seek care, do you think?

Swartz: Well, lacking motivation certainly doesn't help anything. Sometimes it leads to there being problems in functioning, that can do it. But I don't think people have any confidence that treatment will work when they're depressed for a couple reasons. One, they don't think they have a treatable medical problem. Two, if they believe they have depression, they think they have a form that won't respond to treatment. There's no hope for me, that kind of a thing. Then the third thing is, is that the energy to make a call to track down someone that can take care of them to, in this day and age, when it's sometimes hard to connect to services being going through that, I'll often say to friends who say, what can I do to help? I said, you can identify someone who can see them and offer to take them to the first appointment, or make sure their computer is set up if it's going to be telemedicine, because the energy to just initiate all of that, someone with really severe depression may not have it.

Fowler: Karen, if you're the clinician, if you're the psychiatrist who's working with the clinician and you get a sense that their level of depression may in fact be influencing their ability to function as a clinician, even in the short term, what would you say then?

Swartz: I think when people are in certain roles where they're influencing other people's health, other people's safety, we have to be careful. Someone's a nurse, they're a doctor. They're working respiratory attacks, something like that. We have to make sure they're actually functioning. If they're not, it's the same way that you wouldn't say someone should keep working if they're in the middle of an intensive period of chemotherapy. Sometimes people need to take medical leave. Often they don't, because the depression, thankfully doesn't get that severe, but it's possible. It's really important that the clinical team taking care of them takes that seriously, has an understanding, and that they themselves understand that I don't want to compromise my ability to function, because that would obviously compromise someone else's care.

Fowler: What if it's a colleague that we're working with and we we're concerned that there's something going on. Clearly we're not the experts, so we're not making a diagnosis. But at the same time, there's just something about the way they're showing up that has us concerned, either that they're truly depressed and need help for that, or perhaps that they're not quite functioning at the level they've been functioning at before. How should we approach it? Because we don't want to impose any additional harm on them. What's the right way to start this conversation?

Swartz: That is a challenging conversation to have, Carolyn, because it it depends on what your relationship is with the person. If it's your closest friend at work and you have a really long standing, close friendship, that's someone you might talk to directly and say, I'm really worried about you. I've known you for 20 years. You're not yourself. These are the things I'm seeing. Coming to work, and you look a little rough. You look exhausted. I've noticed you don't have your usual confidence. All of these things worry me. I've identified a resource. I think would be great if you would at least get this evaluated. But most of us aren't going to have that relationship. Then you have to think, who is the right person to have that conversation? It might be that you express your concern to clinical supervisor, because that leader will have a responsibility, can get information about functioning, can check and if there is an impairment in functioning, can be in a different position to talk about. We really need you to do this because we just need to make sure you're okay. It is the usual thing to want to ignore this, because it's such an awkward position to say to someone, I'm worried about you. I will tell you. Years ago, I was anemic for a very treatable reason. But my friends, my friends on the floor, especially the nurses, came up to me and said, what is going on with you? You're very anemic. I was so grateful because I said, well, this is what's going on, this is what I'm doing. And they said, well, we care about you. We don't want something happening to you. That's all straightforward because it was such a straightforward problem. Imagine trying to have that conversation when someone's saying, I'm fine because they're telling themselves they're fine, versus you're right, I'm in the middle of a terrible depression. I can't think, and I'm worried that I'm never going to be able to work again and all these other worries in their mind. But you have to say something. You owe it to the person, and of course, we have to protect the patients. That's what's different about taking care of clinicians than, say, someone that has a another role where their work doesn't so directly influence the safety of others.

Fowler: During the pandemic, we saw so many people with a full range of experiences. For some it was stress, maybe just getting into that yellow level of getting towards distress. Then we saw people going through burnout and into full scale depression. Could you maybe talk a little bit about that range of experience across that spectrum that we experienced during the crisis?

Swartz: Absolutely. I think that that goes on because clinical work is incredibly rewarding, but it's also hard. It's emotionally draining. It's long hours. It's high stress when you're on duty. I think that continues. I think it got heightened, and maybe one of the only positive things that came out of COVID is that we're having these conversations much more openly, and that perhaps, I hope people are a little more open to getting help. But there's a level at which people are just getting tired. They notice they're a little more irritable. They're not disliking work. They're not having classic signs of burnout. But they need to take better care of themselves. That's where saying, am I getting enough sleep? What am I doing in my downtime? What am I doing to refill the tank matters. That again, is a conversation perhaps friends would have. But that's not going to be at the level that the organizations involved because you're not noticing anything necessarily the person's noticing themselves, they're the ones that are seeing it. That's important because sometimes that can especially with burnout, not lead to it getting further. With burnout of course, people start feeling emotionally exhausted and they start disconnecting from the patients. They aren't engaged in the way they typically would. That's been shown, obviously, to affect the way people function in their clinical roles. That's where time and looking to see what is going on. Are there ways I can change how I'm working. That's where things like doing mindfulness again, paying attention to your own stress level, getting more exercise and thinking about your schedule, perhaps not signing up for extra shifts, making sure that you're working in a way that's sustainable can be helpful. But for others, it progresses into depression. I will say this generally, I've taken care of many clinicians in the time I've been at Hopkins, which is more than 30 years. In general, I would say that clinicians, when they come to treatment, their mood disorder has advanced to a more serious level than the average person because they've tried to manage it on their own, or they haven't taken action, or they were too busy or all the things. All the things that get in the way of going for your general checkup or going to get that colonoscopy or whatever it is. Then you have to say, we have to do something about this because we don't want it to go to another level where it's actually changing your ability to function.

Fowler: What then would you say is the responsibility of organizational leadership in making sure that clinicians who may be struggling are supported?

Swartz: I think one of the best things that an organization can do is to have some resources available on campus that are easy to access. If you think about clinicians, think about the shifts you're working, the different times you're on service, just getting somewhere else to get care can be daunting and be enough of a barrier that people don't follow through. Having available services. Now, some people will appropriately choose their own choice to get treatment with someone who's in no way connected to their organization. I will say that if you're working with therapists, psychiatrists, psychologists, their level of confidentiality doesn't change whether their clinic is where you're working or somewhere else. That has to be absolute. That's not practically a worry, but I think it's a worry that some people have. Where would I be seeing someone, etc., would someone know? The the organization investing in having resources, I think is one of the most important things they can do. The other is to train their leaders so that they're aware when people are struggling and to encourage them. There was a really interesting thing that happened years ago in the Air Force. They decided to make suicide a number 1 priority, and they started at the top. The top generals were telling, the colonels telling the, you know, all the way down the line to the the youngest people. If we let something bad happen, we've all failed starting at the top. That changed the suicide rate in one year it halved it. This idea that we all need to take this seriously and we have to encourage it, and sometimes we have to be open that we think this is important or I myself use this resource. Those messages go a long way.

Fowler: Reducing the barriers.

Swartz: Reducing the barriers, making sure that there are not unrealistic expectations for work hours. I am old enough that when I was an intern, we had no duty hours and that wasn't good. It's good that the residents now have restricted hours. The nurses and attendings. It's less clear to me that anyone's paying attention to the number of hours they're working. If people get called in to cover or work extra shifts or just have to do the work until it's done. I think we have to think as an organization, have we set up duties for either attendings, senior nurses, the floor nurses, others where their duty hours are unrealistic or not healthy?

Fowler: Not just the official duty hours, but the the encroachments onto their time when they leave work.

Swartz: Or their encroachments, they have a shift, but the documentation requirements, and they're there for an hour or two later and all of that, that we just have to be thoughtful. That part of what helps people refuel is sleep and time and energy enough to go do something. It might be really great for any of us to go take a walk on a beautiful day in a park, but you have to have the energy to actually go and do it in the motivation, but also that you just don't think. I remember my internship, we just wanted to sleep. We thought that was the greatest thing you could get to do. If you're working 120 hours a week, it probably is the best thing you can do. But if you're too tired, all the other opportunities to refuel just seem overwhelming, and I don't think people will take advantage of them or be able to do it realistically.

Fowler: Karen, as we get towards the end of our time, I just wanted to open up another topic and I hope it isn't too big of a topic, but let's just give it a try. You and I had some conversations about how much grief we thought we were seeing in our colleagues, and then recently we've seen two other things. One is this escalation of violence and interpersonal violence, often from patients and patient families, which is creating a sense of of fear, sometimes even in our clinicians. Then finally, these incredibly rapid change cycles that we're seeing in healthcare right now. How do those come together to influence the risk for depression or other mental health challenges?

Swartz: Well, Carolyn, I think when you have enormous stress, we know that that is a risk for depression. It probably is that each of us are born with a different vulnerability, depression like other medical problems, and then what life throws at you makes it more or less likely to happen. If you are working in an incredibly stressful environment where pretty much every minute you're at work, you're worrying that a disaster is about to strike. I do think that with the most frontline healthcare workers that has happened with this change in violence. The level of tension and the cortisol levels and everything all day, I do think that's a risk factor, particularly for those that perhaps have a family history or themselves have a history. I think that's a big factor. Then with grief. Grief itself, sometimes that will trigger an episode in someone who's vulnerable. I think that there's all kinds of grief. There's obviously the grief of losing a patient or a friend, but there's also the changes of it's, wow, we've really changed how we operate. I think that there's grief associated with thinking we now have to worry about violence in a way we didn't before. That sense of we've lost the ability to work as clinicians. For many people, they came into this work because of the joy and the satisfaction. Then if you layer on a level of fear that really changes those positive emotions. We all spend our day having positive and negative experiences, and you hope on balance most days it's more positive than negative. I'm not going to be perfect, but it's really hard if you just feel like I just am exhausted from being at work because I never know what's going to happen and I don't feel safe. It's a pretty basic need.

Fowler: Karen, I wonder what advice you would give to those of us who work with new clinicians, new graduates, the new residents, the new interns, people who have just finished their training and are coming into this environment perhaps not fully prepared for what's going to hit them? What should we be looking for and what should we be saying to them as they come into this environment with us?

Swartz: I think all of us have a responsibility to our younger colleagues to be there with them. What I mean by that is it's not just training, but it's checking in. It's finding out if they are well suited to this work. There are individuals I work with, one of my own classmates in residency, who really did not enjoy clinical work and had a really successful career doing non-clinical work because after years of trying to get herself to like it, she just never did. You just have to check in and also find out is there something a skill someone needs or guidance they need to make a challenging situation, maybe a little less challenging. I think we have to be hands on. I do think actually that our current graduates, residents, etc. are open to that teaching and support. More than maybe 10 years ago or 20 years ago, when there was much more of a sense of I can do it all, I'm ready to roll. I think that's good that they're open to it. But I think we need to make time for it. As the more senior members of the team, I think we really have to make time for it.

Fowler: Well, thank you for being here with us today, and I'm going to give you an opportunity just to tell our listeners, anything else you would like to tell us about how to think about depression and clinicians and how to protect clinicians? After all your years of experience?

Swartz: I'll close by simply saying, I chose to focus on mood disorders for my career because people get better when someone's in the middle of the depression, they don't believe it. I've been called annoyingly optimistic. I've been called relentlessly stay optimistic. I would always say is my optimism that you're going to come out of this depression and feel well. Comes from experience. That is what the message I hope that people take away. Depression is very treatable. Anxiety disorders, other psychiatric conditions are very treatable. They take a long time to get better on their own without treatment. I would hate to think that people are suffering unnecessarily.

Fowler: Karen, thank you so much for everything you do, and thank you for the gift of your time today.

Swartz: Oh my pleasure.

Fowler: Thank you to you for listening to our podcast. I hope you'll come back and listen to another one very soon. That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. Always, we welcome your feedback.

Fowler: If there are any topics you'd like to hear about, please e-mail your ideas to us at [inaudible 00:26:17].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Karen Swartz, M.D.
Professor of Clinical Psychiatry Johns Hopkins School of Medicine 
Director of Clinical Services at Johns Hopkins Mood Disorders Center 
Director of Johns Hopkins Adolescent Depression Awareness Program

1. An estimated 1/3 of clinicians are not getting preventive screenings or primary care.
2. We need to make it easy for clinicians to access care. Two strategies for organizations are:
   1. offering confidential, high-quality mental health care on campus and at convenient hours, and
   2. training supervisors to recognize when someone is suffering.
3. We all need time to rest, so we have the energy to do our best work and to enjoy life. Leaders and clinical supervisors should consider how they are protecting clinicians who often have long hours and take work home.
4. When we notice that someone is suffering, we have an obligation to support their ability to access care. Treatment for depression and other mood disorders works. 

