HEALTHY WORK ENVIRONMENTS QWQHC’S 2010 SUMMIT Healthy Workplaces in Action: Working to Delivery Quality Care February 25, 2010

Purpose To provide an overview of: The work of HealthForceOntario The importance of HWEs in the health care system The Ministry of Health and Long-Term Care’s (MOHLTC) Healthy Work Environments (HWE) initiative Evidence supporting HWE Initiative Examples of innovative HWE interventions Future directions for HWEs Good afternoon everyone. I am very happy to be here on behalf of the Ministry of Health and Long-Term Care to present at the RNAO’s Healthy Workplaces in Action, 7th International Conference. Keeping our health care workers safe and healthy is one of the priorities of our Health Human Resources strategy. One way we could achieve this is by recognizing the importance of healthy work environments and adopting a safe, violence-free, and positive workplace culture in the health sector. Today, I will be talking to you about why HWEs are important; some HFO initiatives underway to support this strategy; and, how everyone in the health care sector can take an active role in implementing and promoting a healthy work environment.

What is HealthForceOntario? HealthForceOntario (HFO) is the province’s strategy to ensure that Ontarians have the right number and mix of qualified health care providers, now and in the future. The strategy: Identifies and addresses Ontario’s health human resources needs; Engages partners in education and health care to develop skilled, knowledgeable providers and creates health care delivery teams that will make the most of their abilities; Introduces new and expanded roles to increase the number of providers working in health care and builds on the skills of those already in the system; and, Makes Ontario the employer-of-choice for all health care providers. MOHLTC and the Ministry of Training, Colleges and Universities are delivering on the HealthForceOntario strategy in partnership with the province’s health care consumers and providers. Slide as is… 3

Quality Worklife Quality Healthcare Collaborative (QWQHC) What is a HWE? A HWE is a work setting that takes a strategic and comprehensive approach to providing the physical, cultural, social, and job design conditions that maximize the health and well-being of health care providers Quality Worklife Quality Healthcare Collaborative (QWQHC) “….promotes and maintains the physical and mental health of its employees” (Robson, et al., 2000) “…culture, climate, and practices in an organization create an environment that promotes employee health and safety…” (Lowe, 2002) 4 4

The Need for HWEs 88% of health care workers report insomnia, headaches, depression, weight changes, and panic attacks related to work stress. 35% of Ontario nurses report at least one musculoskeletal condition. 28% of Ontario nurses report that they were physically assaulted at work over the past 12 months by a patient. 46% of Canadian physicians report that they are in advanced stages of burnout. Average number of days of work lost due to illness or disability is at least 1.5 times greater for workers in health care than the average for all workers. If the average absenteeism rate for health care could be reduced to that of all Canadian workers, it could mean the equivalent of more than 13,700 “extra” full-time employees on the job, including 5,500 Registered Nurses. From these statistics you can see that most health care workers are reporting that they are experiencing high levels of work-related stress, or illnesses, or they have been assaulted by a patient; and almost 50% of physicians are reporting that they are suffering from advanced burnout. When health care workers are themselves unhealthy, or the conditions in which they work lead to further injuries or illnesses, then it can be expected that the quality of patient care provided would be compromised, and the occurrence of medical errors increases. It would make sense then, that in order to improve quality care and positive outcomes, a positive work culture and environment is necessary. 5

Compared to other occupations, health professionals have the: The Need for HWEs Compared to other occupations, health professionals have the: Least supportive and healthy workplaces Least influence on workplace decisions Lowest ratings of workplace communication Lowest level of commitment to their employer Lowest level of trust in their employer

Costs of an Unhealthy Workplace (Shamian, 2003) 3x Heart Problems 2x-3x Conflicts Infections 2x - 3x Injuries Mental Health Problems Back Pain 5x Certain Cancers 2x Substance Abuse STRESS High Demand Low Control + High Effort Low Reward 7

Why are HWEs important? (1) To help Ontario improve recruitment, retention, and absenteeism HWEs can help retain older workers who may be considering retirement, as well as help recruit and retain younger workers who tend to place a higher value on work-life balance, positive work environments, etc. To improve patient safety and quality of care The 2004 Canadian Adverse Events Study suggested that the greatest gains in patient safety will come from modifying health care professionals’ work environments, creating better defences against adverse events and mitigating their effects when they do occur. To support health system sustainability and achieve cost savings Healthy work environments yield improved health outcomes for employees and reductions in employer costs related to turnover, lost-time injuries, and absenteeism. From these statistics you can see that most health care workers are reporting that they are experiencing high levels of work-related stress, or illnesses, or they have been assaulted by a patient; and almost 50% of physicians are reporting that they are suffering from advanced burnout. When health care workers are themselves unhealthy, or the conditions in which they work lead to further injuries or illnesses, then it can be expected that the quality of patient care provided would be compromised, and the occurrence of medical errors increases. It would make sense then, that in order to improve quality care and positive outcomes, a positive work culture and environment is necessary. 8 8

