Helping team members be their best: Implementing change in the hospital (Proceedings)

An organizational culture consists of the values, beliefs, traditions, attitudes and behavior of the practice and the people that work in it. It's stories about "How we do things around here." It is maintained and carried on by everyone who works in the practice, from the owner to the most part time kennel person. When it comes to making big changes in a practice, the culture of the organization becomes very important. Healthy systems support and encourage changes, along with the growth of individuals on the team, while unhealthy systems prevent it. When you want to implement changes in your practice, for example when you get home from this conference intending to improve your hiring system, how will you be received? Will you be allowed and encouraged to implement what you've learned?

Stephen Covey says that "An organization is made up of individuals who have a relationship and a shared purpose. The highest challenge inside organizations is to set them up and run them in a way that enables each person to inwardly sense his or her innate worth and potential for greatness and to contribute his or her unique talents and passion to accomplish the organization's purpose & highest priorities."

Peter Senge's book "The Fifth Discipline" talks about five stages or levels through which decisions are made and goals are reached. There are many decisions reached in a busy veterinary practice every day, and each will lead to change, whether big or small. Some are simple – which brand of paper toweling should we buy. Others are complex – what should our medical protocol be for hemorrhagic gastroenteritis, or how much money should we budget each year for marketing. Most people don't blink when you change your brand of paper towel. The larger the decision and the more dramatic the change necessary to implement it, the more you will need to manage that change.

Some decisions are made on-the-spot by individuals. Others involve a group of people – the receptionist team, the management team, the marketing committee. Major decisions are usually made with input from at least some of the team. Some goals cannot be developed without a group effort. Regardless of the level of decision needed, it takes practice to make decisions at a higher level. An organization cannot move directly from square one to the fifth and highest level. It must first develop a team through discussion and dialogue.

The Five Stages or Levels Are

Stage I: Telling

In this system, the business or the people working within it do whatever the boss says. Staff members have no opportunity for input. The message is "This is my vision. Be excited about it or choose to work elsewhere." This is the traditional authoritarian method, which is especially prevalent in small businesses with one or two owners/managers. It is also the level that is used in crisis management – "We've got to do this."

Stage II: Selling

At this level, management says "We have the best answer. Let's see if we can get you to buy in." The leader(s) attempts to enroll the staff in the vision. The employees are like the boss's customers and he/she is trying to sell them on a product.

Stage III: Testing

Testing implies the staff will influence the results and the final decision. At this level, management asks "What excites you about this vision? What doesn't? How could we make it better?" We determine how enthusiastically the team will support the vision and what aspects matter most to them. Then the boss reserves the role of judge and final decision maker.

Stage IV: Consulting

Here we might get input from the staff, present two or three scenarios that we have pre-selected and then recognize input from the staff. The question asked is "What vision do team members recommend that we adopt?" We already know that either of the options presented would be OK.

The Last Stage Is Stage V: Co-Creating

Here, team members work toward what they collectively want to build for their future, vs. what the boss wants. The theme becomes, "Let's create the future we individually and collectively want and then move forward." The staff uses personal vision and proceeds via self-realization. Teams articulate a common sense of purpose. Each individual is a part of a creative organization.

One of the tools you can use to implement change is appreciative inquiry. Appreciative Inquiry (AI) is a positive, proactive approach to change, which deliberately focuses on what is already working well in order to build on success. As the name implies, the two basic tools of AI are appreciation - putting attention and focus on what is already working for a business; and inquiry - which is about asking good questions and searching for meaning. Rather than asking, "What's the problem?" AI asks "What's working here?' Once a group understands their conditions for success, they are much more capable of dealing with "problems" constructively.

As a change process, AI is parallel to the positive reinforcement methods that we use with animals. For example, a dog who jumps up on visitors can learn to do an endearing trick instead. Similarly, people can focus on strategically shaping their strengths and skills. AI is particularly useful because it focuses upon the value of every person's successes and contributions. It does not engender defensiveness, finger pointing, or guilt and anxiety about fault and blame.

AI has been used successfully in small and large change projects with hundreds of organizations and corporations worldwide. It is based on the simple idea that organizations move in the direction of their questions. For example, when groups study or try to work on their problems and conflicts, they often find that both the number and severity of these problems grows. In the same way, when groups study their achievements to date – such as successes, best practices, and emerging skills and innovations – these phenomena, too, tend to flourish. The artful creation of a positive, shared image of the future may well be the best activity that individuals and organizations can engage in if their aim is to help bring to fruition a significant future.

Positive images and discussions lead to positive actions. Organizations tend to evolve in the direction of positive, anticipatory images of the future. The AI process consists of Discovery – identifying the organization's root causes of success or what is already working well; Dreaming – envisioning bold, new possibilities for the future, or how we want to build on what's already working; Designing – preparing the organization for excellence with collective, clear intentions, protocols or guidelines; and lastly Destiny – committing to meaningful, lasting and achievable plans and goals, and celebrating every step.

With Appreciative Inquiry, everyone involved has a voice in creating the vision and the plan. It helps people to discover, study and expand upon what is already working, which builds confidence and competence for future planning and achievement.

AI is about the best of the past and the present, and an awareness of the value, strength and potential of ourselves and others. It also means overcoming the limits we impose, often unconsciously, on our own capacities. The background of our culture tends to throw us into a chorus of hopelessness, irony and negativity. What we pay attention to has everything to do with how we see ourselves, how we envision the future, and how the future actually turns out. What is the best part of yourself and how does it fit the best part of the practice philosophy?

