Challenges with Building Compliance: Engaging Leaders with Compliance

I was once walking through the hallways of a hospital with the hospital’s CEO.  I was there, in part, to celebrate their past success, which put them in the top 10% of our database, as well as helping them build on their success.  We were chatting amiably when he stopped short and said, “I have to be honest with you about something.  You say we are in the top 10% of all of the hospitals you work with, but I don’t see it.  Everything looks the same as it was last year.  I am not sure if this data is fake or if it doesn’t really matter, but I am not sure what the fuss is all about.”  I was taken aback by this comment, since he had never said anything like this before and because I had seen improvement over the year or two that I had been working with them.  I was quickly alerted to two things.  First, in all the work we did focusing on the bedside, we had not done enough work building appreciation for the work up the corporate ladder.  Second, because we hadn’t done that, the gains we made were not likely to last, since continued staff compliance relies heavily on messaging from leaders.  The takeaway, then, is that any work done to build compliance needs to address not just those doing the complying but also address those who ultimately are requesting/requiring/demanding the compliance.  In this essay, I will examine some key messages that need to be shared with leaders, including senior leaders, up-the-ladder if the training investment down-the-ladder will be realized.

Change is not flashy

I asked the CEO what he meant by this.  What was he not seeing?  What was he expecting to see?  He was not able to articulate what he meant; he only thought that he would see or feel something.  I joked that PX work would never create a Disney movie.  People were not likely to randomly break into song.  There would be no team of bluebirds that would helpfully tie PPE or surgical masks in place.  I pointed out, as we walked, that staff made eye-contact with us, even gave us a head-nod or brief greeting.  That didn’t happen a year ago.  We stood in the lobby for a few minutes and saw people walking into the building being greeted and assisted; not passively waiting for someone to approach a desk but actively approaching people.  He did not understand that the work we were doing was not about grand gestures, not flash mob dance numbers, but about straightforward work done consistently. 

While working on the patient experience can and should have collateral values, it is expressly created to change how patients experience care.  It won’t reduce absenteeism.  It is not going to magically turn numbers from red to black on a balance sheet.  It won’t instantly turn turnover around or create a line of a thousand applicants for every job posting.  Over time, it will indirectly improve those numbers, but only a snake-oil salesman will try and convince you that this magic elixir will cure whatever ails you.

Change is incremental

The patient experience is not changed because one person hourly-rounded once on one patient.  Instituting a commitment to PX today will not magically change your scores tomorrow.  You must factor in all the moving parts, each one going smoothly, if you want to realize improvement.  (This reminds me of an argument I had with a CEO over where it was easiest to raise PX scores.  I will save that conversation for another time.)

None of this work is designed to create instantaneous change overnight.  It is all about improving the margins, the percentages.  Athletes don’t practice and watch game-film, expecting to become perfect.  They are looking for marginal improvement, knowing that improving their free-throw shooting by 7% or improving their pass-blocking and buying their quarterback an extra second in the pocket, will likely translate into an extra win or two over the course of a season.  Likewise, staff improving their communication skills won’t convert every patient into a die-hard fan but will likely move a few ‘satisfied’ patients into ‘engaged’ patients. 

Change is slow

Just as change will be incremental, it will also be slow.  There are a number of reasons for this, but everyone knows that overnight successes don’t happen overnight.  There are a number of touchpoints and opportunities to leave an impression, good or bad.  I enjoy a good meal.  In presentations I have pointed at my belly and have said that I did not put this weight on in one day and I am not going to lose it in one day.  People will chuckle and nod.  But the hidden corollary to this is that incremental change is not always quickly noticeable.  During a span of focused and directed effort to lose weight, I lost about forty pounds.  I was proud and my clothes were looser, but I didn’t really feel any different.  When I was at the store, though, and hefted a big bag of dog food into the cart, I realized that the bag was equivalent to the weight that I lost.  I thought it was crazy that I carried this bag around with me 24/7 without blinking and I could not imagine how I didn’t notice this change.  It was eye-opening that I only realized my progress when it was presented to me in one lump-sum. 