Why are HWEs important? (2) Business Case: HWE Effect on Sick Absence From these statistics you can see that most health care workers are reporting that they are experiencing high levels of work-related stress, or illnesses, or they have been assaulted by a patient; and almost 50% of physicians are reporting that they are suffering from advanced burnout. When health care workers are themselves unhealthy, or the conditions in which they work lead to further injuries or illnesses, then it can be expected that the quality of patient care provided would be compromised, and the occurrence of medical errors increases. It would make sense then, that in order to improve quality care and positive outcomes, a positive work culture and environment is necessary. A Healthy Work Environment is significantly related to lower sick days Better People Management ©Metrics@Work and Brock University, WHRL, 2008 Brock University Workplace Health Research Laboratory 9 9

Why are HWEs important? (3) Business Case: HWE Effect on Individual Health A HEALTHY WORK ENVIRONMENT IS SIGNIFICANTLY RELATED TO HIGHER EMPLOYEE HEALTH Better People Management ©Metrics@Work and Brock University, WHRL, 2008 Brock University Workplace Health Research Laboratory 10

Why are HWEs important? (4) Business Case: HWE Effect on Performance A Healthy Work Environment is significantly related to higher productivity Better People Management Brock University Workplace Health Research Laboratory ©Metrics@Work and Brock University, WHRL, 2008 11

HWE Conceptual Model Conceptual Model for Healthy Work Environments for Health Care Providers / Workers - Components, Factors, and Outcomes* *Adapted from: Griffin, P., El-Jardali, F., Tucker, D., Grinspun, D., Bajnok, I., and Shamian, J. (2006). Conceptual Model for Healthy Work Environments for Nurses- Components, Factors, & Outcomes. In Developing and Sustaining Nursing Leadership Healthy Work Environments Best Practice Guidelines (p. 12-15). Toronto, Canada: Registered Nurses' Association of Ontario. (Used with permission of the Registered Nurses’ Association of Ontario, November 2007) From these statistics you can see that most health care workers are reporting that they are experiencing high levels of work-related stress, or illnesses, or they have been assaulted by a patient; and almost 50% of physicians are reporting that they are suffering from advanced burnout. When health care workers are themselves unhealthy, or the conditions in which they work lead to further injuries or illnesses, then it can be expected that the quality of patient care provided would be compromised, and the occurrence of medical errors increases. It would make sense then, that in order to improve quality care and positive outcomes, a positive work culture and environment is necessary. 12 12

The Ministry’s HWE Initiatives: 2007 to Present Appointed two HWE Champions in April 2009. Established a HWE Expert Advisory Group. Worked with the Ministry of Labour to introduce the Needle Safety Regulation, which mandates the use of safety engineered needles to all health care workplaces. Funded the development of a variety of tools and resources to support HWEs in hospitals, long-term care homes, and home care, including: $3.5M to support 20 projects in 2007/08 and 2008/09; and $2.8M to support 18 projects in 2009/10 through the HWE Innovation Fund grant program. 13 13

The HWE Champions’ Role The role of the HWE Champions is to: Promote the benefits of HWEs among fellow leaders in the health system and encourage them to implement HWE initiatives in their workplaces, including speaking to LHIN CEOs and health care employers (e.g. hospitals, long-term care homes, home care agencies). Speak at key health care conferences, education sessions, etc., and support partners’ efforts to showcase HWE leadership. Provide advice to MOHLTC on how to effectively implement HWEs, recognize leaders in HWEs, and build a culture of workplace health safety across the province. Collaborate with the HWE Expert Advisory Group to provide advice on HWEs to the government and the health care system. Slide… 14 14

The Expert Advisory Group’s Role The role of the HWE Expert Advisory Group members: To advise the HWE Champions (and through them, MOHLTC) on the implementation of the province’s HWE strategy. For example: How to enhance knowledge transfer; Support for change management; Promoting organizational leadership; Using technology and social media to support HWEs; Enhancing interprofessionalism / teamwork; and, Strategies for successful sectoral outreach. Slide… 15 15

