How Quality Improvement Supports Clinician Well-Being

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How do quality improvement and clinician well-being intersect? Michigan Medicine’s Dr. Michael Englesbe, a transplant surgeon, joins Dr. Elizabeth Harry to discuss scaling change from the bedside, reducing burnout by removing unnecessary work, and lessons from Michigan’s opioid prescribing success. 

A candid conversation on leadership, standardization, humility and why empowering frontline teams is essential to better care and a healthier workforce.

Transcript

Liz Harry:

Hello and welcome to Well-Being, a Michigan Medicine Podcast. I'm your host, Dr. Liz Harry, and today we're honored to have Dr. Michael Englesbe with us. Dr. Englesbe is the darling professor of surgery at the University of Michigan. And is that right? That's right. That's what we really call it, right? The darling professor of surgery.

Michael Englesbe:

That's what I think about myself, yes.

Liz Harry:

In the section of transplantation surgery, he serves as the Department of Surgery Vice Chair for Resident Mentorship and then University of Michigan Medical School Capstone Curriculum Director. Dr. Englesbe is a renowned surgeon and change maker in the field of healthcare quality and well-being. And thank you so much for being with me today. I'm really excited to have you here.

Michael Englesbe:

Honored to be here. Thank you for the work that you and your team do.

Liz Harry:

Well, thank you. So let's start kind of at the beginning. So you were doing individual cases, you were being a surgeon, and then you got pulled into quality improvement at scale. Was there a moment that sort of flipped the switch for you?

Michael Englesbe:

Yeah, I mean, I think it's essentially entitlement, to be honest. My mentor was a quality improvement kind of icon. And within the institution, he was former chief medical officer, and he started this what we call the quality collaboratives across the state of Michigan that are a big part of my life now. So I was kind of born and raised in quality improvement, born and raised in collaboration. And then a big part of my junior faculty life was health services research. And I guess if there's a moment, it was probably after you'd written enough grants and papers, you realized that you're mostly just speaking to yourself in the work and kind of wanting to do something real, something that potentially changed practice. So essentially take the research and apply it to practice change, I think. And so yeah.

Liz Harry:

And then, you didn't go small. You went really big. You decided to do these big statewide collaboratives. What did you see there that you couldn't do in a local improvement initiative?

Michael Englesbe:

Yeah, no, I think it all started local. It's just we had this platform. So I won't talk too much about it, but it's worth mentioning. In Michigan, we have a really interesting environment around quality improvement and really we're internationally known because Blue Cross, who pays for a lot of private healthcare, really outsourced their value-based reimbursement scheme to a bunch of professor types like me at Henry Ford Health System and at the University of Michigan. And we essentially try to improve care and we keep score. And when we say improve care, what nurses and patients at the bedside think improvements is. And we measure that and try to align financial incentives in that space. So it's a really progressive program. We're really the only state that has such a robust system. And I was kind of born and raised in that, the first surgical one. My mentor wanted to start it and I was pretty good at writing things.

So I wrote his ideas down on a piece of paper. So I've been part of it since. That said, good quality improvement starts at the bedside, listening to patients and nurses and people who are actually at the bedside. So the early stuff always started there. And then if it got legs, then we would kind of scale it more broadly across the state. And I think one of the privileges of being at the University of Michigan is part of our task is to... Our calling, for lack of a better term, is to improve care in Michigan, serve the state of Michigan.

So it's kind of a natural thing where there's stuff that we figure out we're pretty good at and we could keep it to ourselves or we could try to help every nurse, every doctor, every patient improve. And it's really fun to be part of that. If you talk about well-being, being part of such an exciting community where people have ideas and we can scale them up with a big infrastructure, there's over 350 staff that work in this thing where we can scale them up and measure the impact, and it's a total privilege.

