Mark Briesacher, MD: Hi. I'm Mark Briesacher. I'm the President of the Intermountain Medical Group and the Chief Physician Executive for Intermountain Healthcare and I'm here with Dr. Steve Swensen. He is our Medical Director for Professionalism and Peer Support. I was thinking, Steve, about one of our earliest conversations and in there we discovered a common interest, and my understanding is, if I remember correctly, is that this is something you've done for an extremely long time. It's something I just started to do last year, and that is skate skiing. And in fact, the idea of being able to come to Intermountain Healthcare and join our team and live in the mountains, so that you actually have options for both skiing on flat ground and some hilly ground may have influenced your decision a little bit. But welcome. Welcome to Salt Lake City and Intermountain Healthcare. I can tell you that I'm absolutely counting on getting some lessons on how to appropriately skate ski.

Steve Swensen, MD: I'm sure I can learn more from you than vice versa. I started doing it back when Bill Cook innovated it in the mid-1980s. He started with the marathon skate, and he improved on what the Norwegians had done for 4,000 years and flipped the organization and flipped the whole sport, so it's a lot of fun.

Mark Briesacher, MD: Well, for those who don't know, an hour or so out on a flat golf course skate skiing, it's an amazing cardiovascular workout. You will sweat and breathe and get tired, but it's also ... there's a rhythm to it and creates some mindfulness, I think, as you just kind of cruise along that I particularly like about the sport.

Steve Swensen, MD: It really does. It's one sport where I just get into the zone. Where I can get out there and get in a rhythm and time just flies by. I don't even know it.

Mark Briesacher, MD: If there's maybe one takeaway from listening to our discussion today is maybe this winter some people should try skate skiing, take a lesson and give it a go. I suspect a lot of people would enjoy it also.

Hey, you've come here to help us continuously improve on our work of having this be a great place for all caregivers to, each day, do their best to take care of customers and patients, and you know that this is really important to me, personally. In practice, it was the ability of our physicians and the nurse practitioner who was on our team to gather with our whole team and talk about how things are going and how are we doing today, how we were doing yesterday, and what can we all do to support each other…get together over lunch and talk about some of these things—it’s really important. Can you talk just a little bit about why you've ended up in this spot from your career in clinical care to now leading and helping to lead the Intermountain Healthcare, and I would submit the whole nation, in this very important topic?

Steve Swensen, MD: For most of the last decade, I've been working on professional burnout and, put more positively, world class esprit de corps. Esprit de corps is basically caring about each other for our patients, and it's a combination of resilience and satisfaction, engagement, and teamwork. So it's this camaraderie that's focused on a vision, and the vision of Intermountain Healthcare is beautiful. It's helping people live the healthiest lives possible®, and we can't do that unless we care about each other first.

Mark Briesacher, MD: What are some of the things ... so if I'm in the car and listening to this right now, and I'm thinking hey, I completely agree with that, are there some things that people could do right away that would help build their esprit de corps in the unit in the hospital or in the operating room or in the emergency department or in the clinic? What are things that you have found to be really important for teams to do together to improve on their ability to care for each other?

Steve Swensen, MD: The beauty of this space is that we can make a lot of progress by caring for each other, and there are three basic human needs that come into play that give us the opportunities. The first is camaraderie. You talked about that, Mark, of the teamwork and sharing of experiences with members, colleagues, caregivers with whom we work. The second is to be passionate about something, and that connects us to the meaning and purpose of working at Intermountain Healthcare. And the third is the space of being trusted, so that the feeling that we're trusted by our team members, by our immediate supervisor or boss, chair, leader, manager, and people who feel trusted, feel passionate about something and feel this camaraderie are set up to be extraordinarily resilient to all of the stresses in life in healthcare.

If you start with something, I'd start with carving out intentionally time with your team or mentors or coaches at Intermountain Healthcare to have lunch, to have a break in the morning, to visit. With all the pressures of our lives, we've lost a lot of those scheduled opportunities and time together, so we have to be intentional about that. That's the simplest, easiest thing to do, and friends and family are a part of that core of resilience.

Mark Briesacher, MD: That makes a lot of sense to me, and as you answered that, I had the realization that this really applies to all teams, both in healthcare, even if you think about faculties and how they work together at a college or a high school or a grade school, or a shift of the policemen that are the swing shift or the overnight shift at a precinct, but certainly in healthcare. This is really a broad thing.

In fact, just this morning I saw a colleague who I had not seen for several months. He's from our Technology/Information Systems Department, and I was so happy to see him, because we were this multidisciplinary team of clinicians and information systems and communications and people from HR that were all coming together to work on getting something done. You talked about trust. I had such trust in that person, and still to this day do, for the work that they do.

