In the first essay on why broad action plans focusing on things like “be nicer” have a high failure rate is that it is more difficult to define those terms than it may seem at first glance. I suspect that some were skeptical that this was so difficult, but in reading the essay, I hope that they realized that hardwiring the behaviors under a vague sentiment is a bit trickier than simply printing up BE NICE posters. I also suspect that, in calling out the need to be more precise, many readers thought, “Yeah, we can be a bit more concrete and prescriptive and get the job done.” Indeed, the message in the last essay was that you need to use the same strategies in building this action plan that you would use for building any other more targeted action plan. The only real hurdle is getting over the belief that an action plan on a valence issue1 doesn’t require very much work. “Be Nice” is a fundamental principle that feeds into all work in an organization and therefore requires more work building it, even if everyone generally agrees with it. Implementation is equally challenging since both the organizational hierarchy and the need for multiple points of ownership make any broad initiative like this struggle.
All action plans require behavior change and all behavior change is hard. There are softer and harder ways to accomplish this. There are proactive and reactive ways. Organizations often avoid making broad pronouncements that cover all staff because of this difficulty. One could point to mandatory COVID vaccinations that some hospitals put in place during the pandemic as evidence that they CAN make these system-wide behavioral rules. To me, though, that is the exception that proves the rule. It took a world-wide pandemic to establish a uniform policy, covering the least to the greatest and even that policy had exceptions. Short of that, and setting basic minimums for deportment, it is difficult to get an organization to adopt any one-size-fits-all initiative.
Organizations don’t often function in this lockstep fashion and do so only in the most extreme situations. Organizations are more successful in places where the vision and strategy are articulated by senior leaders and that is translated into concrete steps shaped by the middle management to fit their specific environment. This is reasonable and effective but expects those managers to accept the responsibility with the same urgency and importance that the senior leaders do. If they think that it doesn’t really apply to them, or is punitive, or is burdensome they won’t do it. So, I will discuss the importance of applicability, accountability and appropriateness in turn.
Applicability: Everyone means everyone
If an organization seeks to modify all interactions between staff and patients, they will need to address how to hold all people accountable to their behavior. This is where my last essay on healthcare’s self esteem problem comes in. The manager’s need to hold all staff accountable will bump up against their competing desire to maintain a happy team. Because of individual expertise or broad concerns over the labor market, there will be a desire to not rock the boat by choosing silence rather than confrontation. An organization could think that some people on staff are too important to require alignment on a core principle. Tacitly adopting this “too big to fail” mentality means that people are being held to a different level of accountability, based upon their perceived value to the organization. This variation, where some people are expected to be nice, and others are not, will lead the plan to fall apart.
You might think me naïve to expect the CEO (or President or the sole pediatric endocrinologist or…) to do this. After all, he/she has a reserved parking spot, an executive assistant, and other perks of rank. They often get preferential treatment. This may be, but such a visible action plan of ‘be nice’ any absence is easily noticeable. Imagine you pass by and greet people and there are a few people who do not return your gesture. Are you going to continue to exert effort with no expectation of return? If some avoid repercussions or are not held accountable, then it won’t take long for others to claim ‘selective enforcement’ when they get called out for not being compliant.
Accountability: Not all love is tough-love
Part of the problem is that an organization is loathe to create negative consequences, especially for a behavior that they don’t consider germane to the work.2 There are two ways around this. The first is that you make the punishment fit the crime. Not being sufficiently nice is not a fireable offense. But treating it as nothing means the initiative will die on the vine. Addressing it, as a reminder, in huddles can help to keep it in front of mind. Making it an element of annual performance appraisals can also help. I have worked for and with organizations that have made living up to a corporation’s mission and values statement part of the annual review process. Tying this behavior to a core principle makes its presence in a performance evaluation meaningful in the same way that being on-time or being a team player can be.
The second way is more connected to the original purpose. Put a focus on positive accountability. Here, the point is not to make an example of those who fail, but to make an example of those who succeed. This notion of catching someone doing something right (as opposed to catching someone doing something wrong) is most-closely associated, at least by me, with management legend Ken Banchard. This mindset seeks to turn service into positive and affirming behavior and not a punitive one. This is critical because I continue to stress that the patient experience is not about WHAT but about HOW. Negative accountability may build compliance with the WHAT, but it won’t address the HOW. Now positive accountability won’t turn everyone into a compliant employee, but it will tell your team that this is laudable behavior that is recognized. If I know it is useful, valued, and recognized, then I am more likely to do it, even if I don’t always get that behavior mirrored back to me.