Liz Harry:

It's amazing. And you said it starts at the bedside, but in some ways it also ends at the bedside because you're actually making processes different for the end user. For the care team that's delivering the care, for the patient that's receiving the care, the goal is really to have that kind of impact at the bedside. And some listening to this might think, well, why if this is a well-being-focused podcast, on earth are we talking about quality? And so how do you think about that relationship between the work that you all do and the impact of the lived experience for the care team delivering the care?

Michael Englesbe:

Yeah, it's a great question. I think it's the basic question. It comes down to, how do you drive change? And I'll start off with my many, many, many failures. So my first big endeavor, statewide endeavor was around pre-op, I'm a surgeon, so pre-operative preparation. So the mentality was the way you might train for a 5K or something, really big operations, patients come in frail and they come in malnourished, they come in smoking, their health behaviors can potentially be changed. They're very attentive, right? If you're having a big, scary thing, you kind of do whatever the doctor says and we take advantage of that. And we were really effective in getting people to walk and to do various exercises and the change in nutrition, quit smoking. So awesome, right? Let's scale it. And we created this thing. We got a grant from Medicare and pushed it across the whole state.

And we really failed miserably because fundamentally, everyone agreed it was a good idea, but the way we went about trying to implement it was about increasing everyone's workload. And it really, candidly, it backfires because everyone wants to do the right thing. And when you dangle the right thing in front of them, but then you give them twice as much work to do, it really is not... So it wasn't successful. So what did I learn from that? I think improving care comes down to changing behaviors of the excellent people at the bedside. So how do you get them to change papers? One is you reduce their workload. You let them do work that they want to do.

And then two is you empower them as much as you can. And this is obviously not my idea, this is the basics of change management. So why are we doing this change? Give people autonomy to drive the change, and then give them tools and processes that reduce the burden of crap work, so to speak. And one of our mutual friends, Dr. Watts, who is one of these slides, actually, you gave me one of these kind of ideas too, but she talks about blue circle work and brown circle work. I just love it so much. And it's like the improvement work, brown circle work is the improvement work that you kind of have to do, and blue circle improvement work is the stuff that you really want to do. And so trying to focus the improvement on stuff that's really blue circle for nurses, for patients, and for doctors at the bedside, so that you're not just adding work, doing it on their terms and making it as easy as possible.

So how does that link to wellness? Well, I think if we're all part of something special and we're driving it ourselves, then we all want to serve the patient. And if patients are getting great care, we've all been really ranting, but there's parts of my clinical work where I just know it's an amazing team and it's just the care is unmatched and it's just energizing. And if you can create those environments, those relatively micro environments for nurses and doctors and everyone else who does care, the huge teams, then that's successful.

The challenge is, I said micro environment, micro cultures and all that, but old people like me, we got to measure big things. We want a number, and that's the tyranny of the metric. So you have to balance the measurement, which really quickly turns into things that lack nuance, turns things that are very brown circle-y, turns things that are just crap. So trying to hit that right balance of measuring it, because it is a business, you have to have measures, you have to show impact versus local control, local empowerment. So that is the challenge.

Liz Harry:

Yeah. And I mean, I love the way you frame it too, because it can be this sort of just the frontline experience is a collection of all these well-intended efforts. And there can be this perception of, does anyone have any idea of how all these well-intended efforts are sort of confluencing on one individual, and the impact of that. And it does drive this then downstream burnout, because we have all these siloed initiatives that then sort of get put in a place and can have that impact. So tell us about a time it did work then. Think about a change that did improve the outcomes you were looking at, but also maybe lifted team morale. And was it a we added something or was it we stopped doing something?

