Rest and recovery post covid: a necessary step for quality

Twitter: @ck4q @HelenBevanTweet #IHIForum
Rest & Recovery Post-Covid:
A Necessary Step for Quality
Christina Krause
BC Patient Safety & Quality Council
Canada
Helen Bevan
NHS Horizons team
England

Learning objectives for this session
1. Articulate the need for post-pandemic rest and recovery to
ensure the sustainability of our people and the healthcare system
2. Identify the multiple aspects of organizational energy and
implement strategies for addressing in the context of post-
pandemic recovery.
3. Explore how quality improvement can play a pivotal role in
people recovery and service recovery

Our agenda
• Breakout one: Getting to know our breakout groups
• Setting the context for rest and recovery
• People recovery AND service recovery
• Breakout two
• Building energy for rest, recovery and change
• Breakout three
• Highly adoptable improvement
• Case study: the NHS Horizons team
• Breakout four: pulling it all together
• Reflections and close

Breakout 1
• You will return to/remain in the same breakout group throughout the
session
• Introduce yourselves, answering the question:
When have I felt most energized at work in the last 12 months?
What was going on for me?
• You will return to the main room after 10 minutes
• Be ready to add a personal insight from the discussion to the chat box in
the main room when we return

Setting the Context
• Health Care Workers (HCWs) have endured three waves of COVID-19, each
increasingly more severe
• We face unique professional stressors on top of the uncertainty and fear
experienced by the general public
• This has taken a toll on health human resources, with early retirements, job
transitions and vacancies all at record highs

Setting the Context
At the same time, we have also been faced with the greatest global health
threat of the 21st century – climate change
Extreme weather events around the world have not only been personally
distressing, but have also placed additional burdens on our health care
systems

Approximately 5.07 million people
944,735 km2
(larger than France & Germany combined)
5.9% of the population is Indigenous
Approximately 60% live off-reserve and
40% live on-reserve
~62% of the population lives in large urban
centres, while ~14% live in rural areas
British Columbia,
Canada

CTV News Vancouver
CBC News

CBC News
CityNews Vancouver

Global News
Chilliwack Progress

Vancouver Sun
CBC News

The Canadian Press

Moral Injury
First used to describe soldiers’ responses to their actions in war
Experienced when people “perpetrate, fail to prevent, bear witness to, or
learn about acts that transgress deeply held moral beliefs and
expectations”
Can result in long-lasting emotional and psychological damage

The Time to Act is Now
The period following a traumatic incident has been shown to have the
strongest influence on recovery
Main post-incident risk factors that influence recovery are:
Access to social support
The pressure that people experience as they try to recover

Learning From the Military
Evidence largely comes from military programs:
Rest & Recuperation (R&R) Leave
Post-Operational Stress Management (POSM)
Provide military personnel with time to reconnect with family and friends
and “reset” following high-intensity operational duties
Found to reduce mental health struggles and promote well-being and
recovery from the strains of deployment

“Without a physically and psychologically
safe and healthy workforce, excellent
health care is not possible.”
– Don Berwick

18 |
People recovery AND service recovery
Service
Recovery
(delivery
capacity)
People
Recovery
(wellbeing)

Eleven things we have learnt about recovery
1. People recovery and service recovery aren’t just connected. They’re the same
thing
2. Recovery is inherently relational
3. If teams are the primary unit for recovery, we must support team leaders and
line managers as the prime enablers of recovery
4. Invest in the time and (psychologically safe) space to connect, collaborate and
innovate
5. Focus on the areas that are most important for patients
6. Undertake improvement for people and service recovery in ways that
energise, motivate and give people autonomy and control
7. Support and amplify the “positive deviants”
8. Progress is a massive energiser
9. Take the opportunity to work in new, aligned ways
10. Improvement as the default
11. Share, share, share

Source: The Progress Principle: Using Small Wins to
Ignite Joy, Engagement, and Creativity at Work
Emphasise progress
• Teresa Amabile, Harvard Business
School; studied the "inner work
life" diaries of 238 professionals
• Their best days were when they made
progress; were able to move forward in
their work
• 700 managers were asked to rank five
factors that motivate their team members,
including recognition and incentives;
They ranked “sense of progress” LAST

Breakout 2
• Your discussion questions:
What is happening for rest and recovery in my context?
What are the opportunities in aligning people recovery and service
recovery?

