Pebbles in the Shoe: A Multidisciplinary Program to Identify and Resolve Workplace Inefficiencies in a Pediatric Oncology Division

Authors

• Reeja Raj, The University of Texas MD Anderson Cancer CenterFollow
• Kate Gazouleas, The University of Texas MD Anderson Cancer CenterFollow
• Pavilia Francis, The University of Texas MD Anderson Cancer CenterFollow
• Nancy Gordon, The University of Texas MD Anderson Cancer CenterFollow
• Vidya Gopalakrishnan, The University of Texas MD Anderson Cancer CenterFollow
• Amy Heaton, The University of Texas MD Anderson Cancer CenterFollow
• Ishwaria Subbiah, The University of Texas MD Anderson Cancer CenterFollow
• Priti Tewari, The University of Texas MD Anderson Cancer CenterFollow
• Harjeet Singh, The University of Texas MD Anderson Cancer CenterFollow
• Aaron Walton, The University of Texas MD Anderson Cancer CenterFollow
• Shehla Razvi, The University of Texas MD Anderson Cancer CenterFollow
• Martha Askins, The University of Texas MD Anderson Cancer CenterFollow
• Lisa Triche, The University of Texas MD Anderson Cancer CenterFollow
• Karen Moody, The University of Texas MD Anderson Cancer CenterFollow

Document Type

Brief Report

Abstract

Introduction: Occupational burnout is a significant concern among pediatric oncology faculty and multidisciplinary staff, characterized by emotional depletion, detachment from work, or a diminished sense of professional achievement. Inefficient work processes can be important contributors to burnout. This report describes the implementation and outcomes of Pebbles in the Shoe (also referred to as Pebbles), a pediatric division–wide initiative designed to address workplace concerns and inefficiencies.

Methods: The Pebbles program was developed and led by our pediatric division's wellness task force. Division members were invited to anonymously submit work-related concerns and irritations through a QR code–accessible electronic form. Five discipline-based work groups reviewed concerns monthly and developed potential solutions. Submissions, work-group responses, and resolution status were formally documented and made available to division members. Resulting actions were communicated through announcements, emails, and/or newsletters. Program implementation and quantitative and qualitative analyses of submissions, responses, and resulting organizational actions are described.

Results: From program initiation in March 2022 through July 2026, 206 Pebbles were submitted (about 1 per week), with 96.1% (198/206) classified as resolved. Submissions encompassed multiple categories of concerns, including explicit workplace efficiency (e.g., workflows, email overload, understaffing) as well as communication, physical environment, policies and procedures, and clinical or psychological safety of both patients and staff. Pebbles were assigned most frequently to administrative/operations (62/206 [30.1%]), nursing/patient service coordinators (63/206 [30.6%]), and clinical faculty and providers (65/206 [31.6%]). Responses ranged from providing information or clarification to implementing changes within individual work groups, across multiple teams, or at the divisional or institutional level. Pebbles resolutions and responses were shared at department/division meetings and through emails and newsletters.

Discussion: The Pebbles program was widely used across the division and provided a structured process for identifying and addressing workplace concerns raised by faculty and staff. The high volume of Pebbles submitted over time suggests that division personnel are using the program. The anonymity of the submission process may have promoted participation in a psychologically safe manner. The overall transparency of the process along with the high rate of successful Pebbles resolutions may have strengthened confidence and trust in the program. The Pebbles program reinforced that everyday occupational frustrations can be resolved with collaboration among faculty, staff, and leadership. A structured, multidisciplinary approach to identifying and resolving these concerns may help improve workplace efficiency and support professional well-being. Further evaluation is needed to determine whether the program produces objective improvements in burnout among providers and staff.

DOI

https://doi.org/10.52519/ACEQI.26.2.2.a15

Grants and Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.

Recommended Citation

Raj R, Gazouleas K, Francis P, Gordon N, Gopalakrishnan V, Heaton A, Subbiah I, Tewari P, Singh H, Walton A, Razvi S, Askins M, Triche L, Moody K. Pebbles in the Shoe: A Multidisciplinary Program to Identify and Resolve Workplace Inefficiencies in a Pediatric Oncology Division. Advances in Cancer Education and Quality Improvement. 2026; 2(2). doi: https://doi.org/10.52519/ACEQI.26.2.2.a15.