Motivating the Able not Willing

I vacillate on which of these groups are more difficult to solve for—the Willing, but not Able or the Able, but not Willing.  It is clear, though, that those who are Able but not Willing (AnW) pose the more nuanced problem, as they can be harder to spot and more difficult to reach.

When I mention the AnW, you may think of that person who loudly proclaims that service is crap.  They will wear this as a badge of honor and since they feel like they are bulletproof (I am looking at you, cardiovascular surgeons) they don’t even try to keep a low profile.  We will address why they feel bulletproof and what to do about that in a bit, but perhaps surprisingly, I like these ones.  Their proud opposition means that they put the GPS tracker on themselves and therefore are easy to find and easy to keep an eye on. 

There are the ones that are harder to identify and keep tabs on.  There are the “now’s not a good time” crowd.  They will say that they agree that the work is important but will put up roadblocks to doing the work. They act as an ally, but will have a dozen reasons why we cannot start that work right now:

• We are understaffed
• We are in the middle of contract negotiations
• We just went through a ‘thing’ (new EHR, change in leadership, service or staffing optimization, move from 8- to 12-hour shifts, etc.)
• The team is too fragile
• We cannot lose any doctors

Now, many of these are real concerns.  Depending on resources and timing, it may be valuable to prioritize.  As someone who oversaw the service component to  the addition of eleven new hospitals to a system, I know that a go-live with a new electronic health record will suck the oxygen out of the room and other elements do need to take a backseat.  The folks in this bucket are not about prioritizing, though.  You can tell that this person is not serious about beginning any new service process by the fact that they won’t give you a date (or even a process for assigning a date) to start that work.  “Later” is parent-speak for “Not Likely” and “Someday” is not a day of the week.  If someone thinks that this is important, they will engage in setting a timeline.  If not, well, they really aren’t that into you.

The other person that is difficult to identify is the person I call the “wet wash.”  They will sit passively, perhaps smile and nod.  If forced, they say all the right things, but you know that once they leave the room, they won’t think of this conversation ever again.  They are like a pile of laundry taken out of the washing machine before the final spin.  It is heavy and hard to move.  You can prod it, and it doesn’t respond.  It gives no resistance from poking or kicking, but it also won’t move.  If you kick it hard, you will hurt your foot before you move that mess.   They don’t fight; they don’t make excuses.  If you are not attuned to the behavior, you might even think that they will do what you want them to do, but they won’t.  You can identify them by their lack of specifics.  When their action items are “we will try harder” or “we will be nicer” you know that they don’t want to make an effort to change. 

Whereas the best thing for the willing-not-able is to give them training, that is worst thing you can do for the AnW crowd.  They have the training.  They have sat through several lunch-n-learns or seminars and have tasted and spit out all of the flavors of the month.  They often have some level of tenure, so they will proclaim that they have seen these initiatives come and go and that they themselves are the only constant.  At best they will completely check out of any training session.  At worst, they will be disruptive by saying things or asking questions not for clarity, but to cause confusion.

So how do we reach these folks?  We cannot reach them, not immediately and not alone at any rate.  My primary focus with these folks is to limit the contagion.  The real problem with them is not that they are a pain in the butt, but when their behavior goes unaddressed and unchecked, they can infect others and spread their inactivity.  In fact, this can lead to a self-fulfilling cycle, where their disconnection to a new service initiative and that initiative’s eventual death, will reinforce their notion that if you ignore it long enough, it will go away.

Don’t Get Over Your Skis aka Stay in Your Lane: I will often call out early in a conversation with any clinicians that I am not a clinician, and I am not telling them how to practice medicine.  By telling them that, I am both highlighting the respect I have for the knowledge base they have and highlighting the knowledge base that I have.  Any conversation with the AnW needs to start with removing the “but you don’t understand what I do” defense.  Yes, I don’t understand what you do.  You need to understand that I am not telling you how to practice, I am just trying to help you not seem like a jerk to your patients and coworkers when you are practicing.

Look For the Easy First: Every business book (and service book) will talk about harvesting the low-hanging fruit first or stockpiling early wins.  This approach doesn’t just work for projects, but also for people.  Your time is valuable, and more importantly, finite.  There is no reason you cannot prioritize work based upon how eager a team is for your help.  For every wet-wash manager, there are ten who want to get better.  For every crabby doctor, there are five who know the value of service in building a practice.  Focus on those who want your help first.  Depending on your comfort level, you can even call it out.  I was at a hospital for a week, and part of my work was meeting one-on-one with all the managers to help them create a plan.  One manager came in and literally said that this meeting was a waste of his time, and these thirty minutes would be better served doing the job he was paid for.  I said, “OK, then go.”  He looked surprised, but I said that it was not my job to make him care and even if it was, I could not do that in thirty minutes.  So, he should leave and go do the work he was paid for.  I would gladly take a thirty-minute break in my twelve-hour day.  He changed his tune, saying that he was only blowing off steam, but I would have none of it and kicked him out.  This may seem harsh but think about the collateral impact.  If I let him stay, we will talk around the topic for thirty minutes and then he will go back to his work saying, “Yeah, I met with him.  It was a waste of time.”  This will poison the well for others coming to their meetings with me later in the day.  By kicking him out, he went back and said, “I cannot believe it, that [expletive deleted] just kicked me out because he thought I was not taking this seriously.”  This sends a different message.  If you think that makes me sound like an [expletive deleted], perhaps, but given that the manager probably had a reputation with other managers for being a pain, I created a better working relationship with those managers because I called out what they already knew. 

