“In the heart of every high-performing organization are joy-filled teams,” says Stephen Swensen, head of NEJM Catalyst’s Leadership theme. “You will not find a high-performing organization without esprit de corps.” Esprit de corps is the spirit of the body — camaraderie, engagement, and passion, interwoven with joy, he explains. “It is the single most important leading indicator over which we have control of patient experience, patient outcomes, patient safety, and patient costs.”
Swensen lives near the oldest and largest living organism on the planet: Pando, a group of more than 40,000 quaking aspen trees that share a single root system estimated at more than 80,000 years old. “This is esprit de corps,” says Swensen. “It’s the connectedness, the trust, the camaraderie, the fulfillment, the passion, and the loyalty of people to each other and to their mission. If we want to become high-performing organizations, we need to learn from the highest-performing organism on Planet Earth.”
For an organization, esprit de corps is the connectedness of its people, sharing a common purpose. There are no barriers between employees of various backgrounds or with different titles or roles, or between departments or brick-and-mortar buildings. “This is a learning organization that trusts each other. Economists call it social capital. Brookings Institute experts tell us that the single highest, most valuable part of U.S. organizations is our trust and interconnectedness of the people in our organizations,” Swensen says.
Health care systems need esprit de corps to achieve high performance. But, as Swensen notes, “Most of you already knew this.” He references a recent NEJM Catalyst survey, where respondents said the biggest barriers to high performance are unaligned goals and weak culture. “Social capital, esprit de corps, helps us connect, align, and build a culture that focuses on the meaning and purpose of caring for patients and their families in the communities that we have the privilege of serving.”
How do you measure esprit de corps? By counting pronouns. When former Labor Secretary Robert Reich visited organizations to assess their vitality, he listened to the people doing the real work and counted how many times they used the pronouns “we,” “us,” and “ours.” He also counted “they” and “them.” The organizations that used first-person pronouns were set up to thrive; the ones that used third person were set up for mediocrity. “We need to shift to the right pronouns, to have it reflect our engagement and our fulfillment in our purpose of the work we do.”
Swensen likens U.S. health care to a glass half full — a vessel with extra capacity for its purpose. Fully a third of the $3.2 trillion spent on U.S. health care is excess capacity, according to the National Academy of Medicine — approximately $1 trillion in waste every year.
Six categories of waste build this excess capacity, and health care systems own the first three: overtreatment, failures of care delivery, and failures of care coordination. The ramifications of that waste, beyond money, are staggering. It hurts patients, the care team, and esprit de corps. “On a more positive note,” he says, “this $1 trillion of waste, the excess capacity in this glass of water, is the funding opportunity for co-creating quality that will both address these defects of care and rebuild esprit de corps.”
Quality pioneer W. Edwards Deming said, “A bad system will beat a good person every time.” Swensen emphasizes that waste doesn’t come from bad people, but from bad processes. “The solution here is to fix the bad processes so that the great people working in health care can thrive.”
Bad processes buy a vicious cycle that starts with poor quality and leads to cognitive dissonance, “the discomfort between the dreams we had when we decided to go into health care to help people and the reality of the practice of medicine.” Rework of poor quality and the time it takes drive cognitive dissonance and moral distress, as do shortfalls of the care we deliver versus the care we want to deliver, needless harm and preventable adverse events, and practice inefficiencies from 20th-century workflows and processes in 21st-century electronic environments that “drip acid on esprit de corps.”
When a care team loses esprit de corps, physicians have twice the medical error rate, and burnout among nurses in intensive care units correlates to measurably increased mortality rates. “More cognitive dissonance, poor quality, and you’ve got this vicious cycle that, by the way, adds cost to the system in and of itself,” says Swensen. “We need to break this cycle of viciousness.”
Maureen Bisognano, past President of the Institute for Healthcare Improvement (IHI), taught Swensen that you cannot give what you do not have. “If you’ve lost love, passion, loyalty, and spirit, you can’t share that with patients,” he says. “Patients’ surgical wounds heal faster if they feel like their care team love them. And if care teams have companionate love, their productivity goes up, their adverse events, medical errors go down, and their resilience grows.”
Bisognano once asked Swensen to work with a group of 50 hospital leaders. During the opening session, a hospital system CEO spoke about her son’s kidney transplant in one of her hospitals. The transplant was a success, but the CEO described her and her son’s experience as “no love in the system.”
“If there’s no love in the system, it ain’t working right, because you cannot give what you do not have,” says Swensen.
To change this, we need to change our thinking. Swensen describes the work of Marcial Losada, who has studied high-performing teams in high-performing organizations. Losada’s ratio of 2.9013 is a ratio of positivity to negativity on a team for it to function. For high performance, the number is 6:1 positivity to negativity. “Let’s look at how we can change that ratio to flip ourselves out of a vicious cycle into a virtuous cycle,” Swensen says.
Swensen references Deming again, stating that the purpose of quality improvement is to create joy in work. “Co-creating quality can lead us to esprit de corps for our patients. And it’s relatively simple,” he says. There are many models — such as Ask, Listen, Empower — where leaders ask those on the front lines, “What are your frustrations? What doesn’t work? What’s broken in our care on this team?”
Leaders must listen to their answers, says Swensen, and then empower the whole team to together address those issues. “And it works,” he says. “We know that includes esprit de corps, and we know if esprit de corps goes up, then patient experience, outcomes, safety, and costs all go in the right direction.”
“How will it help the patient?” Don Berwick, the IHI’s founder, had a sign on his desk with these words at the Centers for Medicare and Medicaid Services. “That’s a question we should ask ourselves every day,” Swensen says. “If we answer that question sincerely and genuinely, we will do the right thing, and the organization will be just fine if we use that as our guide.”
“I’ll confess, this took me 24 years to figure out,” admits Swensen. He recalls how 24 years ago, he led a department that used quality to drive out waste, variation, and defects, which saved $42 million. But it was the wrong way to start. Whereas 16 years ago, as Director of Quality for Mayo Clinic, Swensen led co-creation of quality to drive out waste, variation, and defects to improve patient outcomes, safety, and experience. “That was the right way to start, and that worked,” he says. When he was Medical Director for Leadership and Organizational Development at Mayo 8 years ago, they used co-creation of quality to drive out burnout — which worked.
“When we took away the variation, waste, and defects of processes close to the patient, it improved morale, it improved the care of patients, and it improved the financial dividends,” Swensen says. “You don’t have to give up any three of those outcomes from co-creation of quality, but you need to start with the patient.”
“This vicious cycle turns into a virtuous cycle by co-creating quality, focused on the patient, that grows esprit de corps, that again feeds back to the patient, lowers costs, and has us end up where we want to, which is an organization that has joy-filled teams.”
From the NEJM Catalyst event Essentials of High-Performing Organizations, held at the University of Michigan’s Institute for Healthcare Policy and Innovation, July 25, 2018.