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler. We are your co-hosts for the Johns Hopkins Medicine Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share some of what we're learning.

Biddison: Thank you for joining us.

Biddison: Hello and welcome. This is Lee Daugherty, chief wellness officer for Johns Hopkins Medicine. I'm your host for Vital Conversations, and I'm excited to welcome today Doctor Manisha Loss, the Associate Chief Medical Information Officer for Johns Hopkins Medicine and Associate Professor of Dermatology at Johns Hopkins. Welcome, Manisha.

Manisha Loss, MD: Great to be here, Lee. Thanks for having me.

Biddison: I have the great pleasure of working with her on the epic well-being clinician well-being committee, together and seeing what's happening there, which has been really fun. Today we're going to talk a little bit about what's happening in health IT and the what's on the horizon for well-being amongst clinicians, as we kick off tell us a little bit about your role?

Loss: Sure. As you mentioned in the intro, I am a Dermatologist at the institution and started my career on the side of clinical operations. Grew up as a medical director and was involved in health informatics early on because I was here when the institution implemented Epic, our favorite electronic medical record system, and in about two years ago, I had the opportunity to come into the role of the Associate Chief Medical Information Officer. Really, I spent my time focusing on how to optimize the use of our EMR, but also other health information systems that enhance both patient care and our operational efficiencies.

Biddison: That's fantastic. We're going to dive right in and just wanted to hear from your thoughts on everybody's got thoughts on this. But your thoughts on, what do you think our main priorities need to be in terms of clinician well-being and interfacing with Epic and with other healthcare technology?

Loss: I think it's actually pretty simple. I think that technology should make our our world, our our jobs, our interactions with people easier, not more cumbersome. I'm afraid that many of the technologies that we have brought in seem to to really be more of a hurdle or a barrier to us doing that. I think that these technologies should be a tool that help bring us patients, physicians with their patients or even physicians with physicians closer together. I'm reminded about those interactions you have with patients and at least in the ambulatory setting where a patient comes in and you have actually received their medical records, or they're part of a system where we can see their external medical records in our system, and we review those, and a patient comes in and you talk with them about things and they're related. That's what the EMR is supposed to do for us. It's supposed to make people feel like they're understood and they're known, especially when it comes to content or information that is hard for them to explain because they might not understand it. I think really, it's that simple. It should make our jobs easier and it should bring us closer together.

Biddison: How are we going about that as an institution at Johns Hopkins?

Loss: I in thinking about that question, I was reflecting on how we've done that until about a year and a half ago. I think historically we've done that by trying to train and educate ourselves out of a hole. Not to diminish the importance of doing that, but I think traditionally we've tried to say, well, let me just give you some classes to make you more efficient. Let me teach you how to use dot phrases or more classes.

Biddison: Exactly. Let me give you more things to remember on how to do your job Because your job wasn't complicated enough in the beginning. But let me tell you three different ways to figure out how to do the one thing you need to get done today. I think that has led to a lot of the frustration. I think the, the burnout that we see amongst our colleagues and ourselves at times, when you're trying to click around the screen because it's so busy and you can't figure out how to do what you need to do. I think traditionally we've tried to really hone in on what those pain points are and provide information to help educate, train our way out of that. I think about a year and a half ago, that mindset had a change, and I and that's the area I think that we're most excited about. That is how can we really refocus to have technology do things for us that make our jobs simpler? How can we reduce that cognitive burden because the technology is actually bringing things forward or taking care of a few of the steps for us that traditionally weighed us down.

Loss: That's fantastic. I love it shifting from the here's here's something else you need, tacking on something else you need to try to do your job to how do I how do we as an organization simplify rather than adding? It's almost a streamlining and taking away. I love that so much. What tools are we talking about? Which is what's what's what are you. Tell me more about what you're thinking specifically.

Loss: There's so many. There's right there's so many. I think most of us probably remember the around the holidays when we first heard about ChatGPT and these large language models were coming into everyday use, and there was this explosion of excitement around how can I use this to answer questions for, for my kid or to make my grocery list or, we remember the excitement around Siri or Alexa in our house, and all of a sudden about a year and a half ago, we had this opportunity to really figure out how to use those technologies in our workplace. I would say there are a couple of different ones that we're most excited about. I thought we'd start by talking about AI scribe, because I think that.

Loss: People love that idea.

Loss: People love that idea. the excitement around whether we call them digital scribes or virtual AI scribe, really the concept is how can I use artificial intelligence assistants, Copilot is a term that's been dubbed in the industry to really help me with my clinical documentation. at a very basic level, to start from the top, these virtual AI scribes are AI powered assistants that are designed to help us with our clinical documentation. Really, it listens to a patient and a provider physician conversation during the encounter Counter and automatically generates a detailed note. It takes that administrative burden of let me listen and transcribe in real time or in my generation. I trained to where I had to listen, scribble some notes, and then I had to recall in a dictation after the fact. I had to repeat that story back together after the fact. Really, what this does is it decreases that administrative burden in real time because it uses ambient AI technology, which is really this unobtrusive, seamless technology in the background where the tool is listening, and not only is it just Word for Word transcribing the conversation you're having, it's turning that transcription using natural language processing into a Soap note for you. It's been trained to to Decipher what is background chatter about your grandkids or your golf game this weekend, from what is relevant medical content to the visit at hand, and it teases those things apart in order to generate a note that includes what we would traditionally have to parse out in our mind into the various different parts of a note. It does it in real time. When we use systems that are supported by the institution, it does it in a compliant and secure way, and it creates this efficiency because it generates that content, it generates that note within minutes. Instead of we call it context switching. Instead of going from listening to the conversation to doing a physical exam and coming up with your medical decision making and then having to step out, and if you're in a training environment, you might be listening to someone telling you this and putting it all together in these scenarios. When you come out, the note is in front of you, and so you're not having to piece together the different components of it in order to clean it up. Now, it's very important that I emphasize that these tools are intended to assist you in your work. They are not perfect. They still require that you read the content, that you ensure accuracy, that you ensure there's no omissions. You also need to ensure that it didn't add anything. That's not true. You've heard about hallucinations and some of these language models where it adds content in that isn't accurate.

Loss: Actually not heard about hallucinations. Wow. Yeah.

Loss: Some of these language models will essentially make up, what it thinks should be in the context. Interesting. In the world of what you and I do and our colleagues do, it's important to remember that these tools don't replace what we were doing before. They're simply intended to be, again, your co-pilot, your assistant, and decrease that cognitive load where you're having to do that while attending to the family members in the room or putting in orders. It's really intended to help provide you with an outcome, a product, which is the note, that you that still need to refine.

Loss: Does it work for everybody?

Loss: Yeah. that's a great question. I think the example that I think is most analogous is in our world, we talk about using medications on label and off label and all of these AI tools that we're exploring. We're created with a specific intent in mind and a label indication or use. When these models first came to the market, they were trained in primary care and internal medicine and actually adult internal medicine. In our mind, it worked best in adult primary care. Now, that being said, these models are evolving, the language models that they're using to train them are evolving rapidly. We are finding that for parts of the medical exam or the or the visit, you can get this to work because it's just using language processing. Is it great at documenting when you do an in-office procedure or bedside procedure or really physical exams, which are very unique to each specialty? I'll say it's not there yet. But we have found and what we have. I can talk a little bit about how we rolled this out at Hopkins Medicine, that if we start with its labeled use, we get a better understanding of how it functions, of how it's how effective efficient it is to then allow us to push the boundaries and limits to see if it can be useful to people outside of that original label or off label use. Just to dive into where we are at Hopkins in October of 2023, when these tools and these vendors came to market with these tools for us, we rolled this out originally in primary care, we did it at Johns Hopkins Community Physicians, which is a close network of physicians where we have a lot of engagement. It was well received, and by January of 2024, we were able to expand the use of that particular vendor's tool. We wanted to test it outside of primary care. We extended it to more primary care within the School of Medicine, but also then to specialists and surgeons, because we wanted to start getting feedback on whether or not we thought this would be a tool that could be broadly used at the enterprise. We then realized at this point, if you Google virtual AI scribe, you will find there are probably at least two dozen vendors in the in the marketplace. The landscape is growing rapidly. We wanted to ensure that we were looking for vendors that would be great partners, and so we decided to do a head to head trial. We brought in a second vendor. and at that point, what we were able to do were taking take the people that originally used the first product to market and shift them to the second product that came to market, so that we could get a sense of what are the true differences in these tools. Is there? Are they comparable to one another? are they as easy to use? One of the things that's so important when we talk about technology is how do we get people to adopt it. I don't know how you feel, but when your phone has an upgrade, is it easy or is it hard for you? When you're when it's time to get a new phone or a new laptop, how how accepting are you of that change? We recognize introducing these tools into an already stressful job environment, work environment. we want that to be less burdensome for people. doing the head to head comparison helped us to really get a better understanding of what it what it meant for an individual physician to switch from one tool to the other. When we did that, switch to the second vendor. That vendor's tool allowed us to expand to people beyond ambulatory medicine. The original tools were intended to, be used by people who had patients on a schedule. you would click the patient, the scheduled patient, and then start the recording. The second vendor allowed us to expand to the emergency department and hospitalist, because it's not based solely on a scheduled patient visit. At that point, we shifted our users to the new vendor, and so then we also were able to bring in another set of, new people, including trainees, which I think is a fascinating area to really study what these tools mean for higher education and medical training. We are right now running our head to head trial, we have two vendors systems live in our in our production environment. we're hoping to pick a partner, in this competitive vendor Indoor landscape by the summer.

Loss: It's really exciting. I've got so many questions. Tell me a little bit about, well, let's start with what is this like for patients? What's the feedback from patients?

Loss: Yeah. A couple of things to just highlight and keep in mind as we talk about that experience. I have to throw in the one thing that's really important from kind of a regulatory or a compliance standpoint for those of us that practice in the Maryland area or in the Mid-Atlantic area, Maryland is a two party consent state as far as audio recordings, and so it's very important that we have open conversations and be transparent with our patients, family members, staff, students that are coming in and out of the rooms, potentially to ensure that people know that they are being recorded. We've worked with legal and with some of our, um, patient education liaison to really talk about how do we introduce this to patients. Right. How do I say, is it okay if I use this technology or this tool that's going to help me focus more on you and what brought you into the office today, so that I don't have to be behind the computer? That's the first thing I would say is we've really tried to emphasize the importance of being transparent about using this, because I think that engages the patient and their family members to know that we're really just trying to be more present with them. I will say that we have had only a few reports of patients who are not comfortable with the idea of being recorded, and some of the feedback we've received has to do with one, the content of what they're there for. If it's something that is hard for them to express, we have found that sometimes those visits turn people off from the reporting aspect of this. The second piece of feedback that I think is interesting and we should study a little bit more is there seems to be a little more hesitancy amongst people in healthcare. We've had a few people-

Loss: You have a few patients who are clinicians.

Loss: Yes, patients that are on the clinical side. I think that would be interesting to study and explore once we start really delving into the patient experience side of it.

Loss: It is super interesting.

Loss: Yeah.

Loss: Wow. By the way, on the two party consent thing, just to tell everyone, Manisha did consent to being recorded for this podcast, and so did I. Where are we headed with the, you mentioned making a decision about this summer and hopefully developing or identifying a key partner for this summer? Let's just presume that all goes smoothly. I guess the question is sort of what's next?

