What are some "pebbles in your shoe"?

Diana Savitzky, MD
Port Washington New York
Chair of ACEP Wellness Section

When you think of "Wellness" you might be envisioning practicing mindfulness or meditation, enhancing your mental or personal health to build resilience or participating in social events to connect with colleagues. While these are excellent approaches to achieving wellness, the Stanford Model of Professional Fulfillment highlights they are not the only contributing factors. Often, feeling good at work simply requires improving day-to-day operations to make the day more manageable. This is exactly what the third aspect of professional fulfillment, efficiency of practice, addresses.

The Well Workplace ACEP Policy Statement was created by the ACEP Well-Being Committee this past year. We'd like to highlight #5, "Practice Environment Influences," which emphasizes the importance of improving operational flow through human factors engineering. This approach involves considering human capabilities, limitations, and unique characteristics when designing workflows. It requires a deep understanding of your team and actively seeks input from all members. This not only creates more effective workflows but also fosters greater satisfaction by giving the team a sense of ownership and autonomy in their work.

During an Emergency Department (ED) Wellness meeting at our local hospital, we discussed creating a space to address small workplace frustrations that impact efficiency. One ER doctor shared an example of spending 15 minutes searching for a COVID swab, describing it as a "pebble in the shoe" that wasted time and energy, nearly pushing them to the breaking point.

The concept of addressing "pebbles" to reduce burnout was highlighted in a non-peer-reviewed AMA article. The article describes how one healthcare system annually asked physicians to identify small frustrations-or "pebbles"-in their workday. We expanded on this idea at our hospital, creating an ongoing initiative to provide a larger platform for physicians to voice their concerns and improve their daily work experience.

So, what is a pebble problem? It's a small but irritating issue that is relatively easy to resolve, typically within three months. The rationale is that addressing these minor frustrations can lead to a significant positive impact on the workday.

The first step in the Pebbles Project is building the right team. Start by identifying leaders who can set the tone for the initiative and provide top-down support. Equally important are clinicians who directly experience daily frustrations and can contribute to designing practical solutions. Team leads play a key role in driving the project forward, managing administrative tasks such as tracking identified pebbles and assigning them to the appropriate parties for resolution. They also serve as the project's strongest advocates, educating colleagues on resolved issues and promoting engagement. In our ED, we've successfully included leaders from supply and inventory, nursing, administration, and clinical departments. The success of your project depends on assembling a dedicated, well-rounded team.

To address pebble issues, we hold bi-monthly Webex virtual meetings. These meetings provide a dedicated space to discuss problems, identify solutions, assign ownership for action items, and update the database to track progress. Consistent, scheduled time is critical-this work cannot be effectively managed through email alone. These meetings ensure accountability, foster collaboration, and help leaders better understand the nuances of issues that may not be clear from written submissions. Representation from both adult and pediatric clinicians is also important to ensure all perspectives are considered.

This project has a broad impact beyond addressing operational frustrations. It enhances wellness by improving clinical efficiency and creates opportunities for scholarship and quality improvement projects that can boost departmental productivity and positively impact patient safety. The key takeaway is that small changes can have a big impact on your department. This project is low-cost but high value, addressing everyday frustrations to improve practice efficiency and staff wellbeing.

Right now what's your biggest "pebble in your shoe"?

Would you like to start a similar initiative in your department? Let us know, and look out for an upcoming ACEP webinar for resources and support.

Diana Savitzky MD (Chair Wellness Section) & Jennifer Goebel DO (Chair elect Wellness Section)