Whether you approach change via AI or by another route, the truth is that people don't like to change. However,, any new idea, method or program will involve change. It will create problems you will need to discuss and iron out. It will require buy-in. How will you convince your owner doctor or the team? What will you do when the doctors don't agree or your boss says "no"? When people attempt to sabotage the program or simply don't do what they are supposed to do? When it doesn't go as expected?

If you fail to plan you can plan to fail, so have a strategy. Then communicate your strategy to your staff. Tell the staff your goals, focus on the vision that you have for the change you want to make. It should be clear not only what you want to do but why – how will it improve customer service, patient care or the health of the business?

Involve everyone and listen to fears, needs and concerns – really listen, don't just pretend to listen. Brainstorm how to go about the change you want to make. Paint pictures in peoples' minds by telling stories, or musing about what if... For example, if you are introducing a new medication, talk about a sick patient who could have benefited from it. If the change is going paperless talk about how the practice will function once you've made the change. How will they interact with the clients? What part will they play in the program?

Address any concerns that you can. Be sure to ensure continuity of what is really important –. again, the customer and patient care and the business. Discuss positive rewards for the team. Assign charts, reports and tasks to keep everyone involved.

As you go along, review and revise your program if needed. Remember that the things that push you the most help you the most. Success is the culmination of failures, mistakes, false starts, confusion, and the determination to keep going anyway. You may not get it right the first time, so learn from your mistakes and give it another go if it seems a worthwhile change to make.

If you aren't the owner of the practice but you want to make some changes, how should you go about it? Again you need to plan and strategize. How important is what you want to change to your manager? How will it impact your consistency of care? How will it impact the practice financially? How much time will it take?

Conflict arises from unmet expectations such as:

• I thought, since you sent me to the conference, that you would want me to utilize what I learned

• I expected to get a raise

• I expected to always work these hours

Conflict can also arise from inaccurate assumptions:

• I thought we were deciding on that together

• I thought we had all agreed that we would...

• I thought she would do it this way

• I thought I was making that decision

Decisions can be about how you practice medicine, how you do reminders or A/R, how you organize your work areas. They could be about who works when, what hours you are open, how many staff members work each shift, how you schedule appointments or about customer service issues. The more clear you are about who is making which decisions and why, the better off you will be.

There are 7 levels of empowerment when it comes to making decisions. This, too, should be clarified at the very beginning of a project.

1) Wait until told

2) Ask

3) Make a recommendation

4) "I intend to"

5) Do it and report immediately

6) Do it and report periodically

7) Do it

As trustworthiness and trust increase, so does the level of empowerment. Your job description does not empower you. You empower yourself based on the issue or the problem or the challenge at hand. You exercise your own level of initiative or self-empowerment. The key question is always: What is the best thing I can do under the circumstances?

No matter what the change being discussed, you will never get universal support. In any given situation where people are asked to change: 30% will hop on board, 50% will sit on the fence and 20% will resist the change.

Life is a series of attempts to resist change, and then after incorporating change, to resist the next change; that's human nature. However, you have the right as a leader in the practice to have certain expectations for how your team members will behave when change is introduced. In a business setting, there are only four ways that an individual can respond to a decision made by the team or its leader(s)

1) Agree and back it 100%

2) Disagree but back it 100%

3) Disagree but keep quiet

4) Fight it

There should be an expectation that it's never OK to choose #4. It's not acceptable to refuse to change, to undermine the change or to bad mouth it to team mates. We choose every day whether to act within our sphere of influence to make things better or whether to choose a negative behavior. in Stephen Covey's The Eighth Habit he lists five bad behaviors that people can choose to engage in when they are unhappy:

• Criticizing – you didn't do it right

• Complaining – this or that sucks

• Comparing – she's better than you

• Competing – I'm better than her

• Contending – defensive communication or hostility

We are free to choose but we often make our choice unconsciously, without thinking through what our choice will mean to our boss, our team mates or our own performance evaluation. Whenever you want to implement a big change I think the four choices we could make and the five behaviors we could choose should be reviewed with the team. This way you are setting clear expectations for peoples' behavior when the change actually comes.

Covey also says that "Consciously or subconsciously, people decide how much of themselves they will give to their work depending on how they are treated" or how they feel about their job.

• Rebel or Quit

• Malicious obedience

• Indifference

• Willing compliance

• Cheerful cooperation

• Heartfelt commitment

• Creative excitement

You can see all these levels when you make changes, depending on the person or the idea. As with the four choices, you shouldn't tolerate behavior that falls below the level of willing compliance, and you need to make that expectation clear.

No matter what changes are occurring, we will need to prepare for the inevitable "pushback" from the practice's team/stake-holders. Change always produces anxiety, which often presents itself as un-teamlike or unprofessional behavior. When people feel threatened sometimes it's "every man for himself." Not everyone will like the changes the leaders or team wants to implement, and certainly not everyone will be comfortable with it. "If you want to make enemies, try to change something." – Woodrow Wilson

The way past these is to continuously reinforce the message, the vision, the mission. Use your management skills of directing, facilitating and coaching.

If you don't feel excited to implement changes when you get home... Do something about it! "Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that most frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be?" All of us can consciously decide to leave behind a life of mediocrity and to live a life of greatness – at home, at work and in the community

• What is a life of greatness for you at work?

• How would we know you are being world famous?

• What help do you need from others to become your best self?

• What can you contribute back to your hospital?