Wither the Woodshed, 2: The Power of We

In a previous essay, I wrote why organizations that focus on a punishment-dominant model for PX don’t generally have long-term success.  I don’t like writing essays where I cannot provide a way forward, though, so I will discuss here one central way to change the dialogue and perception.  Most organizations won’t define themselves as punishment-dominant organizations.  The reason is often that punishment-first models are so ubiquitous that it is hard to even see the characteristics anymore.  The challenge is that many of the people reading this don’t wield enough clout to change or control how their organization approaches behavior modification.  So, saying that organizations should stop beating staff with bags of oranges will likely elicit the general response of, “Tell me something I don’t know.”  Crafting alternate approaches is easier to discuss than to do. 

Before beginning, I will acknowledge that a lot of what I talk about here focuses on adjusting language and mindset.  There are likely some who will roll their eyes at this approach, feeling that changing their word choice or personal behavior won’t stem the flood of negative stimuli.  To that person, I ask, “what other option do you have?”  If you passively accept the woodshed¹ approach, you will likely fall into one of three suboptimal places. 

• You will become a martinet.  You will align yourself with the strict message and transfer the pain downstream.  You will say things like, “that’s why they call it work,” or “I didn’t come here to make friends,” or “you all know, shit rolls downhill.”  By adopting this approach, you have cover with your superiors.  You are, after all, delivering the requested beatings.  The problem is that you will lose control of your staff.  They may fear you, but they won’t respect you, and fear is a horrible motivating tool, especially when it comes to service.
• You will become an ineffectual best friend.  You will align yourself with your staff.  You will say things like, “I know you are busy, but the brass upstairs are demanding that we do…” or “We all know this is bullshit, but we gotta try and do this anyway…”  By adopting this approach, you try not to alienate your team.  After all, you are really just one of them.  Again, while this may feel better, your staff will quickly see you as ineffectual.  They don’t need a best friend; they need a leader.  They want someone who can explain requests and effectively take concerns up to their superiors.  If you cannot do the former, they have no confidence that you can do the latter and they will ignore you.
• You will become a checked-out zombie.  You don’t invest yourself in any of the work.  You will avoid confrontation with anyone in an effort to make no waves, stay under the radar, and every other overused metaphor for life in corporate America.  You will say things like, well, you mostly don’t say things.  You repeat the mantra to yourself, “I just gotta make it to Friday” every week until you die. 

A focus on mindset is at least an effort to change in a constructive way.  While these approaches won’t change the corporate culture in a week or two, nothing will.  Even if the CEO was magically replaced tomorrow, the punishment-forward mindset is so fully baked into many cultures, it is far more likely to change the CEO than the CEO is to change the culture.  I know, as everyone trying to lose weight knows, I didn’t put on the excess pounds in one day and I won’t get rid of them in one day.  Building a personal outlook and creating messaging accordingly may not shed the excess weight in a day, but it is better than eating your feelings and hoping for the best.

It is about WE and not I

No matter who you are or where you are in your organization, it can feel like you are a lone voice in the wilderness.  I have spoken to plenty of PX people who will describe their situation as being an army of one.  In many of those organizations, according to the org-chart, they are right.  There is one FTE dedicated to the universe of PX.  But even in those situations, there are supporting individuals.  There are nurse leaders who are needed to reinforce PX messages to staff, since that army-of-one cannot be in every place all the time.  There are people in a variety of departments whose expertise is needed to respond to patient complaints and grievances.  While there may always be one name at the bottom of the response letter, ² that work cannot be done alone.  Recognize that it is not YOU that has a dozen unaddressed patient complaints, but that the organization has a dozen unaddressed patient complaints.  Even if you are an army of one, you still need to delegate work to the subject matter experts around you and—this is the important part—let them know that they are an important part of the team.

If you don’t address this, you will find yourself in one of two extremes.  You will feel perpetually exhausted.  Without the ability to delineate tasks and responsibilities, you will be unable to prioritize.  Without this, you will always feel like you are failing someone.  Focusing on frontline training means letting the complaints go fallow.  Doubling-down on grievances means missing an opportunity to craft a useful plan and message to leadership.  Or you will create a cult of personality.  If you are expertly able to juggle everything, people will think about how great you are, without really thinking about the weight of the work.  In fact, if you make it seem easy, they won’t seek to understand what goes into the work.  It may feel dizzying to be so well-respected.  The problem is that at some point the carousel will end.  You will drop a ball—the data may slip or the complaint by a VIP may get missed or the new locum doctors are not read into the service process—and because you made the work seem so easy, it will be easy to blame you for the gap.  Even if you avoid making mistakes and being a scapegoat, when you decide to leave the organization, the whole process will collapse because the system can continue with a book of work that they didn’t really understand.

It is about WE and not THEY

In many ways, focusing on “WE and not I” is easy to do.  After all, unless you are an unreflective narcissist, you realize that you need others to help with tasks, even if your name is the only one attached to the job title.  Further, since misery loves company, the guest list is extensive when things go sideways.  Stressing “We and not THEY” can be a bit harder to embrace.  Here the focus is on globalizing the message and responsibility. 