Michael Englesbe:

Yeah. I mean, probably the easiest to explain success that we had that started vocal and really we scaled, I guess around the country, was around opioid prescribing. So it really started with an observation. My day job was I'm a transplant surgeon. We do a lot of traveling around doing organ procurements. And we had this weekend where I had three patients in a row that were young, actually women. When I say young, teenage, like high school, early college, who had overdosed on opioids. And they frequently, before the donor operation, there's a little story that you try not to listen to, but I couldn't help, but we all are humans, right? And it was like a beautiful young woman, soccer injury in high school, got exposed to opioids, really struggled to stop taking them, and then actually overdosed. Next one was wisdom tooth extraction, same fricking story, all in the same weekend. In two days, three donors in a row. And the third one was a young college student who had experimented with opioids and alcohol and overdosed.

So this was a while ago before the opioid epidemic was really a thing that anyone talked about. So I was like, wow, I'm a surgeon. I write for lots of opioids. And really the idea that we as surgeons, dentists, physicians in general were doing harm, that was kind of a powerful narrative. So then lots of good collaborators, we were able to start measuring these things and appreciate that really most people who overdosed got their introduction through prescription opioids. It's no longer true, but it was true 15 years ago. And the journey from exposure to overdose is five or 10-year journey of chronic pain. And so that was kind of like the why, so to speak.

So we had a good why, do no harm. All nurses and doctors want to do that. Then kind of the how, so we basically realized in the smallest little experiment, medical student idea, this guy called every person who had an elective laparoscopic cholecystectomy at the University of Michigan over a year, like 300 and something people, and was like, "Hey, how many pills did we give you?" He looked up how many pills, and it was like generally 40. I made you take six, but about 10% of people take all of them. And they're a vulnerable population, but most people take six. So that was a little paper that we wrote.

And then our boss at the time said, "Hey, it wouldn't be easier if we all just gave everyone 15?" And everyone's like, "Oh no, everyone's going to be calling." Well, well, how about this? We're all going to give 15 now for this. That's the new rule. And I was like, okay, we made a process, and it was amazing. Like you tell a surgical resident what to do, it went from all over the place to, for the next year, everyone got 50. And then we just started asking patients how their pain was and trying to understand. And turns out talking about it, setting expectations and stuff, so we were able to improve pain care overall.

So that little experiment, which was in the perioperative space in elective surgery and the minimally invasive group at the University of Michigan, small little thing, we ended up scaling pretty, I don't want to say across the country, but kind of across the country. Started in general surgery, all the other surgical specialties. We set up a whole infrastructure with lots of good partners. Chad Brummett really was the protagonist, the leader of this. He's an anesthesiologist at Michigan. And then essentially came up with recommendations, this is how many pills you should give for a patient who is opioid-naive, which is most of the patients. And then we just set up processes where it just automatically happened. Everyone's like, "Oh yeah, we'll do that. We'll do that." Blue Cross put some incentives, so if you do this the right way. So then we just programmed it into the machine so no one had to think about it for an opioid-naive patient. And we reduced opioid prescribing by like 80%. So now most patients don't take any opioids after surgery in the state of Michigan.

Liz Harry:

Wow.

Michael Englesbe:

I'll say it again, most people take none. And people have better pain control than ever. Chronic opioid, the problem is those people that never stop taking them, that's largely gone away. So the people in five or 10 years who are going to have really problems with what you call substance use disorder addiction and heroin and fentanyl type things, that kind of pool of vulnerable people has really gone way down and it's scaled kind of across the country. So what we do, we had a good story, one. Two is, it's easy. We're counting pills, asking patients if they have pain. So it was an easy change.

And three is that we could program it into a system where electronic health record, lap chole prescription just kind of comes out. But most importantly, it was done by nurses and doctors at the bedside. So we've spent a really hard, a long time identifying patients who this wasn't going to work for. It's like these clinical rules don't work for everyone, and we're 100% committed to their most vulnerable patients. Some patients with complex pain, some people do need these pills, and we were able to improve the pain care for everyone through the process because it was so much less work to do it. So the patients who really needed attentive pain care were able to get higher level care than before. So it's kind of a long story, but we had a great why, and then we had processes that we had learned from before, just we'd had to make it as easy as possible, and now it's just kind of standard of care.

