Michael Gustafson, M.D., M.B.A., is Chief Executive Officer at the Schwartz Center for Compassionate Healthcare, a nonprofit that partners with health care organizations to advance compassion for patients, clinicians and care teams. Before joining the Schwartz Center earlier this year, Dr. Gustafson served as President of UMass Memorial Medical Center and President/COO at Brigham and Women’s Faulkner Hospital. He also held leadership positions at Brigham and Women’s Hospital in Boston, including Senior Vice President for Clinical Excellence. Dr. Gustafson trained as a surgeon and has focused on improving patient safety throughout his career.
Patient Safety Beat: You recently spoke at the MHA Healthcare Leadership Summit on Well-Being. What is the role of compassion in well-being and how does it relate to burnout?
Michael Gustafson: Compassion provides emotional engagement, whereas burnout is described as emotional exhaustion. Compassion allows deep connection and affiliation versus depersonalization and can provide a sense of reward and fulfillment. Burnout is a lack of self-efficacy, the sense that you don’t have the ability to impact patients positively.
Research shows that people experiencing burnout are less likely to be able to provide compassionate care. On the flip side, compassionate care can act as a buffer against burnout, almost like an antidote.
We all went into health care for the same reason, to relieve pain and suffering. We need to make it easier to wrap the systems, culture and mechanisms of health care around that desire so that compassionate care is the default, not a struggle to provide.
There's some biology and biochemistry behind this, which I find fascinating. First, we empathize with a patient in pain, and then compassion leads us to want to help. If we are prevented from providing what we know the patient needs, that's a negative neuronal pathway that's not countered by the positive effect and reward of being able to help. We are all hardwired to do this. Compassion can be taught and strengthened.
Patient Safety Beat: You’ve been a patient safety leader for more than 25 years. How do you apply what you’ve learned in patient safety to this relatively new movement to address burnout and improve workplace safety?
Michael Gustafson: We have the luxury of looking back over two decades of work to see where we’ve had the biggest impact on patient safety. It’s clear to me that leadership, culture and a rigorous, data-driven approach to performance improvement are three of the most important factors.
Starting with leadership, I'm so proud of the early work we did at the Brigham with our courageous CEO, Dr. Gary Gottlieb, who was willing to go out on the floors with us and ask staff members, “What keeps you up at night? What problems are you concerned about? What do you think the next major safety event will be on your unit?”
Listening to staff answer those questions helped inform our priorities and strategies, even though we couldn’t immediately fix all the problems. As the safety movement matured, we realized we must include board members as leaders. They needed to learn about patient safety — the extent of the problem and the risk — and their role in governance, overseeing quality and safety. That helped us advance the agenda faster than we could have without them. We need similar involvement and leadership from boards in workplace safety and caregiver well-being.
Some people view culture as too nebulous to measure, move or improve, but we've shown that there are very specific questions that underpin the culture. If we target certain areas with initiatives designed to mature and improve the culture over time, whether that's “just culture,” psychological safety, teamwork, or communication, we can address issues that are key drivers of safety events.
Patient Safety Beat: What’s the role of data in efforts to improve workplace safety and clinician experience?
Michael Gustafson: The most powerful use of safety data that I experienced was being able to say, “This month, we had 10 catheter-associated UTIs, 10 falls on the units and five decubitus ulcers, and those are all too many.” Putting raw numbers up on a dashboard every month translates the data into actual patients.
Applying that approach to workplace violence is difficult. The data sources are really challenging. Typically, you're seeing the tip of the iceberg because only the most egregious incidents are reported. You have to help people understand what counts as a workplace violence event, including physical, emotional and verbal abuse, and try to capture as many of those as possible. Once you start to have better data, be transparent. It’s the same thing. You put up dashboards to say, “This month, we had a hundred of these workplace violence incidents, and here are the key areas where they’re happening.”