Energy for change

Another view:
Quality of …
Level One:
doing
(processes)
Level Two:
thinking/
decision making
Level Three:
information that
influences thinking
Level Four:
information that influences
behavior
Level Five:
relationships (information flow)
Level Six:
perceptions and feelings (culture)
Level Seven:
individuals mind-sets (personal beliefs and values)
“Engine” of quality
D. Balestracci. Data Sanity. 2009
“Fuel” of
quality

© Stanton Marris
What We Mean By Organisational Energy?
The extent to which
an organisation has
mobilised the full
available effort of its
people in pursuit of
its goals
Direction of energy
Level
of
energy

© Stanton Marris
Where organisational energy comes from
The level of energy that people bring to their work is shaped by the ‘Four
Cs’ – the energy generators
Climate: how far ‘the way we do things round here’
encourages people to give of their best
Connection: how far people see and feel a link between what
matters to them and what matters to the organisation
Content: how far the actual tasks people do are enjoyable
in themselves and challenge them
Context: how far the way the organisation operates and
the physical environment in which people work make
them feel supported

© Stanton Marris
What are the enabling and restraining factors?
Baseline energy
people bring to work
Connection
Content
Context
Climate

Energy Matrix
Corrosive Energy
Productive
Energy
Resigned Inertia
Comfortable
Energy
High
Intensity
Low
Negative Quality Positive
Heike Bruch & Bernd Vogel (2011) Twitter: @ck4q @HelenBevanTweet #IHIForum

Three Energy Traps
1. Acceleration
– High productive energy, pushed too long
2. Complacency
– Low energy zone (resigned inertia & comfortable
energy)
3. Corrosion
– High negative energy (corrosive energy)
Bruch & Vogel, 2011

Acceleration Trap
High productive energy … leading to:
– Increased number and speed of activities
– Raised performance goals
– Shorten innovation cycles
– Introduction of new management or organizational
systems
Making this pace the “new normal” … becomes
chronic overloading
Bruch & Vogel, 2011

Psychological
Physical
Spiritual
Social Intellectual
Teams perform best when five energies are high
Source:
https://nhshorizons.passle.net/post/102f
6wr/coaching-nhs-leaders-to-build-
energy-for-change
The NHS energy for
change model

Social energy
Energy of personal
engagement, relationships and
connections between people
It’s where people feel a sense of
“us and us”
rather than
“us and them”

Workers who feel
connected to their
colleagues are
three times as
likely to report
that they
maintained
pre-pandemic
levels of
productivity
https://sloanreview.mit.edu/article/what-youre-getting-wrong-about-
burnout/?social_token=4df7d91cfd5e8fca190db7c686480995&utm_source=twitter&utm_medium=social&utm_campaign=sm-direct

Spiritual energy
Energy of commitment to a common
vision for the future, driven by shared
values and a higher purpose
Gives people the confidence to move towards a
different future that is more compelling than
the status quo

Psychological energy
Energy of courage, resilience and feeling
safe to do things differently
Involves feeling supported to make a change and
trust in leadership and direction
@HelenBevan #improveUEC
Psychological energy is high when social and
spiritual energy is high

Physical energy
Energy of action, getting
things done and making
progress
The flexible, responsive drive
to make things happen

Intellectual energy
Energy of analysis, planning and thinking
Involves gaining insight as well as planning and
supporting processes, evaluation, and arguing a
case on the basis of logic/ evidence

The challenge of over-focus on intellectual energy
• Intellectual energy on
its own isn’t
transformational
• It keeps leaders in
their comfort zone
(intellect to intellect)
• Common values drive
behaviour change
more than data
http://www.newyorker.com/magazine/2017/02/27/why-facts-dont-change-our-minds
You can’t change fundamental behaviours without changing fundamental beliefs

High and low ends of each energy domain
Social isolated solidarity
Spiritual uncommitted higher purpose
Psychological risky safe
Physical fatigue vitality
Intellectual Illogical reason
LOW
HIGH

Breakout 3
We will move back to our breakout groups
How do we build social and spiritual energy for change
to support rest and recovery?