The Needle Safety Regulation The Needle Safety Regulation was introduced in August 2007 under the Occupational Health and Safety Act to mandate the use of safety-engineered needles in hospitals as of September 1, 2008. In October 2007, the regulation was amended to extend it to long-term care homes, psychiatric facilities, laboratories, and specimen collection centres as of April 1, 2009. In November 2009, amendments were made to the regulation to extend it to other health care workplaces / services (e.g. public health, home care, physician offices, ambulance services, independent health facilities, etc.) to come into effect on July 1, 2010. 16 16

The HWE Innovation Fund The Ministry launched the HWE Innovation Fund Grant Program in August 2009. The purpose of the HWE Innovation Fund is to identify, develop and disseminate HWE tools and leading practices There are four areas of focus for the HWE Innovation Fund which are: Workplace violence prevention Worker safety Respect in the workplace HWE leadership development The 18 projects that were selected for funding covered a broad range of health care environments including hospitals, long-term care homes, community care, family health teams, CCACs, LHINs, mental health facility, and geographically across Ontario. 17 17

Other HWE Tools RNAO Best Practice Guidelines CREW (Civility Respect and Engagement in the Workplace) 18 18

RNAO Healthy Work Environment Best Practice Guidelines Workplace Violence Leadership Effective Teams Safety and Wellbeing Staffing and Workload Professionalism Cultural Diversity 19 19

CREW Intervention Outcomes in VA system Veteran Healthcare Administration (VHA) developed CREW Implemented in VHA 150 facilities across the USA. Units grouped into those with High, Medium and Low civility Changing Low Civility units to Medium or High Civility units has a significant financial impact on: Sick leave Equity/Discrimination Suits Patient Satisfaction 20 CIVILITY Baseline Expectation Fundamental Rules of Interaction On-stage Behavior Courtesy RESPECT Trust Compassion Ethics Listening Honesty ENGAGEMENT Authorized to Act Accountable Osatuke, K., Mohr, D., Ward, C., Moore, S.C., Dyrenforth, S., & Belton, L. (in press). Civility, Respect, Engagement in the Workforce (CREW): Nationwide Organization Development Intervention at Veterans Health Administration. Journal of Applied Behavioral Science. 20 20

Financial Impacts and Patient Satisfaction from VHA Sick Time Financial Impacts and Patient Satisfaction from VHA Equity/Discrimination Complaints 21 21 21

Relationship of Workplace Civility to Employee Outcomes with VHA 22 Employee Satisfaction Intent to Stay 22 22

CREW CANADA Michael P. Leiter, PhD Centre for Organizational Research 23 Michael P. Leiter, PhD Centre for Organizational Research Acadia University Heather Laschinger, RN, PHD University Of Western Ontario Arla Day, PHD & Debra Gilin-Orr, PHD St. Mary’s University Funded by the Canadian Institutes for Health Research http://cord.acadiau.ca 23 23

Crew Process Commitment Assessment Training Community Implementation 24 Commitment People Values Assessment Training Community Implementation Civility Sessions Mentoring Evaluation Assess Kickoff Training Sessions Civility Midpoint Meeting Civility Sessions Reflection Wrap up Six Month Cycle Companion Mentoring 24 24

CREW significantly decreased co-worker incivility. 25 CREW significantly decreased co-worker incivility. 25 25

CREW significantly decreased exhaustion. 26 CREW significantly decreased exhaustion. 26 26

CREW significantly decreased intentions to quit. Intention to Quit 27 CREW significantly decreased intentions to quit. 27 27

CREW significantly decreased absences per month. 28 28

Nurses’ Trust in Management 29 CREW significantly increased trust in management 29 29

Nurses’ Empowerment Subscale: Support 30 CREW significantly increased access to support. 30 30

34% 2008 2009 CREW Absences Financial Impact reduction days per month 31 Financial Impact 34% reduction =0.83 2008 2009 =0.54 Approx. Costs Approx. Savings w/ CREW Unit @ 100 Members $55,060 $18,720 Hospital @ 3,000 Members $5,000,000 $1,700,000 Hospital @ 10,000 Members $25,000,000 $8,500,000 days per month 31 31

CREW WORKS Conclusion It Improves Civility and Lowers Incivility 32 It Improves Civility and Lowers Incivility It Improves the Downstream States: Exhaustion Attitudes Towards Work Evaluation of Worklife It Improves Career Activity Missed Days Intention to Quit CREW WORKS http://www.Workengagement.com 32 32