Loss: Yeah. Our team that has been looking at these technologies and looking to roll them out, are keenly interested in one, making sure that as we do this, we study the impact of this on our workforce and our patients and on their outcomes. We are really trying to partner, um, with some of the researchers at the institution that study human factors engineering, implementation science, how we make decisions in healthcare, the business of medicine, right. These tools are not free. I think there's many other aspects around the decision making, are going to really drive how this plays out at the institution. I will say our primary focus has been, from the beginning, how can we improve the well-being of our clinical workforce? We know, right, that these aren't free and they are going to come with a cost. But if we can improve the experience of our clinicians and the joy of seeing patients come back, then we create a healthier environment, I think, for people to want to work and to stay here, to work and to recruit people to come and work, to take care of our community. I think we started with this focus on wellness. We recognized that there are many other aspects that need to be looked at and studied as we bring in these tools. We're in that phase right now where we're trying to socialize some of the initiatives or projects that we're bringing in. Then really the the nitty gritty or the operational side of doing this is once we select a vendor or a partner in the marketplace is how do we want to roll this out to get it in the hands of people, where it does improve their interactions, their well-being, their joy that probably originally brought them into medicine? I think if the tool isn't for everyone, and I think that's why the research component is so important, because as I mentioned, it's not free. We want to be sure that we get it in the hands of people where it is going to improve their experience. Their well-being is going to make their interactions better, and it might make them more efficient. We're not sure about that. It might mean that they may want to see more patients. They may not want to see more patients. They may just want to get to go home at 5:00 and not have to chart after their kids go to sleep. But we want to be sure that we explore where it could be most beneficial. Our plan is once we find the right partner, um, that we start to talk using podcasts like this with the community about the fact that this tool is coming so people can start thinking about whether this is something they would want to trial. In our pilot, we've only been able to put so many people into the pilot because we only have so many licenses. But going forward, this would be something that, in the same way, you might buy Microsoft Office tools on the marketplace because you like to use Word or you like to use OneNote. This would be something you could just purchase through the institution. Because we would have a contract with a vendor to do this, and then you get to use it in your practice. We do know that it will start in the ambulatory setting, and so we're going to we're going to focus just based on the technology and how it integrates into our EMR, we'll start in the ambulatory setting. The two vendors that we are, you know, really seriously considering have planned to make this available to ED docs and hospitalists going forward. That is definitely on their roadmap. Then we'll get it into the hands of people and we'll figure out how to pay for it, which is which is a tough piece of it. My initial conversations with some of our clinical leaders at the institution is the joy that humans thrive brought people would be impactful. The problem is humans are human scribes. We have a workforce problem. Sometimes they come, sometimes they don't. Sometimes their quality is variable. They're very expensive. This is really potentially an option which drastically drives the cost down and becomes more reliable at the same time.

Loss: Sounds like a win-win.

Loss: Yeah. Super exciting.

Loss: I could keep you talking all day, but I don't want to do that. But I do want to hear if there are any other, we've talked a lot about digital scribes. Are there other technologies that have come across your desk that you're excited about, as we move through, mature our process with digital scribes that you're sort of thinking, oh, I want to look at that next.

Loss: Yeah. There's a few that we're playing with right now that I think have some great potential. I probably don't have to spend too much time. But just as a reminder. Coming out of the pandemic, our community's use of the patient portal, or what we call MyChart at Hopkins, grew exponentially. People got connected to healthcare remotely, and that led to a massive influx of what we call in-basket messages, or basically e-mails from patients about health concerns. One of the challenges we face with that shift in how we deliver healthcare was we flooded the recipient with just a hodgepodge and a sundry of messages that weren't all clinical, and we had built our framework of how we delivered that care on a large body of clinical expertise. Sometimes the messages went straight to doctors, sometimes it went straight to nurses. Sometimes it went to certified medical assistants, or there were different pools of people that would look at it. It varied a little bit, but it was a skilled labor force that was the pool that received those messages. Well, we learned that those messages weren't always clinical. A good portion of them had to do with, I need a letter. I need to cancel my appointment. I need to reschedule my appointment. I lost my prescription. I just need it again. I dropped it in the toilet or something, right? And so some of those, some of those messages didn't require a, for example RN to respond to it. This gets us into that realm of scope of practice. How do we get our workforce to work at the highest level within their scope of practice? We were struggling because there was no way to tease out what all these messages were. One of the projects that our team really worked with experts in data science and AI was, can we train a system to tag messages to tell us are they clinical or are they administrative? Let's start very simply because if we did that, we could respond to patients in theory quicker, because right now it's first message in its first right is the message that goes out. There's no triage within there without somebody having to read every message that comes into your in-basket. If we could divide them up and say, well, this is something these are non-clinical messages. Our front desk or patient service coordinators could handle these, versus we need really RNs or CMAs to deal with some of the clinical messages that would help us respond to patients quicker and use our labor force at the highest level of their skill or effectiveness, which is always a goal. We embarked on this great project with some partners to really see if we could train a model to help us do that effectively. We're super excited that this model has, again, we started in primary care because the language models that have been developed with some of these vendors in the marketplace were really already looking at that kind of primary care data. We started in primary care, and we've been categorizing messages, tagging them to be clinical administrative. Now we're expanding that project to look at surgical messages. Is there a way that we can do that in other fields and other specialties. That project is super exciting. We're hoping we'll continue to roll out. The second project that we haven't touched on, that also has to do with In-basket, has to do with, can you draft a response to a patient for me based on what they sent in? This project is fascinating because it makes us think about how much effort goes into when you get an e-mail for you to generate the reply de novo versus if somebody primed the response for you, or does that work with how you think about things, or is reading what somebody prompts more of a cognitive load or burden for you? In this project or this initiative, we're using this auto draft response or this response technology to see when the In-basket message comes in. Can I prime it? Can I prime the response to send the message back? It's been interesting. Some of our colleagues on the West Coast that started with this and have done some studies around it have found that it hasn't necessarily made us more efficient. The one thing that we have learned is that it has made us more empathetic. What's fascinating is that, you have to prompt the AI tools in order to draft the message back. If you've ever used ChatGPT, you have to ask it a question. You can tell it to be kind. You can tell it to be angry. You can prompt it to respond. We find in the literature that's been published that we tend to respond to messages somewhat curtly. We're a little short sometimes because we're busy and we got messages to respond to. You might send back a very quick response without the dear Mr. Biddison, thank you for your message. Sorry to hear you've been having this concern. Here's what I would recommend. These tools help us respond in a way that I think keeps us a little bit more empathetic. The thing that's tricky is that these tools can't give clinical advice. They're actually prompted to not do that. It comes down to whether or not you're somebody who would accept the, let's call it flowery response, versus would you rather prefer you just respond to your patient with a simple answer? More to come on those tools. One area where we're exploring, the role of that tool is actually not from the physician response, but could this be something that could help our nurses or our clinical staff respond to messages? Ultimately, is this something that would help our administrative staff respond to some of the responses they get by decreasing their cognitive load and burden in responding to messages? I think more to come on that project. We've got to find the right place for it. But I do think that it has potential.

Loss: I just love all of this. It's so exciting to see what the future holds. Well, Manisha, like I said, I could keep you talking all day, but I think it's time to wrap things up. But I do hope that we'll have an opportunity to reconnect as some of these things take further shape and hear more, because it's been such a pleasure to just hear about all of this today. Thank you so much.

Loss: Thanks, Lee.

Loss: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail your ideas to us @[email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Manisha J. Loss, M.D.
Associate Professor of Dermatology
Associate Chief Medical Information Officer
Johns Hopkins Medicine
Medical Director, Patient Access Services
Office of Johns Hopkins Physicians

1. Until recently, we have expected clinicians to simply adapt their practices to new technologies: to take classes on EHR optimization or develop work-a-rounds, which add to the burden of clinical practice. We now understand that, instead of adding to the work, we must find ways for the technology, like AI, to make work easier rather than adding to the burden. 
2. In its best iteration, AI has the possibility of supporting one of the most rewarding aspects of medicine- our relationship with our patients. The renewed connection with patients and their families can enhance our sense of meaning in work and promote retention. 
3. Because these technologies are so new, it’s important to study outcomes in different clinical settings and with different members of the clinical team. Roll outs need to be carefully planned so not to unintentionally add to the burden on our teams. 

Lee Daugherty Biddison: Welcome, I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler and we are your co-hosts for the Johns Hopkins Medicine Office of Well-Being Podcast, Vital Conversations Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share some of what we're learning.

Biddison: Thank you for joining us.

Biddison: Welcome, everyone. It's great to be here today for our next Well-Being podcast. We have the pleasure of welcoming today my colleague and good friend, Dr. Kim Peairs, Associate Professor in the Department of Medicine at Johns Hopkins. Kim also serves as Vice Chair for Clinical Affairs in the Department of Medicine and Primary Care, Value and Innovation Medical Director in the Office of Johns Hopkins Physicians. We're going to be talking about Prior Authorizations today, and a Pilot that was rolled out in the Department of Medicine over the last year. Kim comes at this with not only the experience I just described, but also her experience as a Practicing Internist and Former Medical Director of one of our primary care clinics. Welcome, Kim. Thank you for being here.

Kimberly Peairs, MD: Thank you, Lee. It's wonderful to be here.

Biddison: I'd like to just jump right in, if that's okay and I'll start with our first question, which is, can you just tell us about the Prior Auth Pilot, as we've been calling it that, how it was rolled out in the Department of Medicine and who's involved? How did this work?

Peairs Well, as you're well aware we have several primary care practices within the Department of Medicine, and some are located at a hospital-base, some are in a more community-based setting. They have different payer mix but they're busy primary care practices. As we all know we are really trying to work in team-based ways in primary care to manage the volume of patient needs that we have. We're also well aware that prior authorizations is a reality in our insurance landscape, and we really want to make it effective workflow for patients to be able to get their medications in a timely manner but what we were finding is that a lot of this was falling at the clinic level and in done in various ways. Either it fell on the provider's shoulders to do that, or very busy people who want to be taking care of patients directly or the nurses in the clinic who really we wanted to use their resources to interface with patients and troubleshoot their medical conditions and so it's a lot of work. We base this on a program that our endocrinologists had been doing for some of their higher priced diabetes medications or medications that need prior authorization in diabetes which there are many. They had worked with our pharmacy group, in particular, a subset of pharmacy technicians that were very well organized in knowing the workflow for getting prior authorizations done for these medications. We thought that would be a great way to support primary care, which is already an overworked group. We worked with the pharmacy group realizing that primary care is a little bit of a different beast that there's all medications that come through for prior authorizations and that can be challenging. We started to pilot in one of our practices and then moved it to several other practices. It involved us standardizing a workflow of how the prior authorizations would come to the clinic and then through our epic EHR sending them to this prior authorization group and then them working on it and setting up the workflows for us to achieve this to try to take the burden off doing the prior authorizations from our clinical frontline providers. That was the concept behind that.

Biddison: Fantastic. Really a team effort with a number of different clinics and leadership in the Department of Medicine, it sounds like and our pharmacy colleagues.

Peairs Yes, and I will say that the team aspect of that is very important for this to be effective.

Biddison: What feedback have you received from the staff and the involved clinics? We'd like for it all to be good, but it doesn't always work that way but what's the feedback been like?

Peairs As any new workflow, there was a learning curve and I think we were very lucky to have a very strong clinical administrative leader that helped from the clinical side to work with the pharmacy team because it's change and it's change management and identifying the best workflows and meeting weekly with the pharmacy team from the clinic side and getting process improvement weekly on how this worked and communicating with the clinic staff on this, and that included educating the physicians and the nurses and other support staff in the clinic to understand the workflow because it really is a team effort to make it happen. The feedback so far has been very positive. I think the support that the clinics felt and the clinicians felt was great because they finally said, hey, you're helping us do something that really doesn't add value to what we want to do day to day. The pharmacy tech group actually enjoys it because they're efficient, they know how to do it. They can give feedback to the clinics that's helpful, actually, in clinical care, and we can talk about them a little bit but it's putting the skill set in a specific group of individuals that can be efficient in doing that. I think the clinics felt very supported and as the physicians and the nurses very much appreciated the effort.

Biddison: That's fantastic. I love the idea of really trying to move work into those spaces of the folks who can do it most efficiently and for whom it does bring meaning. Meaning and work is such an important part of our our being engaged and feeling fulfilled in the workplace, I love that. What impact have you seen on patients or feedback have you gotten from patients? Is it impacting them, do they even notice?

Peairs I would say they probably don't notice and I think that's a win because our goal at the clinic is to make this fairly seamless for patients. They need their medications, we need to get them their medications and the workflows that we had prior to this achieved that. But it was a little more scattershot in how it was done, and again, probably done by individuals that could be doing other things in a more meaningful way for patients. I don't think that patients probably have noticed the change, which I would say is a good thing. If anything we have a more accurate way of letting patients know where the prior authorization request is in its life cycle from the time that the request is made from the pharmacy, to the approval, to the patient getting it. We now have a tracking mechanism for that, which unfortunately, we didn't have prior to instituting this pilot.

Biddison: Eliminating the black box of I think something's happening and really being able to track it, that's so great.

Peairs Yes.

Biddison: Tell me a little bit about what the folks who were involved in the prior auth are doing with their time now. I know folks, you had RN's doing some of this and some of it was providers, but how has this changed what they're actually able to do in the clinic, do you have any specific examples?