Steve Swensen, MD: What's interesting, Mark, the social scientists tell us that we're less happy as Americans than we were 30 to 40 years ago. And the research shows that the primary driver is that we are less socially connected. And if you look at the valuation, how economists would value Intermountain Healthcare, 30 years ago it was largely physical assets. Tangible assets like tables and operating rooms and robots. In the 21st century, the main valuation of Intermountain Healthcare is in intangible assets, and that is people, and specifically social capital. Social capital is a measure of the trust ... you mentioned trust, Mark ... and interconnectedness of the people in an organization.

The organizations that have the highest levels of social capital, trust among each other up and down, left and right, back and forth, and connectedness are safer. They're more efficient. They diffuse the best practices and ideas faster, and they learn from adverse events faster than organizations that don't trust each other and aren't connected.

I think the story you told is fundamental. The more that we spend time with each other and appreciate each other's diversity and our backgrounds and genome and phenome, the better off we are for our patients.

Mark Briesacher, MD: Steve, I was meeting with some physicians just the other night and we were talking about the patient experience, and I was impressed with how they were leaning into trying to understand this and to improve. And a statement that was made was no one person or no one professional at Intermountain owns or is responsible for the entire patient experience, but each of us is responsible for our own moment with them. And that struck me as being a really powerful concept.

I'm wondering: what's the link between esprit de corps and trust in each other and strong social capital, strong relationships? And then how each of us does in those moments that are so important to patients who are trusting us with their health and their life.

Steve Swensen, MD: What's fascinating, Mark, if you look at relationships between clinical caregivers and patients…it’s one of the most powerful healing relationships, if it's done properly. As caregivers lose esprit de corps, the first thing to go is empathy and kindness. Scholars have looked at patients' perceptions of kindness in relationships with doctors, nurses, pharmacists, social workers. And if they perceive that they're being treated kindly and with empathy, their wounds heal faster. They need less narcotics for their pain. They get out of the hospital faster. They are more likely to do what's best for them, like take their prescription medications or follow through on the routine for exercise or diet or whatever it is. And so the highest-value way to improve patient experience is to make an investment in staff esprit de corps.

And patients get this. I did some research maybe five years ago for the Institute for Healthcare Improvement, on leadership in healthcare, and we interviewed leaders from across the world of medical centers, including Intermountain Healthcare, and we wrote a white paper. I think it was interesting. The most important learning for me had nothing to do with those leaders. It had to do with patients and their wishes. And so I learned from that research experience the top two wishes of patients.

The first is, “Give me the care that you would give yourself.” And the second, I thought was particularly insightful, was, “Care for each other.” They were talking about us. Nurses and doctors and social workers and managers caring for each other, because they knew that their results would be better if the esprit de corps of Intermountain Healthcare caregivers was better.

There's this virtuous cycle where if nurses and doctors and social workers can be empathetic and kind to patients, patients have a better experience. They have better outcomes. They have safer experience, and it comes right back at the caregiver as immunization against burnout, and to bolster the caregiver's experience and their esprit de corps.

Mark Briesacher, MD: We have talked about how when a patient says thank you, how it is in our nature to think, well of course, this is what I've trained for. Of course, I was going to do this, as opposed to pausing and breathing in the gratitude and the sincerity and the appreciation for the help that we've provided, whether that was a bit of advice on how to maybe help your newborn infant sleep better at night or advice ... or the technical skill to repair a heart valve that isn't working the way it used to.

And I think that's what you're talking about here, this virtuous cycle. Would you agree with me that we should all be intentional and focus on taking in that gratitude when patients, and even when teammates express that to each other?

Steve Swensen, MD: That's so well said. You do need to just take a deep breath in and smile to yourself. Scholars, like Professor Losada, have looked at this in the organizations that he studied. He looked for the positivity in the organization contrasted with the negativity, and he came up with this number of 2.9013.

Mark Briesacher, MD: It's like pi, it's like 3.14.

Steve Swensen, MD: Yeah, exactly. It's close to pi. The basic stakes for an organization to be functioning at a reasonable level is to have the ratio of positivity to negativity be about 2.9013. The optimal is 6. The more that we as leaders and colleagues and caregivers cannot, in a Pollyanna way, but look at the positive things that have happened with patients and with teamwork and with organizational decisions at this great organization, the better off our patients will be.

Mark Briesacher, MD: As you were telling that, I was thinking of the work out of Duke around gratitude, and their direct link to safer, higher quality care that's related to people expressing gratitude for each other. And again, this isn't a Pollyanna-ish type of gratitude. It's just those simple thank-yous and recognition of a job well done that every human being really deserves to have. I don't know if you're familiar with that work out of Duke.

Steve Swensen, MD: Yeah, it is a whole field in that area that is rising to awareness of the leading organizations like Intermountain Healthcare, and so the beauty of it is...

Steve Swensen, MD: Gratitude is a powerful enabler of healthy humans. I've done some research in this area that looked at five behaviors of the most effective leaders in healthcare, and these are not presidents and CEOs, like yourself, although it works at that level, too. I'm talking about the nurse managers and the physician leaders up close and finance managers down closest to the point-of-care.