What Can Be Done – One Hospital’s Story The TEGH Experience Hospital began major focus on healthy workplace in 2005 following staff satisfaction survey that showed significant room for improvement. The approach to a healthier work environment involved a number of different tracks covering wellness, workplace safety, violence reduction, training and development, and regular measurement to name a few. Moved from below average staff engagement scores to top performer scores over 4 years. 33 33

What Can Be Done – One Hospital’s Story The TEGH Experience – Wellness TEGH Fitness Centre opened in February 2005. Wellness Centre opened in June 2007. Programming has very broad range spanning: Yoga Spinning Photography Massage Running Club Etc. 34

What Can Be Done – One Hospital’s Story The TEGH Experience – Wellness Mental Wellness Strategic Plan developed in 2009. Wellness programs need not be a major investment – broad programming at TEGH supported by .6 FTE. 35

What Can Be Done – One Hospital’s Story The TEGH Experience – Workplace Safety Historically TEGH had a very poor track record for injuries and lost time. Focused program to reduce injury and speed return to work. Strategies to reduce injuries included: Becoming the first hospital to go needleless Lift training More robust return to work and modified work programs Improved accident investigation process. 36

What Can Be Done – One Hospital’s Story The TEGH Story – Workplace Safety Lost time rate dropped from 2.42 to 1.36, .14 below peer group average. 37

What Can Be Done – One Hospital’s Story The TEGH Story – Violence Reduction Violence towards health workers has gone on for years. Has been an unspoken problem. There are misperceptions around issues of capacity and violence within and outside of healthcare. 38

What Can Be Done – One Hospital’s Story Weapon risks are real… 39

What Can Be Done – One Hospital’s Story …and extensive 40

What Can Be Done – One Hospital’s Story The TEGH Story – Violence Reduction Started in December 2006 by pulling together a working team including staff, management, organized labour, OSACH. Program includes a number of elements such as: Policy Signage Threat Assessments Employee Training Communications system Incident tracking and analysis system Flagging system for violent patients 41

What Can Be Done – One Hospital’s Story Preventing Workplace Violence What Can Be Done – One Hospital’s Story Is the Program Working? Example Statistics Employee Survey Results – Personal security and safety in the workplace positive scores 2004/05 - 72.9% 2006/07 - 79.2% 2007/08 - 82.5% 42

What Can Be Done – One Hospital’s Story The TEGH Story – Training and Development Moving towards a distributed leadership model leading to greater staff empowerment through 1001 Leaders Program. 43

What Can Be Done – One Hospital’s Story The TEGH Story – Measurement Used standardized survey instrument to monitor progress and compare to other like employers. During first four years survey administered quarterly. Now reducing frequency for ongoing monitoring. Survey results openly shared along with action plans. 44

What Can Be Done – One Hospital’s Story The TEGH Story – Key Lessons/Enablers/Reflections Healthy workplace initiatives are not a luxury. Demonstrate value through clear business cases that show a clear and measurable value proposition e.g. reduced lost time, absenteeism etc. Link initiatives to patient safety. Ensure that leadership is engaged and active. Always present solutions and not problems. 45

What Can Be Done – One Hospital’s Story The TEGH Story – Key Lessons/Enablers/Reflections Engage partners in organized labour. Challenge will be to hold, or not erode significantly, gains made as Hospital works through the impact of current fiscal environment. 46

Future Directions for HWEs Working with the HWE Champions and HWE Expert Advisory Group, the Ministry plans to move forward with a Healthy Work Environments Strategy that will: Continue to develop and disseminate leading practices in HWEs, building on the HWE initiatives that have already been completed. Promote leadership on HWEs by recognizing and celebrating champions who encourage fellow leaders to implement initiatives in their organizations. Incorporate HWE indicators into existing accreditation programs, accountability agreements, and data collection mechanisms. Support the development of a culture of health, safety, and wellness in the health care sector in Ontario. 47

Our Website and E-Mail Addresses We have established a HWE web page on the HealthForceOntario website at: http://www.healthforceontario.ca/WhatIsHFO/hwe.aspx The HWE Champions can be reached by e-mail at: hwechampions@healthforceontario.ca The general e-mail for the Ministry’s HWE initiative is: healthyworkenvironments@healthforceontario.ca You can reach the Ministry’s HWE team directly through the following e-mail addresses: John.Amodeo@ontario.ca Christy.Hackney@ontario.ca Adam.Nagler@ontario.ca Rosabelle.Sankar@ontario.ca 48 48