Peairs Yes, particularly for our RN's which at least in my clinic we're doing the bulk of the prior authorizations, which was kind to me as the physician to not handle the bulk of that load. But now they're able to do outreach to patients after they're discharged from the hospital which we really think is a priority to helping transitions of care and reducing the need for patients to go back to the hospital. They're able to go in and take patient messages out of the pool in epic much quicker in the day. We can help triage acute issues for patients and they can call patients back, and so it really is transition them to more patient facing work which is what they love. It's much better for patients and I think for those clinics where the physicians were even doing some of this more, it allows physicians to do more of what the nurses were doing also in interfacing with patients patience and giving time to answering patients questions, and things that we think are really paramount to good medical care. Again, and I can't overstate the efficiency component because the pharmacy techs they're efficient at this. They know how to handle the prior authorizations. They know the medications that are going to get approved or denied, and what the physicians really need to be thinking about and can feed that information back to the physicians, and make that more efficient. I think it's been a win-win.

Biddison: It's fantastic. What have we learned, I should say, as an organization, about the volume of work, how much of one pharm tech can handle, are we learning things about how to scale this?

Peairs Yes, well, we're definitely. It's definitely been a learning process. Prior to this, as I mentioned, we didn't have a consistent singular workflow and how it was documented in epic and because of that, we didn't have baseline volumes. We really didn't know the level of work we were doing at a clinic level, which we knew felt like a lot, and if you ask anybody in a primary care clinic, they will tell you it is a lot. But to really quantitate that we didn't have that information, so we ballparked it a bit and I think we were surprised we probably under ballparked it of how much volume there is. As we ramp this up, it became pretty apparent there was a lot. I think there was also the operationalizing it component learning the clinics workflow, learning the individuals in the clinic took a little bit of time. Each clinic came on, but we got more efficient because we've got an operational workflow of every time we replicated it in the next clinic, how it would be best handled, and so now we have that playbook down. I think the pharm tech also got much more efficient once they got comfortable with the breadth of medications that were coming through a primary care practice and it is wide ranging. I would say on average for a reasonable size clinic, they were doing about 200 prior authorizations a month which a singular individual could do probably on the order of seven to 800 prior authorizations a month in a primary care practice, which again, I think gives a little bit different than a subspecialty practice, because the scope of the number of medications and prior authorizations needing to be done is broader. We're still learning and efficiency comes with time and we're working towards that.

Biddison: That's fantastic. It sounds like there are a bunch of lessons in here not just about doing this in one space, but what it would take to make this scalable across broader parts of this organization or any organization, so great work.

Peairs Absolutely. I will say in doing this other divisions in my department that were not primary care started to hear that we were doing this and then started quickly asking if they could do it for their division also. We also had inpatient providers saying, hey, I hear there's a pharmacy tech program that's working well. Can we have that? For the same reasons that we wanted it for primary care, and so I think people think of it as value added. We'd love to be able to expand it and I think we have a clear blueprint to do that resourced.

Biddison: That's fantastic. Can you tell me a little bit about other lessons learned?

Peairs Again, one is that we had a better sense of the volume so that was eye opening just to be able to quantitate that. I think the other thing we have found is we've been able to outline what the prior authorization medications are that our prescribers are writing and by clinic. But primary care we definitely see some themes, and so the pharm tech group gives us feedback on the numbers of top 10, top 20 medications being requested. I think we're really trying to then transition that into some education for the providers. Even not to deter them from ordering the medication that's right for the patient by any means, because we wouldn't want to do that but there are places where we could probably be more thoughtful on the medications we order. If we know there's going to be a hurdle in the patient getting a certain subtype of medication. We know a priori that it'll get covered by a particular payer if we ordered something equivalent. We're trying to use that as feedback for the providers so that they're aware, which is something that they're not always aware of to help support them.

Biddison: Just a real education piece, so there's a two-way dialogue between the pharmacy and the frontline provider?

Peairs Yeah.

Biddison: That's fantastic.

Peairs In my clinic, we actually asked the pharmacy tech to just give us a one pager on common medication that we prescribe now or GLP-one agonists. Those are a lot of the weight loss drugs, but they're also diabetes drugs, and the landscape on how they're covered by insurers is highly variable, and it's very hard to keep track of that. It changes all the time, and so our pharmacy tech gave us the quick one pager on. Just remember you can order this way for this type of usage, and this way for this type of usage and I think the physicians were really appreciative of that because otherwise it really is a big black box.

Biddison: How are we getting that information to the providers?

Peairs Well, we reached out specifically and said, hey, can you give us a quick tutorial? We're sharing that amongst the primary care practices, and then at the practice level, practice administrators or medical directors are sharing it with their teams, with their physicians either keeping it electronically or putting it in the clinic somewhere. Again, it's not meant to restrict the providers from choosing medications that are best for patients but there's certainly many scenarios where the providers just don't know, like if I chose it this way or I wrote it this way, we wouldn't have to do a prior authorization and the whole process would go smoother and to have that information, because it makes it easier for everybody. It makes it easier for the physician, it makes it easier for the patient, and it's more streamlined.

Biddison: Just another simple way to save time.

Peairs Absolutely, and be more efficient and do the right thing for the patient.

Biddison: All at the same time, win-win. Are there other work efficiency related challenges that have become more obvious in doing this work?

Peairs I think what we learned was the many ways that the many workflows that have occurred organically to handle outside requests, prior authorization requests into clinics, and they aren't efficient and they aren't documented well and show the variability of some of the clinics. Again, just like anything, when you get a singular operational workflow and maximize its efficiency, you realize where the inefficiency were prior. I think that definitely has helped. I think what we call medical office coordinators or administrative assistants in the clinic that handle a lot of the faxes coming in or the electronic faxes, if you will, have learned the workflows to be more efficient. I think there's actually a safety component to it, too now, because we have documented workflows, it's all in electronic form. It's all tracked the same way. It's easy to find. Any provider could go in and see where the prior authorization is in its lifespan. That is really important and so I think some of the inefficiencies that were there were unmasked and we've tried to standardize that across the board.

Biddison: Sounds like a wonderful side product of the whole process. If there are folks listening who are interested in trying a similar pilot, what advice might you give them or thoughts as they start out?

Peairs I think having strong leadership. We've been blessed to have strong leadership from our pharmacy team who really have high quality expectations so that it's going to work, so that's important. They have been very good partners. Also, having strong leadership at the clinic level because like with any change management, there are always hiccups, and you have to be able to pivot and adjust and give quick feedback on changes. We had a very strong clinical leaders that were willing to shepherd this along working with the pharmacy tech team meeting weekly. I think you could translate that into any change management project that you wanted to do, but that was really important. Then getting feedback and hearing feedback from the physicians or the nurses, if something wasn't working, it fell through the cracks. If a patient didn't get the medication and trying to realize where it may have broken down, what that problem was, and so very clear lines of communication for that. I will say I know in other academic medical centers, they have a pharmacy person at the clinic who may or may not do prior auths for them. We really thought the economy of scale here was helpful, because some of the clinics were a little bit smaller, so they may not be able to support a singular pharmacist or a pharm tech at their clinic. Again, this is a centralized, efficient unit that can support several clinics simultaneously, but the clinics that thematically have the same challenges or the same needs that there's cross-pollination in that which I think has been good for the primary care clinics.

Biddison: It's great. Sometimes when we centralize functions, there's a sense of a loss of control and maybe breakdowns in communication. Do you have thoughts on how to mitigate that?

Peairs I think one of the successes of this is so far we've had one pharmacy tech individual and the clinic gets to know her, so it's always there's a person that you know you can ask with that question, and so we know who that person is. We need to ask. It's not the big black box of the prior authorization group. You know who you can ask, and the director of the pharmacy tech program is very accessible and very quick to respond if we have questions or challenges. I think putting a face and a name and an individual on that has been really helpful to not feel that it's not overly centralized.

Biddison: That's great. Those relationships are important, and being able to know just even the name of person to call if something's not working. I love that.

Peairs Yes and they're responsive.

Biddison: Well, I just want to ask you one last question if I can and maybe shifting gears or shifting hats from your leadership role to just being an internist in your clinic. Can you tell us a little bit about how things feel in the clinic, do you notice a difference in how stress levels or relationships between staff, have you seen impacts there? Is it too early to tell?

Peairs In my other hat prior to this, I was the Clinical Director at my clinic. I'm no longer so but I'm very sensitized to staff well-being because I think that leads to the community and us delivering better care. This dramatically improved our nurses enjoyment in their job, and sense of self-worth in delivering their patient care. That feeds back into everything. The nurses are so important in our clinic to being the bridge for patients to the physicians and physicians are busy in clinic. They were drowning before in the prior office to the point where we were worried we were going to lose the nurses, and now that's not the case. Everybody feels that in the clinic. I think that, again, we were fortunate enough in my clinic that the nurses were doing the prior authorizations before. But I think if it were falling on the backs of the physicians continuously, that is a really draining exercise for physicians. We should be taking care of patients, and I think many of us feel like some of this process is not actually taking care of patients, and that is felt.

Biddison: I love what you're saying about the well-being and fulfillment of the nursing team, because there's so much of our experience of burnout and well-being as a collective team experience. If your nurses are overstressed, burnt out, exhausted, it impacts the whole team, and the whole team's ability to deliver care together well. I love that as we think about interventions to address burnout issues, and improve fulfillment and improve at the same time, we're improving our care delivery thinking about us as a continuum of care and a team working together. I think it's not just about physician burnout, it's not just about nurse burnout, but as we come together and address these issues of work efficiency it can make a difference for everybody, including our patients. I love that.

Peairs I think what we reflected on earlier is the pharmacy tech group, they enjoy their jobs because they're good at what they do. They find it meaningful. They like interfacing with the clinic, and so we've taken a job that some people really don't like or don't feel meaningful and put it in a group that's very efficient who actually really find meaning enjoying getting that done. Again, I feel like that's a win-win.

Biddison: A win all around. That's fantastic. Well, Kim, thank you so much for talking about this wonderful project, and we'll look forward to hearing more as the weeks and months come about how it spreads across the organization and how it impacts both our teams and the patients that they care for. Thank you so much.

Peairs Thank you.

Biddison: That's it for today. If you enjoyed what you've heard, please share this podcast with a colleague, and as always, we welcome your feedback.

Biddison: If there are any topics you'd like to hear about, please e-mail your ideas to us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Kimberly Peairs, M.D.
Vice Chair for Clinical Affairs, Department of Medicine, Johns Hopkins Medicine
Medical Director for Primary Care Value and Innovation in the Office of Johns Hopkins Physicians

1. We work in teams. If one person or group is exhausted and frustrated, it can affect the whole team’s ability to deliver care. As we design interventions to improve care delivery, we need to consider the whole team.
2. We need to look for opportunities to share knowledge within the team. When prescribers know which medication prescriptions are most frequently denied by payers, they can choose an acceptable alternative. Working smarter can reduce the workload and frustration for all involved.
3. Centralizing a service like prior authorizations can lead to economies of scale, but it also comes with risk of disconnection and depersonalization. It’s important to look for ways to retain relationships in order to foster a sense of belonging and connection within the team.

• AMA resources for prior authorization

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler I'm Carolyn Cumpsty Fowler, and we are your co-hosts for the Johns Hopkins Medicine Office of Well-Being's podcast, Vital Conversations: Influencing Workplace Well-Being in Healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share some of what we're learning.

Fowler: Thank you for joining us. Welcome. I'm Carolyn Cumpsty Fowler, your host for the Johns Hopkins Medicine Office of Well-Being's podcast, and I am delighted to welcome back Dr. Elizabeth Harry, who is the Chief Well-Being Officer for Michigan Medicine. Welcome, Liz.

Dr. Elizabeth Harry: Carolyn, thank you so much for having me.

Fowler: Liz and I are going to talk today about cognitive load. If you were not able to catch the first podcast that Liz did with Dr. Lee Pedersen, I recommend that to you, because we're now going to take the next step in thinking about how cognitive load shows up in our clinical environments, but Liz, before I get into that, I would invite you, please, just to tell us briefly, how did this land on your radar screen, how did you get involved and why do you care so much about it?

Harry: It's a great question, Carolyn. It is, I think, a bit of an unexpected journey, but just briefly, when I trained in residency, I actually trained in quality improvement with a focus on quality improvement. When I first left residency, I was doing a role where I was doing quality improvement, and when we did some improvement projects and had really great outcomes for the patients, sometimes our providers in particular didn't love the work. They didn't love the improvement project, and I didn't understand why, because we always talk about how patients first is so important to all of us, and it is to all of us. So why wouldn't we love something that improves their care, their safety, and their experience? I asked folks, and what I heard was a lot around change. This was pre-COVID, but just change fatigue. I got really interested in change fatigue, and as I learned more about change and the impact of change on our ability to process information and having to learn new systems and learn new processes, I started learning about cognitive load, and I got very fascinated, and I felt like we had designed systems, whether intentionally or unintentionally, that were progressively overloading people and I felt like I could see the overload in other people. You could tell when someone was overloaded and not quite with you anymore, not quite attending 100 percent, and I noticed that getting worse over the years. When I moved to Boston, I ended up getting a grant to look at the impact of cognitive load in a post-hospital discharge setting on errors. But one of the things that we measured was frustration when people are overloaded, which turns out is a surrogate measure, we learned in a subsequent study, for burnout. I started getting very interested in the impact of this overload on people. Then we did a study showing that there was a very strong relationship between having a high task load and burnout. That's how I got interested in it. I think we're living in a world where the cognitive overload just increases because the data is increasing, and so it feels more and more salient every day, because I feel like we're all having to battle that much harder to protect our attention.