Another challenge is that we have relied on survey data to measure workplace well-being, and most facilities logistically and financially can afford to survey staff only once every couple of years. Doing frequent “pulse” surveys that are short, just 1, 3 or 5 questions, and that you can repeat over a shorter period can help.
Last, I’ll say that it’s important to look at basic metrics from human resources on every unit. How many vacancies do we have? How long does it take to fill a position? How much voluntary turnover is happening? Looking at that in aggregate, you get a really telling picture. Where in the hospital do you have the most turnover and vacancy? And then map that to your qualitative experiential data. When you pair all of that with data on patient safety, quality and patient experience, you’ll likely find common threads. Local leadership drivers, team dynamics, culture and communication are common themes across each category.
Patient Safety Beat: At the MHA Summit, you described your feelings of moral injury and noted that health care organizations continue to face challenges destined to increase distress. How does that relate to the burnout among clinicians?
Michael Gustafson: We know that moral injury contributes to burnout. It’s the moral tension we feel when we know what a patient needs — the right care, staffing, resources, supplies — but because of our current systems, we're unable to provide it.
We have a significant pediatric behavioral health crisis in Massachusetts, with children stuck in emergency departments for weeks or even months at a time. They're essentially living there, waiting for what their ultimate care site is going to be. We had children in the ED going to school and returning “home” to the ED. The staff are so distressed when they see that happening day after day.
We rightly focus on the frontline caregiver when talking about moral injury and distress, but this also applies to managers, vice presidents, the C-suite and others who also went into health care because they wanted to help. They want patients to get the best care, and they, too, see that systems are failing. That explains, in part, why turnover in health care leadership is so high. In some of these roles, you can only do it for so long, and then you try to find a setting where you can contribute, but maybe with a little less personal distress. It is the same thought process that frontline caregivers are struggling with.
Being a nurse manager, for example, is one of the hardest jobs in the world. We expect so much from them — all of our quality and safety initiatives, patient experience, workplace wellness, staffing shortages, and more. They manage units 24/7 and typically are responsible for 70 to 100 or so staff members. On top of that, they spend much of their time trying fill positions and dealing with some of these escalating problems, like workplace violence.
I was at UMass Memorial during the pandemic. After the acute phase of COVID had passed, capacity issues were still worsening and stress continued to rise. During that time, I found leadership listening sessions to be helpful.
I invited our hospital leaders to join me over lunch and share their experiences. I talked about feelings I had, for example, getting in the car to go home at night and thinking about the day and what I was or was not able to do. Once you give people that opportunity in a safe space, they quickly start to share their thoughts and feelings.
Patient Safety Beat: The Schwartz Center is known for promoting compassionate care with Schwartz Rounds. How does that program help address burnout?
Michael Gustafson: Those who participate in Schwartz Rounds — nurses, physicians, administrators, frontline service workers, and others — find emotional relief and stress reduction and, ultimately, lower levels of burnout. But that is only one benefit of the program.
Panelists who present and discuss the patient story or theme around which each event is structured can be anyone who works in the hospital, which advances relationships and teamwork. The process helps reduce hierarchies and silos, as well as feelings of emotional isolation. We have good data showing Schwartz Rounds improve communication, respect and understanding among team members and expand awareness about how different people function and what they bring to the table. For individuals, Schwartz Rounds have been shown to reduce psychological distress by 50%.
I learned recently about a group in New Jersey that offers an example of how to use virtual Schwartz Rounds to support clinicians. The New Jersey Nursing Emotional Well-Being (NJNEW) initiative reports having held more than 100 virtual rounds, with over 200 panelists and 5,000 nurses participating within the last couple of years. The program is open to New Jersey nurses in all settings: prisons, schools, public health, acute care, post-acute, and so on. They have found that the issues are common enough across settings that they can have really meaningful discussions. And they have expanded with additional specialty-focused Schwartz Rounds to process the issues unique to each group or setting. The feedback on this effort has been tremendous!