So the young physicians now who write for a lot of opioids, we used to give 50. I was like, "What? We give four now." It's just a problem that doesn't exist anymore. And everyone did their own thing and was able to create their own solutions. The one advantage is that we were counting pills, so it wasn't like measuring some nuanced clinical experience for patients who are just counting pills so we can kind of claim victory. I think there's lots of other things that groups have done that are equally awesome, but they're harder to measure.

Liz Harry:

Yeah. So what I love about the way that you did that is that you decreased the burden on the teams who were delivering the care, and you also decreased the potential downstream moral distress of knowing that potentially the narcotics that somebody prescribed contributed to an overdose or of substance use disorder. And so it's sort of a double way that you're addressing moral injury and burnout for the frontline providers as well.

Michael Englesbe:

Yeah. I mean, it was a great success. It was kind of the right place, right time where there's a lot of interest in this by patients also. We kind of started it three or four years before the opioid epidemic was in the news, so to speak. And all the top-down stuff that was done in the state level and the forms you have to fill out, we have good data showing that none of that really worked. So it really is a solution that was in the hands of people who practice medicine, which is where obviously most effective clinical solutions need to be. So definitely proud of the work. And I don't know, hopefully now we focus mostly on, I don't because it gets complicated. I'm a surgeon, I don't do complicated, but my pain doctor friends, they really focus on really precise best pain care for patients with complex pains if they need whatever, a big operation or whatever.

And we've gotten a lot better at that also. That's taken a longer period of time. And one of the things we're proud of, and I never really thought of this, is these types of interventions, they're really great. They're particularly impactful for vulnerable patients. So everyone wants to wake up and feel like they're serving or really our most vulnerable folks. And interventions like this, or the other big one that we work on is smoking cessation. You come into a fancy building, we got to get you, at least to give you the opportunity. Every time you're having a baby, having your spine straightened, or you're seeing your primary care provider, any of the above, we just got to give you the opportunity. And those types of interventions are really, I think, impactful health equity-based interventions for vulnerable patients because disproportionately, our vulnerable folks have more kind of burden around health behaviors and some chronic diseases.

Liz Harry:

So if somebody's listening to this and they're feeling really motivated and they're like, "I want to fix the system. I see areas where either something about the care we're delivering, I don't feel like it's the best quality of care or I want to improve something, but I feel overwhelmed. I feel overloaded by all those tasks that you just talked about." What is one thing they could do next week to try to get involved in improving some of these systems if they're still really feeling inundated and kind of overwhelmed by them?

Michael Englesbe:

Yeah, it's a great question. And I think we all feel overwhelmed, particularly some of the really great clinicians, because they see it all. They see all of the noise that's so important to understand. And so I have a lot of respect for the bedside medical assistant who just seeing the complexity on the bedside, the clinicians who see patient after patient after patient. So what can they do? I think our opioid thing was pretty simple, but it really was started by a medical student going to an ambulatory surgery center, talking to the charge nurse, understanding their perspective and just counting a bunch of stuff, counting pills, counting discs, calling patients. So to answer your question, fix the problem right in front of you and don't complain about it. So I'll say it again.

Liz Harry:

Yeah, I love it.

Michael Englesbe:

I guess you can complain to your friends, but just don't complain and say, all right, whatever this small thing, that's empowering. That's wellness as if... And most folks, I think, unfortunately, don't necessarily feel like they have the power or privilege to do that, and I won't criticize that sentiment because I don't have their lived experience. But I can speak as a leader, if someone comes to me with a solution, yeah, someone comes to me with a problem, I'm just like, "Oh, add it to the list." So, oh yeah, this thing was a thing and then this is what I think we should do. So I just started doing it and it seems like it's working.