Fowler: I've heard so many colleagues say that they feel like they have ADD. They're constantly challenged with where it is they place their attention at any moment during the day. How would you describe cognitive load for somebody who isn't familiar with the term?

Harry: I think at a very high level, the important things to be aware of is that we have a limited amount of working memory. Working memory is what we need really to process anything or to bring anything out of our long-term memory into our ability to act on it, whether it's speaking about it or acting on it, with the exception of habit behavior, and that goes in a different place. We'll take that off the table for the purpose of this conversation, although it is relevant when we talk about standardizing things. We all have a limited short-term working memory, and that is our ability to attend to things, and how much of that short-term working memory is used at any given time is impacted by the cognitive load. The cognitive load, you can think of as, if the short-term working memory is a cup, the cognitive load is the fluid that's filling up the cup. There are three things that impact how much fluid is in that cup. The first is how complex is the task, how complex is what you're doing? That's called the intrinsic load. You can't change that. It just is intrinsic to the task. The second is, how much of your working memory are you spending learning the task? That's called the germane load, and that's the amount of working memory we're spending building mental models or learning the task. That can change, but it takes time. Takes time to learn things. It takes time to build expertise. We're both in teaching organizations, and when we have learners, it's important to realize that they're using a good chunk of that working memory on complex tasks to learn the task, too. Then the third thing is extraneous cognitive load. This is everything that's extraneous to the task. It's not intrinsic to the way the task is itself, but it is the way the task is presented. Extraneous cognitive load is driven by three main things. One is lack of standardization. What I often think about is, if I go into a clinic room to do a visit, and in one room things are organized in one way and tools are in one place, and I go into another room and it's organized in a different way and tools are in a different place, I have to use some of my working memory to remember that difference. It's not intrinsic to the care I'm providing. It's extraneous to the care I'm providing, but I still have to use some of my working memory in order to be effective to remember that difference. We do that all over the place. How we design interdisciplinary rounds varies unit to unit. All sorts of variability that leads to excessive cognitive load. The second thing that impacts that extraneous cognitive load is redundancy, and that's getting the same information multiple different ways. I'll just give you an example. The other day I had a patient discharge from an outside hospital facility. I got a notification about that discharge in seven different times and some paper and some electronic. The problem with redundancy in that way is that I don't know if one of those ways fails, because I don't know how many ways there are. If we have one highly reliable process, I'll know if that fails. I'll know if I wasn't notified that this patient was hospitalized, but if we have six moderately reliable processes or seven moderately reliable processes, it's impossible to know if it fails. It's excessive cognitive load. I already knew he was discharged, and that drives that cognitive burden. Then the third one, which is also really salient in healthcare, is split attention, and this is interruptions. This is when we take our focus off of the thing that we're doing, and we move it to something else, and then we bring it back, or we're partially listening to two conversations at once, or we're listening to something and we're reading something at the same time. We are all doing so much more of this split attention. Those big three drivers of extraneous cognitive load are the places that we can focus on trying to reduce some of this cognitive load for folks.

Fowler: Well, I think people who are listening to this are probably recognizing their lived experience in any 12-hour shift or eight-hour shift that they're working. I'm struck when I'm walking around the units just how many distractions there are in the unit. It's actually frightening.

Harry: It is. I had a colleague from NASA who has shadowed me twice in two different organizations that I worked in, and both times she was horrified that we are making really high-impact medical decision making in environments that are very distracting, and it's different than how they think about trying to protect people's ability to think.

Fowler: It's interesting that you say your NASA colleague was horrified by seeing what they saw. I think for many of us, we just take for granted the way we do business, so perhaps could I invite you to walk us through what we might notice, either about ourselves or our colleagues and teams in practice when we are cognitively overloaded? What might that look like?

Harry: I think the first is just trying to track a task or a concept from beginning to end. Say you were going to pass a med for a patient. If you are able to focus on, I'm going to pass meds for this patient, do the scanning that you need to do, do the documentation that you need to do and pass the med for the patient without anything else inserting itself in that process, that would be a focused environment that would not put you at risk for overload. If you are interrupted during that process, if you end up having to do a different task during that process, that increases the risk for errors. Actually, there was a study done in the nursing literature that showed this. They had nurses put on bright orange or yellow vests that basically said, I'm doing med pass, don't interrupt me, and the med pass errors went down, just the signal of, I'm doing this high-complexity task that is very important. Please don't interrupt me. Please let me focus on what I'm doing. I think being able to track the task and see if you're able to stay on task the whole time and make sure that there isn't any interruptions in that task or that you're doing something else, I think is one good example. The second thing I think is watching your cognitive fatigue. If we are having trouble making decisions at the end of the day, which we know is a phenomenon, a lot of that is because we haven't completed our working memory and we depleted it over the day, but we haven't taken a cognitive break to be able to replete our working memory. We know from a paper that came out recently from John Sweller that you actually can replete your working memory if you take a break, a cognitive break. It has to be a real cognitive break, not where we tend to do social media or e-mail or something else. It needs to be a real break. I think those would be two really good indications of just watching how you're doing your tasks, and how often in your day are you trying to alternate between tasks. Mindful that we don't multitask, we like to say we do, but what we do is alternating tasks. The more that you're doing that, the more that scattered feeling that comes from doing that is part of that cognitive overload.

Fowler: As you were describing it, I was thinking about conversations we've had about the challenges we're experiencing in our teams now that the ratios of experienced providers and nurses and clinicians to inexperienced or learner providers has changed so dramatically. We're now in a workplace where many of our colleagues are really quite young and quite inexperienced. They're trained, but they're in this drinking from a firehose experience that is coming into real-world healthcare. I know it's just human nature for many of us to feel a little impatient with these learners and these new clinicians, as they seem to find things so much harder than we do. What would you say to those of us who are more experienced and have an easier time with decision making because we've learned this? What would you say to us about how you would like us to work with our younger learner colleagues in this space?

Harry: I think to remember that they have a heavy germane load. Not only are they doing the task, they're learning the task, and that makes it harder, and that, by definition, makes them more inefficient in doing it. I think the other piece to think about there is that when we get multiple data pieces that fit with a mental model that we have, we are able to chunk them and put them in that mental model and process them as one data piece, whereas they're not able to do that in the same way quite yet, because they're still building that mental model. That means we are more efficient, but it also means we're more prone to biases and cognitive errors than they might be. The other piece is there's a benefit there to the newness, to the freshness, to the looking at all the things as separate data pieces, and that there's a real opportunity to learn in both directions, and say, well, how do you see this, and do you see something that I don't see because I'm so used to doing this? I think a lot of times our folks that are newer can look at a process and say, but this doesn't make sense and it's like, well, maybe it doesn't make sense. Maybe we started doing it this way a long time ago because there was X pressure that we were trying to work around, but that pressure is gone and we're still doing it this way, and we never stopped to re-evaluate. I think really thinking of it as this bidirectional learning opportunity, it would be great.

Fowler: We want to really encourage that curiosity and that questioning?

Harry: Yeah. That's right.

Fowler: How do the other aspects of our lives impact cognitive load? We have cognitive load building at work, but we also live lives outside of work. Would you like to say something more about the intersection of those?

Harry: Yeah. Well, we try to partition our lives to have our work life and our home life, but our brains don't partition all that well in the same way. We did a study looking at childcare stress, for example, and burnout, self-reported anxiety, depression, intend to leave, intend to reduce hours, all of those things went up if people were experiencing childcare stress. If you're experiencing childcare stress, you're worried that your children aren't in a safe environment or you're worried about what your childcare is going to be, you're thinking about that while you're at work. I can tell you from experience. That is on your mind. You're thinking about that while you're at work. You're thinking about that while you're also thinking about other things, and that is a data point that takes up cognitive bandwidth. We also know that our short-term working memory, this limited thing that we talked about, can be shrunk or shortened if we are emotionally or physiologically stressed. If people are having a lot of stress at home and they come into the workplace, they will have a smaller working memory that they will be able to process information with, and that's important to realize too. Then I think the third thing that's really important to realize is that in addition to that, when we are stressed and/or fatigued, so I think sleep plays a really big role here. We have some data we're starting to look at now that supports this, that your ability to manage your working memory is going to decrease as well, and your ability to function from your prefrontal cortex, which is your, I always say it's like your anti-toddler part of the brain, goes down. That's our behavioral regulation, our executive functioning, our ability to plan, our ability to do high-cognitive tasks such as our medical decision making, all of that's impaired. I think really being attentive to what we have going on at home and how are we setting ourselves up for success, what is the cognitive load that we have from home, and what are we doing to make sure that that part is managed too?

Fowler: What are some of the early signs and symptoms that I should watch for if I'm at work? That would suggest maybe you need to speak to somebody about taking a break. You're not optimally present here.

Harry: I think if we notice ourselves, like jumping from task to task really quickly, if we notice ourselves in that scattered space, or if you catch yourself like, oh, I almost forgot that, or oh, yeah, that thing. If you're right on that cusp there. I need to take five minutes. I need to take a cognitive break so that I can reset. I think one of the things that I often see from people is as we get more overloaded, we get a little less patient, and we get a little quicker to snap at folks and be frustrated about things, and so I think watching that behavior in yourself, is a really good indicator. Then if you're noticing your own cognitive processes, feeling fatigued and we all know that feeling where you're like, gosh, I just I'm zoning out, and I'm not checking in in the same way I listened to like 60 percent of what that person just said, the whole story.

Fowler: I just read that paragraph three times and I still don't know what it means.

Harry: Exactly. I realized I've just read a whole H&P or whatever, but I lost track of it, and I and my eyes were moving, but I wasn't pulling the content in.

Fowler: This is so fascinating. I'm so grateful to you, Liz, that you brought this to us, because, we think that this is a new field, but it's not, is it?

Harry: No it's not. What I always, feel is so amazing in academics, is that we have the opportunity to really reach out to these other industries, like human factors engineers and organizational psychologists. We have folks in business that think a lot about this. There are people all over the academic world that have a lot of expertise in this, and I love the idea of bringing them in to really, help solve the issue. You guys are spoiled, because you have the Armstrong, Institute for Human Factors and Health Care, so you have experts embedded in in your health system, which I think is wonderful. I think where we all need to go, which is really having these folks embedded in our health care, are educated to apply these principles in health care, and helping us solve what is a really complex problem.

Fowler: Is it challenging that norm, that it's normal to be multitasking or feeling exhausted, that this is not normal and it's not okay?

Harry: Yeah. It's not sustainable. I think one of the things that I've watched, is I used to see that cognitively overloaded look on the, on the intern's eyes right at the end of the day. You could tell when, if you were trying to teach them at the end of the day that they just weren't quite listening, or they either you weren't really able to get anything in, and then it went to it was the residents, too. Then I've noticed our nurses with it, I've noticed our mas with it. I think the thing is that we used to have just pockets of it, and as the complexity has increased, as the data has increased and this is all obviously anecdotal. I don't have anything quantifying the cognitive load of folks. But as all of this has increased the cognitive load that we are being bombarded with is increasing every day. Our brains are the same. They're not changing. We are learning new things, but our capabilities are not changing. I worry about the sustainability as the complexity of our patients increase and the number of medications, the number of medical problems, the number of things that we're trying to do. All of that is just more on brains that have the same capability.

Fowler: I know that we're all very concerned about the impact of cognitive load, or cognitive overload on quality and safety and the outcomes we care about. I'm also really intrigued about how it's impacting the quality of life of the people who are doing the work of healthcare, because I've had people say to me, as things become become more complicated, as technology has become more prevalent in healthcare, the things that gave me joy and meaning in being a healthcare provider, have got squeezed out.