Appropriateness: Hire for it as well as fit
Ideally, we can make changes relying on internal motivation. We know what the right thing or the expected thing is and we do it. But if you are like me, wanting to change and knowing it is the right thing to do are not necessarily sufficient to make the change. There need to be guardrails to assist behavior modification and consequences for behavior modification, or the lack thereof. But that core understanding is critical to success. This is why patient experience initiatives are often made successful or not based upon the people we hire.
It is not unusual to have broad service excellence standards discussed as part of on-boarding a new employee. But it is unusual to use those standards as part of the hiring process itself. The closest organizations often get is to insert a peer review or interview with prospective employees to gauge goodness of fit. It is also not uncommon for organizations to use various personality trait measures to evaluate whether a candidate has a mindset that will fit with the job expectations. One hospital I worked with used a personality trait measurement tool to evaluate potential hires and then set a threshold for one of the service dimensions. If a candidate scored below a certain number on this dimension, they could still be hired, but only with the assurance that they were the only available qualified candidate for a job that needed to be filled quickly. The organization claimed that those with a low score here were far more likely to struggle to fit in and were more likely to leave the organization (or be asked to leave the organization) in the first year. So in their mind, the front-end burden was offset by getting the right person to stay in the right job for an extended time.
Their logic was that everyone considered for a professional position had the appropriate training and licensure. So, if you were going to debate the relative merits of education and experience beyond the baseline, it would make sense to also evaluate their corollary skills of being honest and playing nice with others. This organization would also make the employee sign an agreement about the service standards of the organization. This clearly attached ownership to the employee and held them accountable. Now, when one wanted to have a critical conversation with them, they could point to the document as a conversation-starter.
You might say, “But, Joe, that sounds a lot like negative accountability.” I would respond that an organization that puts a high premium on positive accountability is still going to have elements of negative accountability. One does not prevent the other. The question is which one is dominant. To paraphrase an old saying, all organizations have a positive accountability wolf and a negative accountability wolf inside them, and which one is dominant is based upon which one gets fed.
You might also say, “Yeah, Joe, it must be nice to have so many applicants that you can be picky about these sorts of criteria.” I remember talking with a physician recruiter in upstate New York. He bemoaned the fact that when he worked in Portland, he would have forty or fifty applications for every posting and now he was getting four or five. During the day we spent together, I asked every doctor I met why they came to this hospital. Everyone said one of two things and often they said them both.
- They came because they grew up in the area and they felt a mission to be part of elevating the clinical and service quality for their community.
- They came because they felt a strong sense of collegiality and chemistry with the doctors they met during their interview process.
At the end of the day, I talked with the physician recruiter about what the doctors themselves said about the hospital. I said that by accident or design, he might be lucky, because those who wanted to come to his hospital wanted to come for very affirming reasons. The location itself may have weeded out those job-jumpers or those who want to be a very important fish in a small pond. I said that he might not have intended to build a team like this, but that he had. It was his job, now, to not screw it up by feeling like he had to take any stray that ended up at his front door. If you bring people in who fit the expectation, then managing that work becomes quite a bit easier. In other words, holding people accountable for standards they already hold themselves accountable for is infinitely easier than the alternative.
This last story highlights the real obstacle to organization success with these broad initiatives. You need to have everyone on board with this, not just as black-and-white expectations, but also having these expectations baked into the process of hiring and evaluation. That means not just HR, but also the recruiter for every clinical and non-clinical position in the organization. Since this only happens in rare, often exigent circumstances, it really should not be surprising that BE NICER will fail because the structure cannot handle it.
1In the study of politics, a valence issue is an issue about which there is broad support and generally only one winning side. No one runs as the Anti-Education candidate, any more than they want to be the Fiscal-Irresponsibility candidate even though the policy positions beneath those valence issues do vary. So, in this case, no one is going to say, “I support being meaner to our coworkers and patients.” Being Nice is a valence issue.
2Yeah, I know that it is. Preaching to the choir on that, but you know as well as I do that there are those who consider this work to be piffle.
PX Matters with Joseph Snipp 
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