Joining the CREW builds civility at VA

Culture change being better outcomes

You can't just mandate a civil workplace. You have to build one.

That is what the Veterans Affairs (VA) health system is doing, one unit at a time. Today, more than 750 units at 150 facilities have adopted CREW — Civility, Respect, and Engagement in the Workplace, a program that is supported by psychologists and specialists in culture change at the VA's National Center for Organization Development in Cincinnati.

CREW pays off in better outcomes, says Linda Belton, FACHE, director of organizational health at the Veterans Health Administration in Ann Arbor, MI. "The higher the level of civility in your work unit, the lower your sick leave . . . [and you have] lower EEOC [Equal Employment Opportunity Commission] complaints, higher employee satisfaction, higher patient satisfaction," she says. Units are also more likely to meet their performance requirements and be safer, she says.

CREW began in 2005 with a pilot project involving eight units at eight facilities. "It's really engaged around the people you work with every day," says Belton.

It begins with a commitment of support from hospital leaders — in writing. The facility conducts an assessment, which includes a short Civility Scale given to the unit's members. The items are rated one a five-point scale from strongly disagree (1) to strongly agree (5):

• (Respect): People treat each other with respect in my workgroup.

• (Cooperation): A spirit of cooperation and teamwork exists in my workgroup.

• (Conflict Resolution): Disputes or conflicts are resolved fairly in my workgroup.

• (Co-worker Personal Interest): The people I work with take a personal interest in me.

• (Co-worker Reliability): The people I work with can be relied on when I need help.

• (Antidiscrimination): This organization does not tolerate discrimination.

• (Value Differences): Differences among individuals are respected and valued in my workgroup.

• (Supervisor Diversity Acceptance): Managers/ Supervisors/Team leaders work well with employees of different backgrounds in my workgroup.

Facilitators, or "champions," from the unit attend face-to-face training sessions and provide monthly updates via phone calls and written reports. The unit also has regular CREW meetings, which are a critical aspect of the program, says Belton. "[Employees] are asked their opinions. They're given a platform, sometimes for the first time in their employment," she says. "We talk about having honest conversations where you can say the difficult things that need to be said."

In one unit, for example, a physician aired a gripe about how long it took nurses to retrieve an EKG machine when a patient was crashing. The physicians envisioned nurses walking slowly despite the dire need. A nurse explained that they literally ran across the multi-acre campus to borrow the machine from the emergency department. As a result of the conversation, the unit requested the purchase of an EKG machine — which was approved.

No one had ever realized that solving the problem would be that easy, says Belton. "They were able to participate in the resolution of the problem and they felt empowered to do that in the future," she says.

CREW does not specifically address intimidation and bullying; its focus is on the positive. "We visualize what civil behavior is and that's what we go for," she says.

There are some cases in which an individual is causing problems on a unit. That must be dealt with through human resources procedures, Belton says.

CREW simply sets the stage for a workplace that values respectfulness. "If you can create that environment where people have honest conversations, some level of trust and respect one another, then they're less likely to engage in bullying and they're less likely to permit bullying to occur," she says. "A healthy organization is a place where patients want to come to receive care and employees want to work."

Attaining a culture change by working with one unit at a time may seem like a long, slow process. But eventually, the entire organization has a new climate, Belton says. "When you have a certain percentage of your work units participating in CREW, that becomes a tipping point," she says. "Satisfaction and other metrics go up all around the facility."