So I think try to fix your own problem. It's kind of what I tell my kids, "Fix your own fricking problems, kids." So I guess that's my answer. It's a little entitled to say that, but most, I always reflect on our liver transplant program 10 or 15 years ago, we were struggling. And our leader, Chris Sonnenday, he really empowered every social worker, every nurse to work at the top of their pay, just culturally, just brought it all over. Everyone through autonomy, left, right, and center. And now we have the best liver transplant program in the country.

It took a long time, but it's all about good leadership, giving people who see the problems the space to try to fix it. What leaders need to do is give people space, which is hard because it's a business, we got to fill the ORs, the shifts must be full. We have to have a certain number of patients, yada, yada, yada. So I think what leaders need to do is we need to provide some amount of slack to people to do that creative kind of work, to do that improvement. I think that's what we need to do too, is what's on... So people who I think do it well, one thing they all have in common is they are efficient. So if there's someone young trying to, what's a skill to really work on? I think being efficient, because it's always overwhelming. Some people can do it more efficiently than others. So learning tasks to make you more efficient.

So some of the stuff I actually learned from your office, just make the electronic health record work for you. If you read my notes, you'd be like, "Oh yeah, they're adequate. They're not..." You don't read my notes to find the grand truth. I respect that, but generally, I use tools to make things work for me. So then I have bandwidth to try to, I think, what I would call fix real problems.

Liz Harry:

What I love about what you're saying, and there's several times you've touched on this idea of standardization, and sometimes standardization gets a bad rap because physicians in particular will bristle at it and sort of say, "I don't want to do cookbook medicine." And I've always thought standardization is really helpful, because when you standardize that post-lap chole prescription, that's something I don't have to think about that I can think about something else. When you, to your point, build processes and build systems that take some of that cognitive load off so you can think about the more complex things, that frees up cognitive bandwidth. What is your position on this sort of standardization customization tension that we feel in healthcare right now?

Michael Englesbe:

Yeah, great question. I think that the subtext of the fighting against standardization is this hubris or autonomy thing. And I think really great clinicians, I think they need to come to work and try to see if they can make as few decisions as possible and let people, other people make the decisions. So again, there's things, you're the expert, you have to make a decision once in a while, but not very often. The teams are so amazing. Let the teams do it, let the pathways work, let the standard, care less about the stuff that doesn't matter very much. So perfect example is things we do well in transplant surgery. So transplant surgery has a standard care pathway for immunosuppression, always has.

No one gets to do their own thing. Transplant surgery, if you do a liver transplant, there's a liver transplant tray and everyone uses the same instruments and we have to put our clamps on the same way and go about the operation the same way so that our anesthesia providers know what to expect. So anyway, so we standardize everything so that for safety's sake, and certainly we all have our little kind of things, nuances and things like that, but not very many. And that's how you make a scalable transplant program. So I think maybe why I do quality improvement is I've been born and raised in a clinical practice where my actual autonomy was maybe less because it doesn't matter. It just doesn't matter. I've been doing surgery for 30 years.

And the amount of work that our excellent care teams do to try to take care of us, oh, well, Dr. Smith likes this, Dr. Jones likes that. And that is just such wasted angst for them. So what's the moral of my story? I think that the bogeyman or the kind of the tyranny of clinical hubris by physicians who think their way or the highway, is it big? If there's one thing I could change, I would make that go away from our organization. I would just make it go away. None of us matter very much. It's all about the team. Every decision's about the patient and how it works into the care pathways. And we would essentially more and more standardize processes that are best suited to be standardized. Now, every patient is different. That's where the art piece comes in, but so much of it should be standardized. And I think nurses culturally get that more than physicians, but we want our autonomy. And so anyway, where's my balance? My balance is around, I think there's a lot of jerks in the hospital and I like a no jerk zone. And-

Liz Harry:

There's a book about that.

Michael Englesbe:

Oh, is there? Yeah.

Liz Harry:

Well, so it's called something close.