Highly Adoptable Improvement

Impact of Change on Workload/ Capacity
Workload
Time
Baseline
Zone of
change
Post implementation
of change
Unchanged
More workload/
less capacity
Less workload/
more capacity
Source: Hayes & Goldman, 2018

Cumulative Impact of Change
Time
Workload
Unsustainable
Acceptable
Ideal

Impact of Change on Perceived Value
› People are not passive recipients of change; they evaluate, seek meaning and
develop feeling towards change
› Perceived Value
the willingness/ readiness of individuals to adopt change when they believe the
outcome will be of value to them (or things of importance to them.)
› Emotional = That will save lives!
› Practical = I can see myself doing that new practice
› Logical = That new process makes sense

Hypothesis
› Initiatives that do not
add additional
workload and have
high perceived value
are more likely to be
adopted, cause less
workplace burden
and, achieve the
intended outcomes
More
adoptable
Less adoptable
Perceived
value
Workload
Same
Reduced Increased
Design
For
Here!

Highly Adoptable
Improvement
Intervention
Design
Burnout, change
fatigue, cynicism,
error, workarounds
Implementation
Strategy
Sustainably adopt
improvement
intervention
-
+
WORKLOAD
VALUE
CAPACITY
Intended
outcomes
NOT
achieved
Intended
outcomes
achieved
* The person icon represents the collective recipients
of the change; those individuals required to carry out
the tasks associated with the intervention
How we are asking
people to do it
What we are asking
people to do

Highly Adoptable Improvement
Selected Factors Associated Questions
End-user participation Are end-user staff/ physicians involved in the change?
Alignment and planning Does the change initiative align with the organization’s and/or team’s
goals and has the rollout been planned effectively?
Resource availability Are the required resources (training, equipment, time, personnel) for the
implementation of the change initiative known and will they be made
available?
Workload How much workload (cognitive, physical, time) is associated with the
intervention?
Complexity How complex is the change intervention?
Efficacy What degree of evidence and belief is there that this intervention will
lead to the intended outcome? Source: Hayes & Goldman, 2018

Rest and recovery for our team: NHS Horizons
The Horizons team is a small, specialist team within the English National Health Service.
Horizons supports leaders of change, teams, organisations and systems to think differently about
large-scale change, improve collaboration, and accelerate change

We have had a continuous improvement project to
improve the wellbeing of our people since 2016
Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS) © NHS Health Scotland, University of Warwick and
University of Edinburgh, 2008, all rights reserved.
• We use the Short Warwick Edinburgh Mental
Wellbeing Scale to measure our wellbeing every
week
• It is a scale which has been validated for the
measurement of mental wellbeing among groups
of adults: positive states of being, thinking,
behaving and feeling
• The SWEMWBS practitioner guide:
https://www.corc.uk.net/media/1244/wemwbs_
practitioneruserguide.pdf
• Information about the short version of the scale
that we use: https://www.corc.uk.net/outcome-
experience-measures/short-warwick-edinburgh-
mental-wellbeing-scale-swemws/
It is free to use but you need to register for it first: https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/using

Survey tool: Short Warwick-Edinburgh Mental Wellbeing Scale:
https://www.corc.uk.net/outcome-experience-measures/short-warwick-edinburgh-mental-wellbeing-scale-swemws/
Our team wellbeing scores 2020
Team starts
virtual working
0
10
20
30
40
50
60
70
80
90
100
none of the time rarely some of the time often all of the time % average score
Initiated an improvement
sprint on “managing work-
home boundaries”
%
responses

