key: cord-0910653-wl2l1r2v
authors: Berry, Leonard L.; Adawi Awdish, Rana Lee
title: Health Care Organizations Should Be as Generous as Their Workers
date: 2020-10-20
journal: Ann Intern Med
DOI: 10.7326/m20-5172
sha: e3f73f5feae4d4d04d28ee5b58001594f296ec17
doc_id: 910653
cord_uid: wl2l1r2v

Providing excellent medical care, especially during the current pandemic, demands the generosity of health care workers—requiring them to make sacrifices while exhibiting emotional strength, resilience, and compassion. This article describes how institutional generosity is critical in supporting health care workers and in enabling health care organizations to succeed and thrive.

G enerosity is a service organization's most powerful opportunity to excel (1) . Being generous with employees strengthens their sense of community, security, loyalty, and trust and inspires them to go the extra mile to serve others. That discretionary effort-the difference between the effort workers voluntarily expend versus what they must expend to avoid penalty-is critical to the success of all service organizations, especially in health care.

Providing excellent medical care demands the generosity of health care workers. It requires them to exhibit emotional strength, resilience, and compassion; to prioritize patients' preferences and values; to sacrifice family time; and, especially recently, to assume great personal health risk. Health care professionals have every reason, then, to expect their employers to be generous in return and to embed that generosity in the organization's culture.

Coronavirus disease 2019 (COVID-19) is clearly testing the cultural generosity of health systems, and the truly generous organizations are best prepared. Clinicians and other health care workers who exude generosity are more likely to thrive in organizations that have values that align with their own. We propose community and protection as 2 crucial, intersecting domains of a health care organization's generosity to employees.

Generous health care organizations make teamwork a cultural pillar. Teamwork nurtures reciprocal learning, mutual support, and discretionary effort. Feeling valued in a team-based community offers a sense of belonging that is a key antidote to clinician burnout (2)-an insidious condition, for physicians and organizations, that is associated with decreased productivity and increased medical errors and physician turnover (3) .

A culture of teamwork is built on respect among all members, regardless of position, role, or personal identity. Respect means listening to the people closest to the work, welcoming diverse viewpoints, prioritizing fairness and nondiscrimination, genuinely caring for others' well-being, being transparent with information, and sharing power. Such reciprocity builds trust and inspires teams to innovate grassroots solutions so that, when proven effective, they can be scaled up for the benefit of many.

Providence St. Joseph Health, based in Renton, Washington, where the first confirmed U.S. patient with COVID-19 was treated, illustrates the power of a generous culture during a crisis. Guided by a "pandemic playbook" strategic plan and a core value of following the science, Providence prioritizes transparency and humility. For example, during end-of-shift huddles, participants discuss 1 thing that went well and 1 thing that didn't and then, crucially, are encouraged to "let go" of what didn't go well. Providence also launched a caregiver health call center to immediately assist anyone with COVID-19 symptoms and developed a "stay-athome" toolkit with guidance on being homebound, including homeschooling.

Community engagement, service, and philanthropy are core values driving Henry Ford Health System's culture. An expression of those long-held values led employees to donate roughly $1.9 million to an emergency relief fund to help coworkers address COVID-19 -related financial hardship. When a sense of community is ingrained in organizational culture before a crisis, generous acts emerge organically during difficult times.

Employees' physical safety, emotional stability, and financial security are interrelated; the absence of 1 of these compromises the others. The pandemic has greatly escalated the risks of working in health care and the need for institutional protection, as deficiencies in personal protective equipment inventory, supply chains, nationwide logistics, and planning make clear. It is profoundly ungenerous that more than 1 million U.S. health workers do not have health insurance (4) and that many hospitals are laying off or grossly underpaying environmental services staff whose work is critical to employees' safety (5) .

Excellent service companies pay above-market compensation to attract and retain higher-quality employees, and they don't outsource work that affects quality and value (1). Furloughing or firing health workers may reduce short-term expenses, but it diminishes people's sense of community, erodes trust, and lowers productivity when new, inexperienced workers are eventually hired. Employees know when they are seen as expendable, and their lost loyalty is difficult to recover.

Torrance Memorial Medical Center, in Los Angeles County, redeployed 500 idled outpatient employees to build safety face shields, among other necessary tasks (6). Providence pays above-minimum wages across its system and offers free or reduced-cost health care to low-income staff; unlimited use of childcare benefits; additional emergency time off; and free, confidential, virtual counseling by licensed mental health professionals. Henry Ford Health System has trained its leaders in psychological first aid to support teams emotionally. Hospital CIMA, in San José , Costa Rica, does a rootcause analysis of every safety incident within 24 hours and develops a solution within 48 hours (6) .

Organizational generosity during a pandemic, when most health systems have declining revenues and rising This article was published at Annals.org on 20 October 2020.

costs, may seem unrealistic. However, the hidden costs of an ungenerous culture-lower morale, less discretionary effort, diminished trust in the organization, and less teamwork-do the most harm in times of crisis. One such cost, physician turnover, is often estimated at $500 000 or more per physician (3, 7) , largely related to hiring (for example, relocation and sign-on bonuses) and lost revenue (for example, during vacancies and onboarding). A lowturnover health system with, for example, 100 physicians saves millions of dollars annually, which can then be reallocated toward generosity for employees.

One very successful retailer-Costco-offers higher wages than similar firms, affordable health insurance for full-and part-time employees, generous retirement plans, and twice-yearly bonuses for long-tenured, hourly workers. Its annual employee-retention rate consistently exceeds 90%, and its workforce maintains an uncommonly high sales-per-employee ratio (8) . In short, Costco's labor productivity supersedes its "labor wage rate"-a useful lesson for health care organizations.

Organizational generosity engages employees' commitment to excellence. The Drucker Institute's longitudinal study of corporate effectiveness found, for the health care sector, a statistically significant relationship between increases in employee engagement and greater profitability (9) . In addition, Providence's internal research shows that employee engagement correlates with patient satisfaction, quality of care, cost containment, growth, retention, and productivity.

A generous organizational culture is imperative for delivering high-quality health care. However, strengthening a culture is difficult and slow. To start, leaders must narrow any trust gap between them and employees by always being truthful, promoting transparency, listening actively, practicing inclusion over exclusion, investing in the benefits that matter the most, and being visible at the point of care. They should also empower clinicians to work at the top of their license (bolstering their sense of agency) while using data to help them deliver safe, equitable, and holistic patient-centered care.

In service organizations, trust is a precious asset not captured on a balance sheet. The best organizations make generosity a foundational principle of their culture. They epitomize fairness, kindness, and character. They offer a sense of mission and purpose. If health care workers witness and feel that generosity daily, so will patients and their families.

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Physician burnout, interrupted

The business case for investing in physician well-being

4 unconventional ways to support the health and wellbeing of the health care workforce. Institute for Healthcare Improvement

Investing in our first line of defense: environmental services workers

Health care workers protect us. It's time to protect them

Burnout and health care workforce turnover

There's profit in wellness and social responsibility

Accessed at www.wsj.com/articles/the-surprising-way-companies-can -shore-up-their-financial-strength-11591999748 on 28