Michael Englesbe:

I'm a surgeon, so there's a lot of surgeons who... I did 10 years of residency, so now I can be a jerk, right? And I think that in working with... It's funny because the clinicians have stereotypes. I work really closely with the anesthesiologists and they don't have this problem because they switch from room to room all the time. They have multiple rooms. So everything's very standardized. They work so well together. And I think I've learned so much from my anesthesia colleagues around how they do care handoffs because it's so high stakes, right? How they do care handoffs and how they all work to have unified care pathways. And I think at least in the surgical world, there needs to be more and more of that for a hundred reasons, not the least, which is I think it's a really big burden on everyone else on the team when there's these micro cultures of trying to keep Dr. X or Dr. Y happy.

Liz Harry:

I also think it drives burnout in a certain way because there's then so much variability in how we do things that if you don't happen to have strong preferences around some of those things, you walk into a clinic room and then it's different every time because of whoever was in there before you or whatever, and that drives cognitive load for all of us. And so the more that we can just know what to expect, I think the better. But retiring some of these entrenched habits is hard. And so how do you either change culture or de-implement something without taking a big hit to morale?

Michael Englesbe:

Yeah, I think it's a leadership thing. I'm only a surgeon, so I only know that environment. I think the senior physicians need to defer to the junior physicians. It sounds like a small little thing, but my tactic is, "Hey, Dr. X." My partner's 10, 20 years junior to me. "Can you come help me with this part of the operation? You're better at this than me." It's a powerful statement, but it just diffuses hubris and then you empower the more junior people and then you try to make their way of doing it the standard processor pathway.

So at some point, you're pretty good at what you do clinically, so you can adapt. All right, I'm going to start doing it a little bit differently because this is the way these young guns are doing it, and that'll be our new pathway. And plus, they're probably better at it anyway. Surgery gets better, they're slicker. It turns out your hands are better when you're 35 than they are when you're 54. So I watch my 35-year-old partners and they can do stuff I can't do. So that humility I think is just intentionally, with authenticity, don't get me wrong, but that humility I think is really powerful for everyone in the clinical environment to say, "Well, it's a high reliable environment. I can call things out, and it's okay to change."

And that change, it's just like our cultural change as a medical school needs to be informed by our medical students. Our clinical culture or our clinical practice need to be informed by our senior house officers and our assistant professors. I think that's the right thing. There's master clinicians who need to make sure it stays with them. But the processes and the cultures need to be informed by those individuals. And our leaders, our job is to realize that. And how do I realize that? We defer to it and then it just happens.

Liz Harry:

So I love that. And I see where you're going with that, but let's make it explicit. Why? Why do we defer to them? Why are they the ones that should set the tone?

Michael Englesbe:

Yeah, two reasons. One is they have... I think generations are more collaborative. Two is that I think it aligns with what our patients expect. And three, I just think they're better trained at the professionalism and the culture that's necessary to really live this high reliability environment that we hope-

Liz Harry:

I would just add one to that, which is that whether we like it or not, they are the future of medicine and then they're going to do it their way anyways. And so it's part of how do we build a system that invites them into it and their way of doing things? A lot of times I would get pushback from folks when we started talking about burnout, and they would say, "Well, maybe we're just naming something that was always there, but we didn't call it burnout in my day. And should they be experiencing burnout?" And there was all this judgment about the experience that people were naming. And my position was that our job is to address distress. They're naming a distress. And whether we like it or not, this is their lived experience and they are the future of this field. So we should do something about it. And so I would add to what you're saying, just that whether we like it or not, it's going to go their direction anyways because they're going to take it over from us when we all retire.

Michael Englesbe:

Yeah, I love that. And I think the one thing I'll add, and this is like, I think for most folks, they don't think that, I don't know, things, people who misbehave, for lack of a better term, lack kindness, they don't think they're remediated, and obviously they're not enough. But your job as a leader is to have hard conversations with individuals when they are polluting that culture early. Early. Hard candid conversations. I think this is a problem. And that's something that I think leaders just need to do. And I think really great leaders do it. And they do it around just like nuanced cultural things around how people behave, how they talk to other clinicians.