Harry: Yes. I think you're exactly right, and I think there's a couple pieces there. One, we want to be very attentive because those outcomes to deliver excellent care. That's why we all came into healthcare. We all want to deliver excellent care right. Those outcomes really matter. But to your point we were sort of chatting about this before, is that the person is the delivery of the healthcare. We can't lose that person, as you said, which I thought was really brilliant. We can't lose that person in the middle. We can't lose attending to what is their experience in delivering that high quality care. How are we making sure that it's sustainable, and how are we making sure that it's something that they can do safely and for a career for a long period of time? The more and more that's added, the harder it is to find the pieces that bring meaning and joy is really important. I also want to just add a second piece that I think is important to name. There is this little reinforcement, a little dopamine hit of multitasking, a little dopamine hit of checking the e-mails, a little dopamine hit of having this urgency cycle that we live in. I saw this great talk by a Navy Seal once where he said, I think I was living in fight or flight for 20 years straight. I do want to also have us watch ourselves of when is it that we're getting that little reward for being in this frenetic state that's keeping us in this frenetic state, and is keeping us from wanting to sit down and focus in a more focused manner rather than like running all over the place and balancing all these competing priorities? I do think some of it is a little bit self driven because of that reward pathway of that urgency cycle.

Fowler: We feel super productive or we think we're productive, we're just getting reward after reward. This is an interesting conversation that we've had in the office of Well-Being quite a lot, which is our drive in healthcare to be doing. We measure our doing, and we like to count our doing, and we have meetings about our doings, and we tend to ignore our beings, like, how are we showing up? How are we showing up in our work, and how are we showing up in our relationships in healthcare? How does cognitive load influence that piece of our being?

Harry: It's a really good point. I think you can spend a whole day doing a lot and not actually advance what's important. I often talk to people about that priority matrix urgent, non-urgent, important non-important. It can be very tempting to stay in this urgent lane, and not dip into the important. I think, when you're overloaded, you can really miss the things that are important to you, whether it's personal or professional, whether it's making time to write that paper or read that paper, or attend that class, or sit down and talk to that patient. Really talk to them about, you can tell something else is going on, or attend to relationships, or build something personally that is important to you. Those things get squeezed out of the edges when we're in this overloaded state. I think many people have seen that visualization, where you have a big jar, and if you try to put all the sand in first, then none of the rest fits. But if you put the big rocks in first and then the pebbles and then the sand, everything fits. This idea of making sure that we're prioritizing where we're paying attention, and that it's in line with our values, because you can justify having your attention be grabbed from you, to the end of the earth. Well, they needed me. Well, that'll always be the case, and it's going to get worse. At some point, we do have to have some intentionality around. These are the things that I need to accomplish for this patient today, or these are the things that I need to get done for my research career today, or these are the things that I need to do personally today that are most important. If I can't attend to something else that is urgent, is there a role there that can, is there someone that can, or do we need to look at the systems and say, we can't do all of this, so what what do we want to do and be intentional about it? I think we're in this space where we have gotten to a point where we have to prioritize. We have to say, what are we going to do when there's situations of competing priorities?

Fowler: Well, perhaps as we begin to wind down, could we just transition a little bit to some real practical advice? As somebody who's lived in healthcare, you've become aware of your cognitive load, but you've acted on trying to do something to reduce the cognitive overload. Could you just give us some practical tips of things that we could try to reduce our cognitive overload?

Harry: I really try to focus on those three buckets of extraneous cognitive load, and then paying attention to where I pay attention to. In terms of standardization, I try to standardize the way I see patients in terms of when I go through the chart, how do I go through the chart? I do it in the same way every time, so I can make a habit, and then that habit goes into long-term working memory instead of short-term working memory, and doesn't take up that space anymore. I try to standardize things at home. Where do I put my keys? We have something in our house where we basically eat the same five meals in a week, after week because we know the kids will eat them. But it's just adding that standardization. I will name there that people have attention around standardization and say, well, I don't want to do cookbook medicine. The way that I think about it is we should be standardizing everything that's low intrinsic load, so that we have the cognitive bandwidth to think about the really sick, really complex patients, and give them the cognitive attention that they need. I think that piece is really important, so that standardization I try to do a lot of in building routines for me really helps in that space, so thinking about the routines. I try to be very protective of my split attention, so I try to watch myself. I'm a human just like everybody else. My attention gets dragged away and is being pulled on constantly, but I've tried to turn off alerts on my phone and try to make it so that only a few things can come through. Obviously patient care notifications have to come through, but really being clear about what interruptions I want during the day, and what interruptions I don't want, and where I will spend that time. Some of that is like chunking tasks like e-mail, so I do not send an e-mail all day long. I will do it a couple times a day, and I do not get to every e-mail, and everybody who's ever e-mailed me knows that. It's just a personal choice around where I can pay attention. Then I also personally have made the priority of trying to spend focused attention time with everybody who's important to me in my life, in my family, to make sure that I am prioritizing those things that are value to me so that I don't feel like I'm compromising those on behalf of my job, which I do think exacerbates that sense of burnout and moral distress around what we do.

Fowler: Because that gift of presence, that's the most important thing you can give another human being, whether it's a patient or a child.

Harry: Yes. That's right.

Fowler: Well, I'm going to have this be the last question. The reason I'm asking it, is I'm reminded of the times that computers lock up or computers start malfunctioning, and the advice is always just switch them off, give them a minute or two and then switch them on again, and that would seem like a cognitive break to me. Could you describe for us as we wrap up, what is a true cognitive break, and what is not a cognitive break?

Harry: I think I'll start with what's not right. It's very tempting to use that time to check e-mail, or to check Instagram, or to check the news or Facebook or whatever social media you use. That is not a cognitive break, and in fact, it adds to that urgency cycle with the little dopamine hits that you get from it. Things that you can do, are things to actually relax your focus. A lot of people ask me, would meditation be helpful? Perhaps, if you're an experienced meditator, it can be. But for people that are new at meditating, who are new at training their mind and training that focused attention, the goal is to give yourself a break from attending, because you had just done a period of focused attention, so you don't then want to then do an exercise where you're focusing your attention diligently for five minutes again. Instead, the opposite is what's called, mind wandering, which allows the part of your brain that's called the default mode network to activate, which is the opposite of focused attention. You can just sit there and let your mind wander for a little bit, going for a walk while you do that, so changing your physiologic state is really helpful. I'd like to listen to music, so I'll put in music in my ears, and just go on a walk and just let my mind wander and sort of it. It just then runs through everything, and it seems to discharge some of the redundant thoughts that can come through. Those are things that I do, that I think are helpful. I think this concept of mind wandering, is helpful too.

Fowler: Just letting ourselves imagine, perhaps even imagine what we're going to do when we're not at work.

Harry: But the point is that it's not focused attention because you want to then be able to come back and focus your attention again, so you're trying to give that a break.

Fowler: About how often should we be aiming to take a short cognitive break?

Harry: There isn't literature that I'm aware of yet on exactly this timing. I think there are some habits out there, like people use these Pomodoro blocks that are 25 minutes of focused attention and five minutes of break. I think all of us have different skills in focused attention. Some of us, and I think we're learning this with our kids and the way they are being educated, I think have shorter attention spans. You need to understand what is your cognitive limit in in attention? You can train that, and you can grow that over time like we talked about. With meditation, you can grow the ability to have focused attention. But you need to know what yours is, and then give yourself a break before you hit your limit, and then come back. I really do think it needs to be a bit individualized.

Fowler: Liz, thank you so much. Every time I talk with you, I learn something new, and I'm even more excited about this topic than I was when I first heard it from you. Thank you so much for being such a friend to us in the Office of Well-Being. We were grateful for your partnership.

Harry: Well, you guys have an incredible office, and I consider y'all friends and I love getting to chat with you. Thank you so much for having me on.

Fowler: Thank you. Liz. This is Carolyn Cumpsty Fowler, and I am going to sign off today from our conversation with Doctor Elizabeth Harry, who's the chief well-being officer for Michigan Medicine. Thank you everyone.

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Fowler: That's it for today. If you enjoyed what you heard, please share this podcast with a colleagues, and as always, we welcome your feedback.

Fowler: If there are any topics you'd like to hear about, please e-mail your ideas to us at [email protected].

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

Elizabeth Harry, M.D., S.F.H.M.
Chief Well-Being Officer
Michigan Medicine

1. Overload is associated with burnout, and our risk of overload increases as the amount of data coming at us increases.
2. Organizations seeking to address burnout can look at interventions that affect extrinsic load, such as instituting standardization, reducing redundancy and ensuring that clinicians are not forced to split their attention.
3. It’s important to be patient with our early career doctors, nurses and other clinicians, who are experiencing especially heavy cognitive load because they are building new mental models while gaining experience.
4. Cognitive overload shows up in our work and in our home lives. Practical tips for reducing cognitive load: Standardize and set routines, protect our attention by limiting interruptions and prioritize focused attention on the things and people that matter most.

• ResearchED Video: "John Sweller - ACE Conference/researchED Melbourne"
• Armstrong Institute for Patient Safety and Quality

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Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: I'm Carolyn Cumpsty Fowler, and we are your co-hosts for the Johns Hopkins Medicine Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in healthcare.

Biddison: We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share some of what we're learning.

Biddison: Thank you for joining us.

[MUSIC].

Biddison: Hello and welcome. My name is Lee Daugherty Biddison, and I'm here as your host for the Johns Hopkins Medicine Office of Well-Being podcast. It's a pleasure to welcome you to our first episode, and today I have the pleasure of welcoming Dr. Elizabeth Harry, Chief Wellness Officer for Michigan Medicine. Liz comes to us with a wealth of expertise from her leadership opportunities and work and well-being at the Brigham and Women's Hospital and at UC Health in Denver, Colorado, and now she is in this wonderful leadership role, much deserved at the University of Michigan. Welcome, Liz.

Dr. Elizabeth Harry: Thank you. I'm so excited to be your first guest. This is really fun.

Biddison: We're we're thrilled that you are here. Tell us a little bit about your journey to becoming Chief Wellness Officer at Michigan.

Harry: It's a little bit circuitous. I'll try to tell the short version, but I never particularly meant to go into well-being. I was originally actually very interested in quality improvement and trained in quality improvement, and when I was an early faculty member, we did a really large quality improvement project in a couple of our units and saw really great clinical outcomes, and yet our clinical care team didn't love it, and that's not to say all members of the care team didn't love it. A lot of members loved it because they were getting information they had never really gotten as easily before we did these interdisciplinary bedside rounds, but our physicians really didn't love it and I didn't understand why. I asked them, this has all this great patient data. Why don't you like it? This is stuff that we say we all care about, and we're improving the experience for our patients, and we're proving team communication, and they said it's not really about this intervention. It's not this specific intervention. That the problem it's just change. It's just another intervention. It's another thing that I have to figure out to do differently, and I was so fascinated by this, and that was in 2013 roughly. Pre COVID, pre all the change we've all had recently. I started researching change fatigue and just trying to learn about the concept that led me to the concept of cognitive load. I then moved to Boston with my husband for his training, and when I was there, started really looking into this concept of cognitive load and got a small grant to study some of it, and one of the outcomes that we looked at was the relationship between cognitive load and burnout and particularly in post-hospital discharge settings, and so as I was engaging in more and more of these conversations, more of the well-being piece just kept coming up. Then I found myself in this well-being leadership role and that well-being leadership role, and I really loved it, and I got to the place where I really felt like, we have some of the most committed and dedicated people on the planet in healthcare, and they're really suffering, and we can do better by them. This really strongly driven mission to try to make things better so that people would want to continue to have that commitment and drive to be part of our field.

Biddison: That's wonderful. Tell me a little bit about looking back, what are some of the things you would have told yourself or coached yourself 10 years later so that you describe starting on this journey in 2013? What are the maybe some of the things you wish you knew or how you would have coached yourself then knowing where you are now?

Harry: It's such a good question. I think one of the things that I would have coached myself on and I actually just got to hear a coach talking about this recently is this idea of development, and he used the metaphor of pruning, and how you prune trees sometimes really make them look not great while you're pruning them to have these beautiful flowers or beautiful fruit or whatever you're trying to grow later, and I think this idea of when things don't go well, if this project isn't well received or you don't get that grant or you don't get that position or whatever, that it's all pruning for something bigger that can happen later and not to worry about that piece so much.

Biddison: It's a helpful reframe when to think about what might be down the road as you struggle through feeling like, oh, this didn't turn out like I wanted.