I understand that the CEO did not see any change today from yesterday.  The problem was that there was no forty-pound bag of dog food to hand him so he could appreciate the journey that was made.  I have spent a lot of time considering how to quantify the improvement but have not found a good way to do so.¹ The only way I could even touch this realization is to have senior leaders write out what they see on Day 1—the things they hate and the things they want changed—and then have them reread these diary entries a year later, or at a celebration for gains made.

Celebration, it’s Important for staff

Even the most engaged staff will still have days when they are feeling beaten down and underappreciated.  But that is not the reason to celebrate wins.  Celebration is key because it highlights importance.  I have discussed multiple times that attention is currency.  If you want staff to take something seriously, there needs to be messaging that highlights its importance.  There are certainly a host of ways to do this.  The key is to connect this celebration back to the cause.  At the very hospital where we were celebrating being in the top 10% with a few words from the CEO and a few more words from me, I ran into a staff member beforehand, and they asked me who was retiring that generated this attention and party.  I smiled and explained that this was a celebration of accomplishment.  *sigh*

Celebration, it’s important for leaders

Not only does this celebration add a point of connection between leadership and staff, but it also helps to manage expectations that those leaders have.  Since no one right-sized the expectations the CEO should have had, he was comfortable seeing failure because what he saw did not conform to what he imagined the benefits would be.  Just as the world will not end, if one person doesn’t smile, if we get everyone to smile, we won’t create a perfect utopia. 

Too often leaders will dismiss work as being expected or baseline.  It is not sufficient to say that its value is obvious or foundational.  Exercise and proper diet are also obvious and foundational to healthy living.  And yet, we all are guilty of wolfing down fast food while we work sedentary jobs.  We will even say things like “I shouldn’t be eating this” as we eat it or “I should be taking the stairs” as we wait for the elevator.  Even if we simply identify a behavior as part of the organization’s overall mission, it will fail.  Calling out abstract concepts like “Putting the CARE into healthcare” won’t work.  It will likely engender more eye-rolls than compliance.  Leaders should not disrespect the work their staff does by implying (or stating explicitly) that it is not laudatory and is just expected.

Every day is a new day

The one real issue with celebration is that it feels very final.  It is a backward-looking activity.  This is why it is not uncommon to see PX scores dip in the first month of the new fiscal year.  So much attention is paid to reaching (or failing to reach) the goal, we lose sight of the fact that the race keeps on going.  So, we take our foot off the pedal, we coast a bit, [or insert your favorite overused metaphor here] and the scores drop.  It is not that we started sucking, but we stopped doing the little things that turned an 8 into a 9, that turned satisfaction into engagement. 

At that celebration, I said, “People may come up to you and say, ‘you did it!’ and I will ask you to gently correct them.  You didn’t do it.  You are doing it.  Continued success only comes from continued attention and continued effort.  Good or bad, what those patients said yesterday doesn’t matter today.  Yes, please celebrate!  Eat your free cupcake!  Take a minute to reflect upon the long hard journey to this day.  So long as you remind yourself that the journey is not over.  What you do tomorrow is what really matters.”

In the end, please remember that, for staff, compliance is a toolset.  It is being inspired to do what needs to be done and then having the set of tools to DO what needs to be done.  For leaders, it is often more of a mindset.  They are not at the bedside.  They are the ones doing the inspiring, or at least, they should be doing in the inspiring.  Too often, though, because no one explained to them their important work in this space, their inspiring looks a lot like yelling.

¹Things like videotaping physician encounters or comparing security footage from the lobby today versus one year ago, are problematic for privacy issues as well as causing a Hawthorne Effect and feeling a bit too ‘big brother.’  Other things, like reviewing the number of patient complaints and grievances, don’t really measure the work, since PX is about moving “like” to “love” and not “hate” to “tolerate.”  Still others are too fraught with confounding variables to be useful.