Why It Matters
To improve health care, leaders must create the conditions for teams to unleash their agency. According to IHI’s Psychology of Change Framework to Advance and Sustain Improvement white paper, this means activating a team’s ability to act with purpose. This requires courage and manifestations of power that allow each person to reach their full potential within their roles in their institution.
Wania Baia, director at Sirio Libanes Hospital in São Paulo, Brazil, realized she needed to activate people’s agency to enhance the joy in work of her staff. While she was a participant of Especialista em Melhoria, IHI’s 10-month Improvement Specialist program offered in Portuguese-speaking countries, Baia saw the opportunity to use her institutional power to identify the structures within the hospital that are leading to burnout. She focused on increasing the number of professionals in the critical care unit who agree that they participate in the decisions made in the unit’s work processes.
Baia focused on three primary ways to create the conditions to unleash people’s agency:
1. Create psychological safety
The team worked to provide psychological safety at the leadership level and between colleagues. Baia started by asking, “What matters to you?” to understand the intrinsic motivation of her team. The critical care unit where she tested her idea took an introspective journey that focused on finding ways for frontline staff to feel heard and engaged as part of designing improvements. Based on what she learned, Baia implemented huddles and emotional check-ins for the team, distributed power by choosing unit leaders to lead the improvement work, and allowed teams to meet directly with leadership to discuss their improvement ideas.
2. Ensure efficient communication
Baia’s team developed a feedback model that focused not only on negative experiences, but also on bright spots. Some of their actions included:
- Clarifying for leaders and frontline staff the best ways to give feedback and get answers to questions;
- Co-designing groups to lead the feedback process, including surveys to assess frontline satisfaction with their participation; and
- Establishing an “appreciation tree” for frontline staff to highlight bright spots, with data collected every month to identify the bright spots of the month
3. Democratize decision-making and co-design change
To build trust, Baia’s team established key processes to understand and prioritize the improvement ideas. This led to a process of co-design and testing in authentic relationship with staff and leaders. Setting clear expectations and communicating about what happened to ideas was key as they established the norms of this new culture. Once improvement ideas were identified, the team was transparent with the information received. They prioritized what changes were attainable and on what timeline. They worked together to determine how the improvement work would be distributed depending on where the ideas originated and who would fit best within the context of that improvement project.
Baia has seen that focusing on increasing joy in work and psychological safety has shifted the culture of her critical care unit (CCU). Teams are engaged with and excited about their work.
Others in the organization have heard what the CCU has done and have expressed hope about making similar progress. Baia is now considering how to use the tools of open and honest questions, public narrative, and one-to-one meetings to continue expanding the joy in work movement across all units at Sirio Libanes. Baia and her teams plan to use both IHI’s Psychology of Change and Joy in Work Frameworks to continue shifting their culture to one that values feedback and honest and authentic relationships to co-design changes.
Santiago Nariño is an IHI project coordinator.
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