Harry: Yeah, and how many of those things have we all tried. Where you tried something, you had this idea or you tried this initiative and and it didn't work, or people didn't love it or it didn't go exactly as planned, and I think the other piece that really ties into this is this idea of growth mindset, which I know people are very familiar with now. But I think my kids come home, we're talking about growth mindset. I think we've done a good job getting it into the culture. But I think this idea still we don't hold each other accountable with a growth mindset a lot of times. We look at our health systems, if they try something and we'll say that was a failure and it's like, well, that's not really a growth mindset, is it? Maybe we want to look at that and say it's not where we want it to be yet, and how do we continue to iterate around it? How do we learn and how do we be curious together and grow? You asked about how I ended up at Michigan and that was really one of the things that drew me there was, this this area where there are so many people studying so many different disciplines right next to each other, working in this really collaborative way to be curious about things together, and I think this burnout issue is in the water, in healthcare right now. It's everywhere. But the way we're going to solve it is by coming together as teams and treating it like an intellectual problem, not who's doing what wrong or who's hurting me or an us versus them thing. But really, how can we solve this from a really intellectual standpoint and, and how can we lean on those from other industries that can help us think about it with fresh eyes and different eyes than we might have being inculcated in the systems that we've trained in.

Biddison: For sure. Culture dies hard, right?

Harry: Yes.

Biddison: I love this idea of a collective growth mindset. I'm so with you on this. There's some definitely some traction in the space of on an individual basis, trying to learn to be a little bit more self-compassionate. There's a lot of that in the burnout literature, thinking about that, and and of course, so much of of Carol Dweck's amazing work. But shifting from an individual growth mindset to a collective growth mindset so that systems and organizations take on that same approach. It makes a ton of sense for where we need to go. Do you have ideas for how to get there?

Harry: I think it's hard because I think that we're in a tough time where there's a lot of division, and I think there's a lot of othering happening in the healthcare spaces I see around the country, and it doesn't matter what groups you want to look at, you could look at by discipline, by specialty. You could look at people that are providing clinical care every day, or people that are doing administrative work, or you could look at insurance companies or lobbyists. It doesn't matter how you cut it. There's a lot of ways that we other groups of people and then assign blame a little bit, and I think this idea of assuming positive intent is really important, and how do we try to realign around our common why and really believing that we're aligned around that common why, I think is probably one of the first steps, and I think asking ourselves why we want to believe that this other group is responsible for our pain or responsible for whatever it is we're upset about at the moment. How is that helping us in the moment? Like, why are we choosing to frame it that way? Because it's serving a purpose or we wouldn't be doing it. It's really trying to understand what purpose that's serving.

Biddison: Challenge ourselves in that space?

Harry: Yeah.

Biddison: Absolutely. Liz, I would love having these conversations with you because I think it could go so many different directions, but I'm going to try to stay on track with what we said we would talk about. I have a lot to think about already with the collective growth mindset. Tell us a little bit more about how you developed this specific interest in cognitive load and human factors as relates to well-being. You mentioned the early phases of it. Describe for us how that's grown over time.

Harry: I was so interested in this idea that our brains have a limited capacity to process information, and that's not going to change in a very meaningful way, and yet the data coming at us is changing in a very meaningful way, moment by moment, and we don't operate as if our brain has a limited capacity a lot of times. The expectation is I can just process all of this let's add all the wearable data to the EHR, and it will also process all of that, and there is a time at which you just can't, and we have to think about when do we have to change the way we're presenting the data to make sure it's the signal that's getting attention and not all the noise? I think what I found really interesting as I went through my career, from training to early faculty to mid-career faculty, was that faraway look you see on people's eyes when they're overloaded. You can kind of look at someone and say, they're not here. They're not totally with this conversation we're having, and I feel like I used to see that in the intern's eyes at the end of the day. But other people on the team would be doing okay, and if you were doing teaching, they were kind of with you, and then it sort of was the whole learning team, the interns and the resident. They all look that way, and then it gets to the point where I felt like my colleagues looked that way at the end of the day, too, and it was everybody looked that way.

Biddison: Then you look in the mirror and you're like, oh hey, I look that way.

Harry: I'm not paying attention anymore, and so I started getting a little bit concerned that if we continued the way that we're going without pausing and saying has the complexity of our system outpaced our brain's ability to cope with it, and at what point do we need to change the way we're presenting things and reevaluate it? There's so many industries that think about how to do this on a regular basis, and when do we need to start leaning into those industries more so that we don't miss things, or so that we can be more present with patients? Or so that when we go home, we're present with our family, and we're not burning ourselves out in that way by harming those relationships. I think it was just through observing all that to your point, in other people and myself over the course of my career and really feeling like it's probably time to pivot a little bit.

Biddison: Just in thinking about what's prevalent in the headlines today. AI obviously is all over the place. I'm just wondering sort of what your thoughts are on how AI is, and both now and in the future is going to impact this challenge of cognitive load or cognitive overload, and and what are the approaches, you know, that we need to take to leverage the power of it without being totally overwhelmed by it?

Harry: I think it's a great question, and I think the key piece is and comes down to the idea that it's not the technology, it's how we use the technology, and I think this is true for everything. It's smartphones didn't ruin everything. But it very much depends on how you use your smartphone and what do you use it for and what do you spend time on it doing? Similarly, I think how we use AI is going to be really important, and there's a great paper that makes recommendations from human factors literature on how we should think about testing our AI models from a cognitive load perspective to make sure that they're actually reducing cognitive load in the way they're delivering information. I think they can be built in a way that it helps summarize a massive chart in a way that we show can be accurate, and it's not hallucinating, and it is reliable and, and safe to use, and all those things are really important that those are studied and that that's true. But that it could then ultimately really help with pulling that signal from the noise, so that then we use our brain and our attention for deciding and using medical decision making around what to do with that signal rather than trying to find the signal, which is a lot of what we spend our time doing now in addition to the medical decision making. I think that could be really helpful. But I do worry about sheer volume. People are just creating tons of content with AI right now and flooding the Internet with it, and so there's this issue of increasing the noise, if you will, and increasing things that are not accurate that are in information space, and it just gives us more to filter through. Again, I think it's just really depends on how we use it.

Biddison: I think one of the questions you and I spoke earlier before we got online about some of these AI driven resources for generating notes in the electronic medical record, and I think our collective institutions are exploring those because they're cutting edge. We should be. I'm curious what your thoughts are about what the questions we should be. We who are interested in well-being, what are the questions we should be asking as we pilot those softwares? What should I be talking to my CMIO about in that space?

Harry: It's a really good question. I think we want to make sure that the measures that we know we're already looking at that the AMA has helped us with and folks at epic around. How much time are people spending in their in-basket, and how much time are they spending outside of work in the EHR and how many people are helping put orders in? Or how many people are touching an in-basket message when it gets passed around? Making sure that those are being meaningfully impacted by this work, that we can show that we are impacting things that we know are good measures of our electronic experience. I think this piece around accuracy and not hallucinating and having the ability to check the original record, if you will. Check the audio or be able to reference back to the source of truth is going to be really important to ease people's concerns as we start this because I think we all hold ourselves to really high standards when we're delivering clinical care and understand the consequences of something that might be misdocumented, and there's going to be some free floating anxiety around that, and so I suspect for a while people will be doing a lot of double work. Where they use it, but they're also doing their old workflows because they don't quite trust it, and we want to help them get away from that double work. That's just extra cognitive load, but they're not going to do it if they don't feel really safe that there's.

Biddison: Confidence in the technology.

Harry: Confident, and they know they can go back and check if there's ever a question.

Biddison: I think that's huge. Such an important part of all of this. Let me ask you this. You were the first person, I think, who was able to get my attention enough to convince me that we live in an attention economy. This was a talk you gave. I guess not that maybe six months ago now, but I remember listening to you talking about that, and I was like, wow, and probably you've been talking about this to me maybe for years. I don't know, but just couldn't get my attention. But was so convinced about that just in listening to you share about that. I wonder if you would talk about that a little bit. Yeah. And then I have a follow on question.

Harry: Absolutely. I stumbled across this while I was continuing to build talks on cognitive load, and a lot of what we think about when we think about cognitive load is where we're placing our attention because there's more data than we can attend to and process, and so we have to be very intentional about where we're placing our attention. Then I got curious about where do we place our attention and why is that important, and the more reading that I did on it and just learning about this concept of an attention economy and thinking about what does that mean, so you have to break it down. Attention is the ability to focus your awareness on something, and an economy is the study of scarce resources and how they're moved, and I had to look that up because I'm a doctor and I'm not an economist. But what I think is very interesting. First of all, just say sometimes it's called an information economy, which is clearly inaccurate when you look at the definitions. Right. Because information isn't scarce, it's our attention that scarce, and we have too much information. There's this idea that you have a scarce resource, it's limited and it's valuable. It's inherently valuable, and it is being valued. People are placing value on it. It is being being monetized, and so we know that from social media, and there's lots of documentaries out there talking about this, but it is monetized commodity which brings it into the space of economics, and there have been theoretical physicists that have actually said that we were going to move to an attention economy a long time ago, and away from one of goods and services, obviously, we still buy and sell goods and services, but largely what's being bought and sold is our attention, and I think a lot of times people talk about time as your most valuable asset. I was actually talking to someone about this the other day and he was saying how important time is and making sure you have that time with your family, and I was thinking, this is why thinking about an attention economy is so important, because you could spend time with people and not pay any attention. Be checked out or be in your head in there, and then it's not valuable time. It isn't something that contributes to the relationships or contributes to making memories with these people, or something that you're going to feel good about later, likely, and so I think this concept of what is our most valuable asset, and I would argue that it's our attention. It's not our time. A lot of people say it's our time, but I don't think it is. I think it's our attention, and we have spent a lot of resources investing in the brains of people that deliver health care, and so that they can use that knowledge and their attention to understand a problem and help think about how to effectively solve it in a way that is compassionate and connects with our patients. But they can't do any of that if they don't have attention to do it. It doesn't matter how much information is in their brain. I worry about health care systems where we're dividing people's attention, or we're drawing their attention away so often that despite this being our most valuable asset, we're not really treating it as such.

Biddison: Gosh, it's so important. All the lessons that we've learned about not multitasking, but task switching and the degradation of attention and the impact on all the outcomes that we care about, our patients, our relationships all of those things I think are so important. As we wrap up, give us like one or two of your personal tips for managing attention.

Harry: As we were talking about earlier, I don't have this nailed. I would like everybody get down rabbit holes with my attention too. I'm someone who likes technology. I have an app on my phone that locks down attention sucking apps. I won't name names, but it'll lock down certain apps for me at either time I spent on them, or different times of day when I know that I don't want to be spending time on those apps. I find that really helpful in removing some of that temptation. I do think a lot about standardization, both in how I do things in my day to day, how my family does things. What we have for dinner when we have what routines around getting different chores done. Personally, both my husband and I really try to have some focused attention time with the kids and be very aware of this idea of spending. We call it mommy and me or daddy and me time with the kids, but spending time that we say to them, this is your time. You have my undivided attention and giving them that time, and same for us, and I think that piece is really important, and then in in the work world you probably know this. I'm not great at answering e-mail, and part of it is I've intentionally decided that's not where I want to spend a lot of my attention. I love talking to people. I love spending time with them and learning from them, and I feel like I could spend all day in my e-mail and then I wouldn't really get to talk to anybody. Sometimes I've intentionally chosen to be, let's say, less responsive in one way to preserve my attention for interacting in another way.

Biddison: I love it. I'm going to wrap us up here, closing our time with Dr. Elizabeth Harry, Chief Wellness Officer from Michigan Medicine. Thank you so much.

Harry: Thank you so much. This was really fun.

Biddison: That's it for today. If you enjoyed what you heard, please share this podcast with a colleague, and as always, we welcome your feedback.

Biddison: If there are any topics you'd like to hear about, please e-mail your ideas to us @[email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Elizabeth Harry, M.D., S.F.H.M.
Chief Well-Being Officer
Michigan Medicine

1. Solving for burnout at the organizational level can feel overwhelming. Let’s not go it alone. We can learn from each other within health care and also from disciplines outside of health care. We need not only an individual growth mindset, but a collective growth mindset across health care.
2. We now live in an attention economy — our attention is a scarce and valuable resource. We need to be intentional about where we choose to place our focused energy.
3. As we lean into the power of AI, it’s important to consider how the technology is contributing to our well-being. Is AI reducing the number of clicks, steps or human interactions needed to complete a given task? In doing so, is it freeing up cognitive bandwidth for complex medical decision-making?

• Nature Medicine article: "Evaluating and reducing cognitive load should be a priority for machine learning in healthcare"
• TED Talks presentation: "The power of believing that you can improve"
• Opal app for "time sucks"

Lee Daugherty Biddison: Welcome. I'm Lee Daugherty Biddison.