Our team wellbeing scores 2021
0
10
20
30
40
50
60
70
80
90
100
1/7/2021
1/14/2021
1/21/2021
1/28/2021
2/4/2021
2/12/2021
2/19/2021
2/25/2021
3/4/2021
3/11/2021
3/18/2021
3/25/2021
3/31/2021
4/8/2021
4/15/2021
4/22/2021
4/29/2021
5/6/2021
5/13/2021
5/20/2021
5/27/2021
6/3/2021
6/10/2021
6/17/2021
6/25/2021
7/1/2021
7/8/2021
7/19/2021
7/26/2021
8/2/2021
8/5/2021
8/12/2021
8/19/2021
8/26/2021
9/2/2021
9/9/2021
9/16/2021
9/23/2021
9/30/2021
10/7/2021
10/14/2021
10/21/2021
10/28/2021
11/4/2021
11/11/2021
11/18/2021
11/24/2021
none of the time rarely some of the time often all of the time % average score
Following a consistent decline in our wellbeing scores, we
initiated a sprint on “improving our meetings by being
clearer on the purpose of meetings and our individual roles
in meetings”
“It's heartening to
have honest and
realistic conversations
about wellbeing,
capacity etc. These
conversations are very
much valued and have
contributed to a
renewed sense of
optimism.”
Comment on the
wellbeing survey -
July 2021
This week, we had a team discussion about this
dip in our wellbeing results
We then co-designed “5 top tips” for managing work-
home boundaries and “5 top tips for reducing anxiety
and increasing relaxation”
A 30-day sprint
on building
team
relationships in
March 2021
included a
“coffee roulette”

We take action through 30, 60 and 90 day wellbeing
improvement sprints
Examples:
• Improve our meetings by being clearer on the purpose of meetings and our individual
roles in meetings (30 days) September 2021
• Building team relationships (30 days) March 2021
• Photo challenge (30 days) January 2021
• Testing asynchronous working methods (60 days) October 2020
• Managing work-home boundaries (30 days) August 2020
• Random acts of kindness (1 week) February 2020
• Focus on soft deadlines (30 days) April 2019
• Reducing multi-tasking and finding focus (30 days) June 2018
• Building resilience (60 days) October 2018
• Reflection and appreciation (90 days) March 2018
• Team communication (90 days) January 2018
• Kindness advent calendar (30 days) December 2017
• Personal well being (60 days) August 2017
• Being a generous partner in the office (60 days) June 2017

We encourage everyone in
the team to use the national
wellbeing offers
1. Focus on individual wellbeing
We aren’t all feeling the
same but there are things
we can all do, eg, create a
routine, take a proper lunch
break
Graphic by Andi Roberts

2. Resilience is a team sport: create wellbeing through
virtual meetings
The Horizons team huddle
• Always check in and check
out
• Give everyone a voice
• Agenda item no.1: team
wellbeing
• Keep your camera on unless
you’re having Wifi issues
• Focus on purpose and
meaning (Facebook:
Career/Cause/Community)

3. Use this as a time to learn and grow together
“Horizons hangout”
Sessions at least twice a week
for the team to watch recorded
webinars together and/or try
out new systems
The Know More Club
Every Monday to explore a new
area of knowledge, journal club,
mentoring conversation.
Everyone takes something away

Breakout 4
We will move back to our breakout groups for a final time
Based on this session, what actions are you going to take:
At a personal level (for your own rest and recovery)?
At a team or system level?
• Be ready to add one of the actions you are going to take as a result of
this session into the chat box in the main room when we return

“Whether we march with banners or
without - the important thing is
that we march together. All of us.
That’s what this thing has been
about from the beginning. And that
is absolutely how it is going to end.
Together. Us. United”
(Joe in Pride by Stephen Beresford)
What next?
61

Useful free resources
Follow @LizandMollie
• Supporting our NHS people – resources for
wellbeing: https://people.nhs.uk/
• ATTIC: Activities for Transforming Teams
& Igniting Change, The BC Patient Quality
and Safety Council:
https://bcpsqc.ca/resources/attic/
• The SessionLab library of facilitation techniques
https://www.sessionlab.com/library
• Remote work survival kit, Chris Weston and a cast
of thousands:
https://docs.google.com/document/d/1wCeKcivSEseEnrsnDrhnFM
QBPpdKGLdOmZmZ4miLpoM/edit#heading=h.2y39piqqv7gb
• Online meeting resources toolkit for facilitators
during the coronavirus pandemic, Facilitators for
pandemic response group:
https://docs.google.com/document/d/1NyrEU7n6IUl5rgGiflx_dK8C

Thank you!!
Questions/Reflections?

Rest and recovery post covid: a necessary step for quality

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