Commensality – or bring back the lunch break

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Mayo Clinic is widely acknowledged to be a high-performing academic medical centre delivering excellent care to patients. Established more than 150 years ago, it is a not-for-profit system led by doctors and based on multispecialty medical practice. At our annual conference, one of Mayo Clinic’s leaders, Steve Swensen, shared learning and found a receptive audience.

Steve explained that Mayo Clinic appeals to the intrinsic motivation of its 64,000 staff to provide the best possible care to patients. Decisions are made through consensus in a system he described as a democracy, not an autocracy. A key belief is that staff will perform to the best of their abilities if they are valued, supported and encouraged both to carry out their work and improve it.

Mayo Clinic acts on this belief by seeking to promote ‘joy in work’. It does so by building social capital and inter-connectedness between staff. A practical expression of this is the commitment to promoting opportunities to improve ‘commensality’, for example, by staff sharing a meal together. As an academic medical centre, Mayo Clinic has even carried out a randomised controlled trial to demonstrate the benefits of commensality.

Notwithstanding these efforts, staff stress and burnout are a challenge in Mayo Clinic just as they are in other health care organisations in the United States, albeit at lower levels. Research has shown that staff burnout is correlated with leadership behaviours at all levels. Five behaviours have been shown to be important in creating a climate in which burnout is minimised.

These are appreciating the contribution of staff, seeking their ideas, being transparent, showing interest in their careers, and being inclusive. Leadership development at Mayo Clinic focuses on embedding and enhancing these behaviours as part of a wider strategy to value and support staff. There are strong parallels with the work of Michael West and colleagues, which has highlighted the links between organisational cultures, leadership and staff engagement.

Steve’s talk was a reminder of the importance of ‘softer’ factors in explaining organisational performance. It was also timely in the light of the General Medical Council’s recent warnings about staff morale and the damaging effects of the junior doctors’ dispute. Creating time to talk – and doing so over a meal – are simple steps that may help in rebuilding trust and restoring fractured relationships throughout the NHS. One of the trust chief executives who heard Steve speak reflected that in her organisation a decision had recently been taken to stop providing refreshments.

Listening to the experience of Mayo Clinic I was reminded of a wonderful book by Arie de Geus entitled The living company. I discovered this book after meeting the author when I was working on secondment as director of the strategy unit in the Department of Health in the early 2000s. Arie’s writings reflect his experience in Royal Dutch Shell, and his argument that successful companies see themselves as living communities. They follow many of the same precepts as Mayo Clinic and often achieve similar exceptional results.

Arie told me that in any big and complex organisation such as the NHS, the answers to many of the challenges faced by the organisation are to be found within. The role of leaders is to discover these answers by working with staff and supporting them to make improvements. This simple but profound insight has continued to influence my thinking ever since, as in our work at the Fund on reforming the NHS from within.

So where next?

‘Bring back the lunch break’ may not be the most radical call to arms but in its own way it could be revolutionary. We are beginning work at the Fund to better understand the apparent disconnect between frontline clinical staff and trust leaders, even in high- performing organisations, and what might be done to bridge the divide. Creating time for staff to meet, and to do so in a spirit of collegiality and fellowship, could be part of the solution.


Sandy Glossop

Comment date
16 November 2016
Is it just a happy coincidence that the Mayo Clinic appears to be promoting some of the ideas of Elton Mayo the industrial psychologist of the 1920/30's - see Hawthorne effect , and also of McGregor , Theory X & Theory Y, both sets of research sugest people work more effectively if they are given control of what hey do and that their contribution is valued

Alan Fisher

Clinical Effectiveness Facilitator,
NHS Lothian
Comment date
17 November 2016
Always worth revisiting & reinforcing 'old wisdom' about benefits of colleagiality: in this case space to talk, especially over food.
It would be helpful to have a link to the reference about "Research has shown that staff burnout is correlated with leadership behaviours at all levels": felt a Ben-Goldacre-asks-what's-the-primary-source moment coming on .....

john kapp

Comment date
17 November 2016
Well done, Chris, for another great annual conference. You are absolutely right. The origin of the word 'company' is 'con pane', 'with bread'. One of the defining lessons in Dr Jon Kavbat-Zinn's Mindfulness Based Stress Reduction (MBSR) course is eating a raisin. This simple act is used as a teaching to taste your food, and hence inhabit your body, rather than your mind, to become present. This is the essence of emotional intelligence and leadership. Keep up the good work.