Address but Don’t Wallow: Most of these essays so far don’t necessarily highlight it, but I am a numbers nerd.  There is nothing I would rather talk about than statistics, methodology, and data.  But the first thing I will tell people who must answer math questions from their organization is that you cannot win a math fight.  I have talked to literally¹ a thousand doctors and many of them will have questions about sample size, or methodology, or survey construction, or ordinal versus interval response scales, etc.  Sometimes these questions come from an honest desire to understand and sometimes they come from a honest desire to wave their degree around.  Those conversations can be valuable and are often spirited, but your primary focus cannot be to WIN.  Your better focus is to win over the room.

For example, a question I often get is “how many surveys do we need?”  This may seem simple, but it can be conversational quicksand, since your organization’s focus on 20, 30, 39, or 50 surveys is likely based upon a combination of what might be ‘statistically significant’ and what is likely to capture 80% of your physicians.  This number is not magic; it is simply a number that serves an important purpose.  You can make a case for any of these numbers, but there isn’t a RIGHT answer, so you cannot WIN the argument.  Properly collected, a bigger sample size is always preferred, but what is ENOUGH can be tricky.  Since the question is really “when should I care about what the data tells me?” your better answer is to NOT go down a rabbit hole debating whether there is a difference between getting twenty-eight surveys or thirty surveys.  Instead, sidestep the question.  

“Obviously more surveys are better but remember two things.  First, the organization will only report your performance when you reach the threshold of X surveys.  Second, every survey has a story to tell.  They have verbatim comments that can be useful and each one is a building block to your quest for reportable data.  Would I lose sleep over a patient giving me a 7?  No, but when I get three 7s in a row, that is noteworthy given that the average clinic provider scores 90% 9s and 10s.  You don’t have to pull the fire alarm, and if you start early enough, you never have to pull the fire alarm.” 

You are not ignoring the question; you are addressing the issue at the center of the question.  By avoiding the math-trap and addressing the concern that clinicians have (that they are going to be beaten by the data) you show understanding for their concern.  You then can use this to move to the topic of IMPROVING the data, which is ultimately what an audience wants.

Lean on Common Sense: Often, the AnW will want to postpone the work you are asking for until you can prove that this work is going to work.  Sometimes people will ask for the seventeen journal articles proving that this is appropriate best practice.  While there are journal articles that prove the value of most established behaviors, this question misses the point that what you are asking is just common sense.  Do you really need a journal article to tell you that people hate it when you interrupt them?  Or that tells you that patients are less anxious when you sit versus stand?  Or that having patients teach-back a concept helps solidify it in their memory? ² 

Now none of these things will convert the “that one clinician.”  If you focus on that, you will exhaust yourself.  You are limiting the contagion.  You are doing it to connect with the rest of the doctors or nurses in the room. That one clinician was already talking trash about service and about you and your stupid mnemonic devices for months.  By standing up to that person and treating their questions respectfully while still flipping the conversation in the right direction, you will convert others in the room, who were looking for a reason to ignore that one clinician’s ranting. 

There are several things that WON’T get those stubborn folks on board.  Here are the two things that will or at least will have the greatest possibility of working.  In the short term, you should focus on the person who can dictate “that one clinician’s” behavior, like a director of nursing or medical director.  As Bob Dylan said, “They may call you Doctor or they may call you Chief, but you’re gonna have to serve somebody.”  This means, though, that this leader needs to be on-board with the service plan.  If they are one of those “yes, but not now” people, you may need to help them see the urgency of the issue.  I was talking with a clinic manager, who did not want to confront elephant, since “that doctor was going to retire next year.”  I gave her two problems with that logic.

1. Senior leaders were not likely to look kindly upon a “talk to me next year” strategy for improving the patient experience.
2. In that year, what impact will that doctor have on all the younger providers in that clinic?  I had done a presentation for the entire clinic, and I could see the body language of the younger doctors when that older doctor spoke.  Just like Pinocchio, spending a year on Pleasure Island with that senior doctor before retirement threatened to turn the younger doctors into donkeys as well.

Just like in so many situations, if the managers are not leading the charge and owning the work, it will at best have only limited success.  If your REAL problem is leadership, it really won’t help to hammer away at one recalcitrant clinician.

In the longer term, you focus on those other doctors who are open or eager to the service conversation.  By peeling off some and then some more, you are changing the balance within the cohort.  Eventually, the cohort will start norming the outliers themselves.  Again, there needs to be support for this, such as creating a physician champions program, giving out service awards, or even adding service to the physician compensation program.  This logic applies to all clinicians as well—similar recognition can be set up for nurses, lab technicians, or imaging staff.  This doesn’t happen overnight, but once that ball gets rolling, it is hard to stop.

In looking at this work, you may think that it is impossible to convert the AnW into a service mindset.  This is not true, but, like any behavior modification, it requires time.  Senior leaders may push back at this, demanding that the beating continue until morale improves, but meaningful service comes from the heart and that muscle needs exercise.

¹I just the word literally here as literally and not as some people use it, as figuratively.

²At the same time, your action plan should be tethered to a simple concept so it CAN be supported with a commonsense argument.  If your plan is reliant upon creating complex new workflows built on an extended number of variables, it won’t work.  Not because it hasn’t been validated by research, but because no one is going to work that hard at operationalizing it, or in tracking its compliance, or in tying it back to patient data.