And the first of those five behaviors is appreciation. Thank you for your work today. Thank you for going the extra mile with that patient. I'm so glad you weren't looking at the clock when we had to get the job done today at 5:00 and stayed late. I really appreciate it. That's one of the most powerful of those five behaviors for improving satisfaction, esprit de corps, and keeping burnout away.

Mark Briesacher, MD: Yeah, I couldn't agree more. Steve, I know that you're aware of this work, but Matt Pollard and Tim Pehrson and many others from up at McKay-Dee Hospital have really helped our whole organization focus on how we can continuously improve, and one of the things I really like about this work is really that we have this opportunity to understand what's important to every frontline caregiver, where they find joy in their work, and what are the things that we might be able to do or what are their ideas on how to make that work better. And it seems like this fits in with this idea of esprit de corps and building trust in each other.

Steve Swensen, MD: You're absolutely right, Mark. And if you look at the inner section of continuous improvement and esprit de corps, they are absolutely inextricably linked and necessary for optimal organizational performance. And so the idea is ... and this is part of the beauty of this ... is that you don't need a big capital budget. You need leadership time and attention.

Imagine if every point-of-care leader at Intermountain Healthcare sat down with his or her caregiver colleagues and asked them what brings you joy in work and what saps that joy and what makes for a good day and what are the pebbles in your shoes and what grinds your gears and what frustrates you, and then together, not for them or to them, but with them, with the caregivers in that work unit, say, let's fix that broken process. Let's address this relationship. Let's take the pebbles out of your shoes, not for a month or for a quarter or a year, but this is the way we lead, is we ask our colleagues how we can give better patient care, and how we can make our days more joyful, less frustrating. We know that that works at Intermountain Healthcare. It works at any organization, and all it takes is the time and attention of leaders.

Mark Briesacher, MD: This actually came up in a recent medical group board meeting, where several of our board members, physicians who help govern the medical group, talked about how in their clinic areas how powerful and how important the time that the team is spending together around their huddle board and generating ideas and actually solving for most of those things within that clinic, and removing the whole ... this doesn't have to go all the way up through, as you mentioned, a budgeting process. Most of these things actually get solved locally. And in fact, as of the end of September of this year in 2017, in the medical group we have implemented over 1,300 physician-generated ideas, and of course, my question to the team is how can we quadruple that amount? I actually think we've done a lot more than that. You don't capture every time you solve it. I completely agree that these things are tightly, tightly linked.

Steve Swensen, MD: What a great story. I love to hear that. I've worked with the hematology department at another organization. The leader was inspirational, and all she did was ask these questions. The department had the highest rate of burnout of any department in the organization, and with 18 months, she had flipped that. She asked the nurses about the pebbles in their shoes. She asked the doctors about their frustrations. She asked the social workers about what ground their gears.

And then together they addressed these opportunities and their morale started to improve even before they started fixing things, just because their point-of-care leader cared about them and was interested in bringing them more joy in their work. And joy in work came from Edwards Deming. And Edwards Deming is the bedrock of Intermountain Healthcare's quality work. It's validated, evidence-based. It's been around for decades and decades. We know it works and it's patient-centered.

Mark Briesacher, MD: It sounds like to me that ... and first of all, the serendipitous link in Deming's work, because we have focused on his ideas with respect to quality improvement, to then see that actual quote in the talks he gave around joy has been, I think, is just one of the coolest things.

Steve Swensen, MD: He was a gruff old guy. If you ever met him, he was a little bit grumpy, but he would start these meetings ... we had leaders from the automotive industry and manufacturing, and towards the end of his career in healthcare ... remember those old overhead projectors with the transparencies? He started each session, "What's the purpose of quality improvement?" And he'd hear a bunch of answers. He said, "No, no, no. The purpose is to create joy in work." And it does, and it fixes things for patients.

Mark Briesacher, MD: If our teams tomorrow spent time together, huddled, shared a meal once a month, built trust in each other, put their oxygen masks on first, then the care they provide to all the families, all the patients, their neighbors in the communities where they live, that that care advances among every fundamental. Safety, quality, patient experience, access, and so on.

Steve Swensen, MD: Absolutely. You hit the key ingredients of the secret sauce, and that's leaders that care about their staff, that are looking continuously to remove frustrations and inefficiencies in a patient-centered way, and care about each other and take time to visit and share some food.

Mark Briesacher, MD: Steve, thank you so much for being here today. I have the weekend days booked on the calendar, but we can meet on the course and-

Steve Swensen, MD: I'm all in. I'm all in.

Mark Briesacher, MD: can make me a better skater. And I can't tell you how thrilled I am to have you working on our team at Intermountain and helping us through this very, very important thing that we're doing for our caregivers.

Steve Swensen, MD: It's a great privilege for me, and I'm delighted to be on your team. It's my day number 177.

Mark Briesacher, MD: And it's a great day. Thank you so much.