Bev Fitzsimons

Head of Improvement,
Point of Care foundation
Comment date
19 November 2016
We agree Chris - this is also why Schwartz Rounds can help to support staff - gathering together to talk and reflect

Damian Roland

Comment date
19 November 2016
Thanks - interesting insights. Reminds me of a comment my dad made when I was a medical student. Was a little irritated with it at the time but makes more sense now (especially as I am now a consultant)

“The day we stopped having lunch together as consultants was the day when healthcare got worse in the NHS”

My own blog reflecting on your thoughts..

Steve Swensen

Medical Director, Leadership and Organization Development,
Mayo Clinic
Comment date
22 November 2016
Great to spend time with you at the King's Fund and have a few extra days to explore your wonderful country. Thank you.

Some of you were interested in a few references of studies I cited:

Swensen SJ. Leadership by design: intentional organization development of physician leaders Journal of Management Development.;35(4)549-570. DOI: DOI 10.1108/JMD-08-2014-0080

Swensen S, Kabcenell A, Shanafelt T. Physician-organization collaboration reduces physician burnout and promotes engagement: The Mayo Clinic experience Journal of Healthcare Management 2016; 61 (2):105-27

Swensen SJ, Dilling JA, Mc Carty PM, Bolton JW, Harper CM Jr. The Business Case for Health-care Quality Improvement. J Patient Saf. 2013 Mar; 9(1):44-52. PMID: 23429226 DOI: 10.1097/PTS.0b013e3182753e33

West, C.P., et al., Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med, 2014. 174(4): p. 527-33.

Kniffin, K.M., et al., Eating Together at the Firehouse: How Workplace Commensality Relates to the Performance of Firefighters. Human Performance, 2015. 28(4): p. 281-306.

Umesh Prabhu

Medical Director in NHS for 16 years,
Comment date
01 May 2017
Dear Chris,

Very well written article and good to see Steve's comments as well. Mayo clinic, Virginia Mason, Kaiser Permanente all are doing some fantastic work and it has been a great pleasure and honour either to visit or to meet these great leaders.

However, let us not forget US spends 17% of GDP on healthcare and sadly NHS spends only 8.5% of GDP on healthcare and is dropping! US also has 40 Million people who do not have decent healthcare! This is not a criticism of any of these Institutions or their great leaders but a fact!

In Wigan, we have transformed the Trust by making patient safety everyone's responsibility and by making Happy staff - happy patients as the core mantra and we have reduced harm to patients by 90% and received many awards! We have also implemented excellent governance as well. We have done it in spite of huge reduction in NHS funding!

We have been able to do this simply by supporting our wonderful staff and making staff and patient engagement as the way we do things.

Sad reality is in many NHS Trusts there is a culture of bullying, harassment, victimisation, discrimination and so on! Until we get the culture, leadership and governance right, I doubt if we can make NHS safer or better!

NHS and Social care are two jewels in our Crown and we all need it and we all got to think how we are going to make both of them safest and the best and most vibrant.

So it is not just the lunch or coffee break but good leadership, good value based leaders, good governance and excellent staff and patient engagement! When we get all of these right our patients will receive the best and safe care and staff will be happy and NHS will be the safest and the best!

Hopefully Simon Stevens 5 years plan will have leaders who are value based and implement good governance and transform NHS and social care together! Without good leadership and good governance and excellent staff engagement, I doubt if NHS will last for more than another few years!

With Brexit, it is not NHS we must worry but the financial challenges our great nation is going to face over next 5 to 10 years!

We can transform NHS within next 5 years if we get leadership, governance, good IT and excellent staff and patient engagement. We can not only transform NHS and social care but we can save millions of pound which we can reinvest for Primary care, mental health, social care, good IT, Dementia and Public health!

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