And then importantly as an organization, I think we do a great job of this, is you just never settle on who you hire. And that's where I think we're so privileged here. We have such great care teams, nurses and the physicians. There's so much amazing human resources in the organization, because we know it just takes one person out of 50, they cast such a huge cultural shadow in the organization. We should have zero tolerance for that type of thing. And that's something that, I guess for my professional development, I've really had to work on because it is not easy to do that work.

Liz Harry:

Yeah, it's not.

Michael Englesbe:

Yeah, some of the structures really do work against it. But for nurses and physicians I work with, I kind of hope that we'll get feedback and opportunities to improve. And really great individuals want to hear that feedback.

Liz Harry:

So we're sort of talking about the future and talking about how to build the workforce of the future and healthcare of the future. What trend or policy shift are you seeing that gives you real optimism about care value and workforce well-being looking forward?

Michael Englesbe:

Something that gives me optimism about the future, actually, it's a very kind of self-serving thing, but I see a lot of momentum towards doing fewer stupid things that were just hard for the sake of being hard. Perfect example, we used to do about half of our transplants at night. And I'm old, man. If I'm up all night, I'm not right for a couple days. And you couldn't really do transplant after what is in particularly old age because you just can't stay up all night. The young guys can kind of do it, but it's not good for anyone involved. So anyway, we have some new technologies where we put these organs on devices and we do them in the morning and we never stay up at night anymore. I say never, but 95% of the time, we do all our transplants during the day. And the ripple effects of that for our nurses, ourselves, our patients has really been a humbling experience.

So we used to struggle to get a lot of nurses to want to join the transplant team in the operating room because they'd do a ton of call and they'd be up all night all the time. And it was just like hard job and they have busy lives and families. And it's just like, now we have the best team. Everyone wants to be on the team because it's day work and we're nice people. We have transplant surgeons who are hungry to do operations because they're not exhausted. We're doing the most transplants we've ever done. So people are getting more transplants done, saving lives. And then we're doing other operations too, and we're getting home for dinner every night. So it's taken a while for, at least in transplant, for us to appreciate that it turns out you're not as good when you're up all night. And it used to be this badge of honor.

And I think the younger folks, they demand sanity in the way we do our clinical practice. And in retrospect, it's like better for patients. It's better for all the downstream teams. And someone like me, I could demand it happen at night and they'd all have to fall in line and all that. And that's just like... So having been introduced to a new technology, having been introduced to cultural norms of young, kind of a generation or two junior to me, what their expectations are around their life, has been just... It's going to add 10 years to my career, because my lived experience is like, I feel great. Let's do another transplant. Sign me up. I'm not nearly as exhausted and I'm much more well really than I've been in years.

So the moral of that story is one, some new technology. Two, some drive from a younger generation around expectations. And really, I'm excited about just learning the kind of new way that is better for our teams. And the ripple effects of that are just so huge for everything we do, both in the hospital and at home, so to speak.

Liz Harry:

What I love about the whole message is you're not resisting the change that's coming. There isn't this story of, well, in my day. It's like, this is great and this has really good downstream effects for everybody. And maybe the new and the different isn't scary. Maybe it's not a bad, scary change. Maybe it's okay.

Michael Englesbe:

And the change too is like, oh, it's stupid to stay up all night. Of course it is. It's such a big cultural part. And I'm sure there's lots of other stupid things I'm doing on a daily basis and I look forward to realizing what those things are. So I think care is the best it's ever been in my career, and I'm more excited about being part of it than ever. And I think it's just going to continue to improve with the amazing teams that we have here and the new innovations and technologies, and a commitment to take care of ourselves. I didn't realize it, but yeah, now that as a bunch of transplant surgeons, as middle-aged ones who used to work too hard, now we're doing our best work because we're on our A game all the time and we're not up one night a week trying to work the whole next day. And so anyway, it's an exciting time.