>> I'm Carolyn Cumpsty Fowler, and we are your co-hosts for the Johns Hopkins Medicine Office of Well-beings podcast, Vital Conversations Influencing Workplace Well-Being in healthcare. We spend a lot of time thinking about how to influence workplace well-being and healthcare, and we're excited to share some of what we're learning. Thank you for joining us. Most of us know what it feels when our well-being at work is compromised, but do we know how we got there? Is it just that it's been a tough week, or that we didn't have time for yoga today? We'll take our first look at the things that really influence our well-being at work. Lee, why is workplace well-being so important to you?

Biddison: Carolyn, this is such a great question, and I think I could probably talk our entire time together just on this issue, but I think there are a couple reasons. One of them, perhaps the most important is that the well-being at work doesn't just stay at work. It has important repercussions at work, but it has impact on all of our roles as a physician, my ability to focus on my patients, to give them my full attention and to give them thoughtful care that allows them and their families to know that they are a priority, and that they're getting the best care that's possible, is a big is a big part of it. But also, as a parent, giving my kids the attention and the time that they need. Ultimately, we will all be patients, so how we address our well-being in the workplace is going to impact how we end up feeling, whether we're well or sick, and how quickly we end up as a patient ourselves. Then as chief wellness officer. Gosh, this would be something that keeps me up at night. Um, although not too late, I hope. Something that I think about so often and, and a big piece of this really, is that we have the privilege. Carolyn, you and I have the privilege of working with such extraordinary individuals and who are capable of doing incredible work. When the conditions are ripe, they can do that. But when the conditions in which they work, the systems, the structures, the approaches aren't as they should be. We're losing so much of the potential of those colleagues, both in terms of living their full lives to the best of their ability, but also their ability to impact our patients, and our communities.

Fowler: Right. Lee, as you and I have said so many times when we've been chatting, our colleagues are just extraordinary. But they're not invincible and they're not a limitless resource. I think what you've just shared just emphasizes the fact that this concept that we can keep our wellbeing at work or our work at work and our home at home is just completely ridiculous. We live an integrated life at work and at home.

Biddison: That's exactly right. That we need to be thinking about our lives as a whole. We absolutely have ways in which we try to separate things, but ultimately what have traditionally been thought of as very separate pieces of our lives absolutely impact each other. Carolyn, why don't you tell us a little bit about how you've ended up having a passion for this work. I know from the time we've spent talking that we have some of the same concerns or many of the same concerns. But what's been your big driver to be passionate about well-being?

Fowler: Well, Lee, as I've shared with you, I started my nursing career back in the mid 1970s, and this issue has been in the back of my mind for decades. But I've really pinned it down in about the last 10-12 years. That is the recognition of how deeply relational healthcare is. If you think about it, we don't do anything without being in a relationship with another human being. Even taking a history. Then as I began to think about relationships, then it just pointed towards how well-being is so foundational to healthy relationships. In fact, one of the things that drives our well-being is a sense that we are supported and connected to other human beings. If well-being is foundational to relationships, then well-being has to be foundational to everything we care about in healthcare. Then the other thing that I've realized increasingly, is the negative influence of the enculturated beliefs that we carry with us as health professionals and people working in healthcare. We all came into a service profession wanting to help to make a difference. Many of us, and I know I got this lecture in my first week in nursing school, were told you come second the patient has to come first. If you're having a bad day, leave it at home. If your mood isn't what it needs to be, if your energy isn't what it needs to be, just deal with it. Because ultimately you are here to serve, and you may actually have to sacrifice your time, your energy, and your well-being so that you can be a health care professional. Now, the evidence, as you and I know clearly shows that this is wrong. If our well-being is compromised, our ability to serve the patients and families that we work with, and our ability to be a respectful and kind and competent colleague is compromised. But it's so hard to unlearn these beliefs. I think actually, it's sometimes harder to unlearn something than it is to learn something new. That's where I am in my journey in understanding well-being.

Biddison: Really we've talked about this some Carolyn. But really, to get really straight to the point is we're really talking about culture change. I mean, where where do you start with that? That's a tall order.

Fowler: Well, I think the first place we have to start is to get beyond the idea that we will transform well-being at work through focusing on self-care and individual Strategies. Now, I want to be quite clear when I say that I think that self-care and individual level strategies are important. They're necessary for our well-being, and they're necessary, that it's necessary that we provide opportunities for that to our colleagues. However, if we're going to change anything, especially culture, we have to be thinking about systems level change and organizational level and change that requires investment. That requires all commitment beyond just offering one time self-care opportunities.

Biddison: Carolyn, do I have to give up my yoga?

Fowler: Well, of course not. I hope you wouldn't do that. All your healthy eating. All the walks and wonderful things you do with your family, but I do think we need to think bigger. We need to think about how do we reimagine, how we do business in healthcare organizations. Lee, I know you've been thinking about this, so why don't you share a little about how we think about influencing well-being at the organizational level?

Biddison: Carolyn, this is such a great question, and we have talked about this a lot. I know, and there are a lot of different approaches. Maybe what we can do here is just talk a little bit about the model we've been using as a team to think about this. As we walk through this, I think it's helpful to remember that the drivers of well-being are complex, the situation, the burnout, and lack of fulfillment situation that we're in took us a while to get to. It may take us a while to get out, but having a roadmap to be able to think through, and to help us to guide our journey forward, I think, is incredibly important. This particular approach that we've been taking as adapted from some work with the National Academy of Medicine, and really gives us a model or roadmap for advancing healthcare worker wellbeing across the spectrum of roles. We have work to do. In this case, we sort of identify six different spaces to keep our eyes on. The first is around advancing organizational commitment. What are the approaches we're taking as an institution? What are our priorities? What are our key values that support healthcare worker well-being? We're thinking a lot about how we strengthen leadership behaviors. There's a great amount of data now on the association between leadership behavior and the experience of burnout or fulfillment. Getting really thoughtful and intentional about how we build skills in this space is an important piece. Third, we actually need to keep track of what we're doing. Conducting workplace assessment, we need to know where our colleagues are in terms of fulfillment and burnout, and the drivers that are associated with them, so that we can be intentional and evidence informed in terms of our response strategies. We also need to think about our policies and practices. What are the ways that we construct our work and guide practice that either enhance or impede wellbeing in our daily lives? These could be practices around leave or support for breaks during the day. Those types of things. They can also be things like how we think about or how we ask questions around mental health, and the seeking of mental health support in terms of when we engage those questions in licensure and credentialing, those questions can either be stigmatizing or they can be supportive in terms of people getting the help that they need. A big one for me is this ease of work and practice efficiency. I've been thinking a lot and have for many years about how it is we make work either easier or harder for ourselves and for our colleagues. What are the the systems approaches and the workflows that we can put into place that actually make it possible for our incredibly talented colleagues to do their best work, that avoid redundancy, that avoid unnecessary work, and really move into that space of efficiency and meaning. Finally, but most certainly still incredibly important, how do we think about cultivating a culture of connection and support so that people have a sense of belonging when they come to work, that they feel that their team has their back, that they know who to go to if they're in a place of stress or challenge, and that recognizing that we also need to be really intentional about that, that it is in fact cultivation, and it doesn't happen just by accident, as it were. That's the sort of roadmap, Carolyn, that we've been thinking through.

Fowler: Thanks, Lee. I was struck as you were talking that each one of these six areas represents an opportunity for us to really impact workplace wellbeing. You mentioned being really interested in ease of work. Is there perhaps an intervention that you're doing in this space that you'd like to share briefly.

Biddison: We have had some incredible opportunities that I'm super excited about. We've have some within our office and some that are happening across the enterprise that I think have tremendous promise. The one that we've been directly partnering on within our team and within our office is a new workflow around prior authorization for medication, specifically, and involves a partnership with the Department of Medicine and with our pharmacy colleagues to to bring to that process for our primary care clinics and medicine. A pharmacy technician who is specifically trained and charged with supporting the prior authorization process to make it more efficient and also more effective, and also to free up the time of our clinical teams to do clinical work with our patients. That has been really incredibly exciting to see the pharmacy techs have been enjoying it because they have intention and purpose and their work and are really being becoming very efficient at the work that they're doing in this space, and the clinicians are grateful to be freed up from this administrative time in order to really focus on their patients and on the care that they're delivering. That's been really exciting. There also is incredible work going on. We have colleagues in the office of Johns Hopkins physicians who are doing work on epic and our in-basket workflows to help us be more efficient and more effective in that space, and other exciting work in the AI domains. But those are just a couple of things that are happening. But, Carolyn, you've been doing some really exciting stuff too. Can you tell us a little bit about what you've been focusing on?

Fowler: Well, thanks, Lee. Let me start with the thing that I'm obsessed about right now, and that connects both to the leadership behavior domain and building that culture of connection and support. That has to do with listening. Our sense of belonging really is informed by that sense that people see us, they hear us, we're important to them. As much as we talk about communication competency in healthcare, a lot of that is in this space of can I communicate well in writing? Can I be persuasive? Can I get information out? But that idea of, am I actually listening to you? Am I deeply listening to you to understand? Can I listen in a way that respects diverse opinions and holds space for ambiguity? Those are things that I'm really interested in. In general, I would say that the connection between providing support in the workplace and the leadership behavior is around the practice environment we work in. If we create a practice environment that is healthy, that is positive, that is respectful, that tries to minimize these pebbles in the shoe and the boulders on the shoulders, then we're likely to not only get better outcomes, but we're likely to create a space in which people can not only survive, but they can thrive and feel professionally fulfilled. My work is in that. As I've teased you, I say I'm always looking for buy one, get one free strategies. We have to focus on leadership development. We have to focus on team connection and team support. When we invest in this work that supports deeply relational and effective leadership and a culture of connection and support, then not only do we get enhanced well-being, which is our primary intention, but we also just get better leadership and better relationships in general. Those drive everything that we care about in healthcare. Lee obviously, we'll focus on each of these areas in future episodes, but is there anything else you think we should highlight today in this introductory podcast?

Biddison: Such a great question, Carolyn. I think one of the things that has been top of mind is thinking about how we can use policies to influence the outcomes we're interested in ways that feel supportive and not overly directive. I think there's a real nuance here that's important to get at. We can create and implement policies that directly influence health and wellbeing. Those could be policies around a smoke free workplace. We dictate that there was no smoking on campuses, and that directly impacts lung health and other and other aspects and cardiovascular health and other aspects of health. But there are also ways in which we set up and structure our systems through policies and procedures that are maybe not explicitly wellbeing policies, but which we can approach with a lens of and asking the question of what influence or impact will this have on our colleagues daily experience of their work? Can we bring the lens that says in anything that we do and everything that we do around setting expectations and appropriate boundaries or appropriate guidance for our work. Can we take to that conversation and to the decision making and to the implementation around that. A goal of creating environments in which people thrive. That's a little bit gets a little bit it could be a hidden, a positive, hidden agenda, as it were. But I think it's really critical as we think about how we shape, the culture and the environment in which we all work.

Fowler: Well, I am excited to be doing this work with you, Lee, and to have the gift of the time and skills of so many of our colleagues around the health system who've been allies in this work with us.

Biddison: Absolutely.

Fowler: Well, we've got a lot to talk about over the coming months. But to wrap up today, I'd like to share our three takeaways from our conversation. The first is that self-care is very important for wellbeing, but focusing on individual behaviors will never be enough to improve our wellbeing at work. We have to be looking at organizational and systems level strategies. The second is that because wellbeing is foundational to our ability to achieve anything that we care about in healthcare, whether that's safety, quality, professional fulfillment, professional growth, or frankly, our readiness and ability to deliver safe, excellent person centered care. We have to prioritize well-being at the organizational level. Also, finally, anything we care about, there are no simple or quick fixes. But the good news is we do have guidelines, and we do have an emerging evidence base to guide us. We look forward to discussing some of these with you as we continue our conversations about well-being at work. That's it for today. If you enjoyed what you heard, please share this podcast with a colleague. As always, we welcome your feedback.

Biddison: If there are any topics you'd like to hear about, please e-mail your ideas to us at. [inaudible 00:20:26] edu.

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being
Johns Hopkins Health System

1. Self-care is important for well-being, but focusing on individual behaviors will never be enough to improve our well-being at work.
2. Because well-being is foundational to our ability to achieve what we care about (safety, quality, professional fulfillment, etc.), we must prioritize it.
3. As with anything we care about, there are few quick fixes, but we do have guidelines and an emerging evidence base to help us move forward. We need to lean into a growth mindset, pace ourselves and realize that good things take time.