Patients, and frankly most customers, view experiences as a whole.  They are not likely to silo any experience.  For example, our car did not make it through the winter unscathed.  We ³ had a slight mishap involving a slippery road and a road sign.  If you asked my wife about the effort to get our car repaired, she would likely say that the insurance company was horrible and the dealership was fantastic.  Were there individuals at the insurance office that were benign if not somewhat helpful?  Probably.  Were there mechanics at the dealership that were surly?  Probably.  But if asked, my wife would not parse out the pieces.  She would not say, “Well, the insurance company sucked.  Maybe Denise was OK, but the rest just sucked.”  She just would say, “We need to switch companies.” 

Likewise, patients don’t separate out experiences by saying, “Oh, the imaging tech was top-notch, but the emergency department stunk!”  Further, patients are more than happy to define an entire system based upon one piece or one experience.  If they struggle getting appointments at the clinic, they will assume that this is indicative of the entire system.  If they have a bad experience at the emergency department, they will blame the entire hospital.  These negative experiences deliver collateral damage to the entire hospital or system.⁴ We understand the nuanced difference between scheduling for primary care or specialty care.  We understand the issues with having shared resources, like imaging equipment, that are fought over by inpatient, emergency and even outpatient staff.  But patients don’t understand and, frankly, don’t care.  If you think I am wrong, go ahead and explain to the next patient trying to schedule an appointment about the differences in scheduling between long appointments, short appointments, recurring OB appointments, wellness visits, and how some doctors like to not schedule over lunch time, while others would prefer to not schedule past 4pm.  Let me know in the comments how that goes.

I am reminded of a hospital system that asked that their survey would ask a series of likelihood-to-recommend questions that climbed the organizational ladder:

• How likely would you be to recommend this doctor?
• How likely would you be to recommend this clinic?
• How likely would you be to recommend this hospital?
• How likely would you be to recommend this system?

What they discovered was that a vast majority of patients saw no difference between the clinic and the system.  If they were likely to recommend their doctor, they were likely to recommend the system and if not, then not.  This was because patients defined the entire elephant by the part that they were experiencing at the moment.  At best, patients might be more likely to respond “I Don’t Know” as the questions got more broad and inclusive. 

So, as an organization it doesn’t help to compartmentalize failure.  It may feel more comforting to avoid ownership of the tire-fire in the medical office building or med/surg unit or emergency department.  It may make it easier to deliver a severe beatdown on those areas by singling them out.  But the reality is that, from a patient’s perspective, that one area is simply an example of the broader system.  Not to mention the fact that the senior leaders are the ones determining the staffing ratios, hiring the management, setting budgets, signing locum staffing contracts, and building the physical space.  So, it is not just cheeky to call the emergency department “them;” it is inaccurate.

Organizations do this delineation all the time to help them cope.  As someone who worked in the data collection space for quite a while, it would chaff me when a client would say, “the NRC data says…” or “the Press-Ganey data says…”  Those companies collected the data by talking to your patients.  The data isn’t theirs; it is yours.  It isn’t what they are saying; it is what your patients are saying.  Vendors are just messengers.  To be clear, organizations can fire their vendors because they are too expensive or don’t provide good customer service.  But firing them because you don’t like what they are telling you that your patients are saying is just silly. 

By focusing on WE in both situations, you start to tweak how people see the work, so you start to tweak how they define the work.

1. You highlight the collective in a way that no one can challenge.  I have spoken to senior leader groups, stressing WE, and have seen them police themselves.  No one is stupid enough to say “it is not us; it is them” out-loud.  Even if they are, the room will generally call them out on that, stressing that the language of separation is not helpful.
2. It brings people to the table, even if they don’t want to be at the table.  If you say “the clinics have a problem seeing patients in a timely fashion” the registration department will silently nod.  If you say “we have a problem seeing patients in a timely fashion” that forces registration to come to the table and be part of the solution.
3. It focuses attention on what we can control.  Floor nurses will complain about what the ED nurses do.  ED nurses will complain about the imaging department, day shift complains about night shift, and everyone complains about the doctors.  By the time everyone is done pointing fingers, the meeting is over.  By focusing on the collective, we can actually focus on the patient.  The patient doesn’t care WHO should be giving them information.  They just want information. 

I will discuss more concrete ways to redirect organizational energy away from the woodshed and towards more positive and empowering ways to affect behavior modification.  They will take a bit more effort and potentially even some additional resources.  For the moment, though, simply realize that once you treat the problems as impacting the entire organization, you can start to break the blaming culture in the organization.  People will start to realize the truth in the old truism that when you point your finger at someone else, you have three fingers pointing back at yourself.

¹I realize that I have never explained or defined what I mean by the woodshed.  I figured it was a universal concept, but then again, maybe it is no longer the case.  Its meaning is self-defined as a structure to house firewood.  Because woodsheds were historically out of sight from the main house, parents would take children there for corporal punishment.  I use it here as an analog to being called on the carpet, which is also a phrase that may need to be defined.  But one archaic idiom is enough for this essay.

²I have a lot to say about who should sign response letters to complaints and grievances, but, like so many things, I will save that for another conversation.

³Notice I use “we” because the costs of the accident, in time and treasure, were realized by us as a team.  Blaming one person is fruitless since the outcome affected both of us.  The accident would likely have happened regardless of who was at the wheel.  Some of you may think that this is just a cagey way for me to avoid personal responsibility.  Since I cannot dispel this notion without going into details and assigning specific blame, I will simply accept that this is one of the ways to read the subtext here.

⁴This also works the other way, but organizations generally don’t have a problem accepting the reflected glory.