Liz Harry:

I love hearing all of this, and it really just is inspiring to me because there's this whole model of Well-Being 0.0 was kind of the era of distress, and you described it, it was a badge of honor. It was like, I stayed up all night and look how tough I am. And then 1.0, we do a lot more of this kind of community building and individual resilience. Did you do your yoga today and all of that, and that we're a little adversarial, the frontline and administration.

And then Well-Being 2.0, and this is from a paper TD Shanafelt and some of his colleagues wrote, but Well-Being 2.0 is really that we look at this as an academic problem and we look at it as a problem to solve together and we're not sort of blaming one another. We're saying, "How do we look at this from a system lens to try to build systems that work so this is a sustainable job so that people can continue to do this?" And that we've built something that you don't have to not have a life outside of this and you don't have to be physically unwell and you don't have to sacrifice your health and only do this in your younger years, but this is actually something we can do.

And I hear you kind of describing this journey from Well-Being 0.0 to 2.0 in transplant medicine. So that's really exciting. So we're going to do a quick lightning round. I'm going to ask you just a couple questions. So one myth to ditch. So a myth about quality improvement or burnout that you'd love to retire.

Michael Englesbe:

Yeah, don't resist the cultural interventions.

Liz Harry:

I love that. I love that.

Michael Englesbe:

We have t-shirts for everything. So great example story, so we had a heart case and we went through all the blood and patient did great, but it was like five surgeons, five anesthesiologists, heart case and our Seth Waits, one of our partners, basically went down to the blood bank and was like, "Hey, how many people does it take to give us a hundred units of blood in four hours?" And like 50. So he went and he said, "Okay." And he basically brought down 50 team transplant T-shirts to the blood bank, people we never really see. What's the moral of that story? Those little things, those team endeavors that we all kind of sometimes dread, like the T-shirts, those are really powerful tools for all of us. So anyway, when there's a birthday launch, show up. So don't... Yeah.

Liz Harry:

I love that. So playbook pick, and this kind of goes with what you're saying, but one tool or template that you would give every clinical leader tomorrow.

Michael Englesbe:

Try to see how few decisions you can make.

Liz Harry:

Oh, I like that. Yeah. And like, empower your team.

Michael Englesbe:

Empower your team.

Liz Harry:

Okay. Metric, one signal that you'd keep if you had to throw everything else away.

Michael Englesbe:

Yeah. I think I might go for two. One is some metric of patient access to our system. I'm not really sure what it is, but from when they call to when they're seen, I think that's so much stress for patients before they can access the system. I know it's so hard, everyone's working as hard. I may throw another one there. I think mortality is an actual measure that is important for hospital-based care. Nuanced, don't get me wrong, but in transplant, it's a big part of our care pathways and things like that. So I'm going to go access and mortality.

Liz Harry:

I love it. And call to action, one stop-doing experiment that listeners can try this month.

Michael Englesbe:

Stop doing... I don't know. I always say stop sending emails that are more than four sentences.

Liz Harry:

Please, please stop sending emails.

Michael Englesbe:

By sentence five, you should call someone and talk to them.

Liz Harry:

Yes. Or just call them and talk to them because we don't do enough of that.

Michael Englesbe:

Call and talk.

Liz Harry:

I agree. Yeah. Yeah. I love that. Dr. Englesbe, thank you so much for sharing your insights and experiences with us today. Your leadership is making an enormous difference for both our patients and providers in Michigan and beyond. And to our listeners, thank you for turning into the Well-Being, a Michigan Medicine Podcast. For more on Dr. Englesbe's work and resources mentioned today, please click on the links in our show notes. Thanks so much for being here.

Michael Englesbe:

All right, Dr. Harry. Thank you. Cheers.