Keep staff committed to change by rewarding new ideas
Keep staff committed to change by rewarding new ideas
Staff must understand the reasons behind quality initiatives
Changing a process that has been in place for many years is difficult enough. Engendering a culture where change is the norm is an even more daunting challenge. How can health care professionals create an organizational culture in which change is a given, and in which the change process retains a palpable freshness even though it is repeated time and again? QI/TQM asked leading quality professionals to share their thoughts on what nourishes a culture of change and what inhibits change.
Exercise the change muscle
Perhaps the single most significant factor cited was the need not only to value change, but to value the people who support the change culture — to recognize and reward staff who bring forward new ideas. Communication is critical, as it is in any organizational initiative. An important subset of communication, experts say, is clearly explaining the reason for the change and ensuring staff understand how the change will benefit them personally.
"Change is almost like a little muscle; when you exercise it, it grows bigger and stronger," says Duke Rohe, FHIMSS, performance improvement specialist at M.D. Anderson Cancer Center in Houston. "It ought to be the norm of how you do business. The expectation should be that each staff member is to be part of the change; if you are not coming up with an idea for improvement, you are not participating."
"I would say reward and recognition, both professional and monetary, are probably the most important factors," adds Linda Kosnik, RN, MSN, CSCEN, chief nursing officer at Overlook Hospital in Summit, NJ.
"It’s communication," says Kay Steger, MSN, process leader for education/quality integration at Heartland Health in St. Joseph, MO. "And the keys to effective communication are telling them what you’re going to tell them, telling them, then telling them what you told them. Once you’ve done that, go back and reinforce it on an ongoing basis."
It’s not just about money
Reward and recognition do not have to involve money, notes Rohe. "But you do have to celebrate their participation." At one facility, he recalls, a manager would hand out a crisp dollar bill for any idea, big or small. "But the dollar was not a payment for the idea; it was an acknowledgement of the idea," he explains. "People are not satisfied with money; they’ll come back for more. But they are very grateful that you are listening to them. People want to get waste out of the way, but it has to be a downhill slide for them to get their ideas listened to. Or, as a manager, you must help them think through their idea. Welcome them; harvest them — make yourself a little walking suggestion box. You can bring out the greatness that’s inside of them."
Kosnik says she learned a lot about the value of recognition while involved in a research study with the Boston-based Institute for Healthcare Improvement related to the human resource component of the Malcolm Baldrige National Quality Award, which is awarded by the Baldrige National Quality Program in Gaithersburg, MD. (For a closer look at how the Baldrige process can be instrumental in creating continuous change, see "Baldrige criteria spur ongoing change," in this issue.)
"At several of the award-winning organizations, staff had the opportunity to present their work on best practices to high-level administration," she observes. "This earns the staff member recognition from the board that he or she is a driver of a significant accomplishment." Rewards can take many forms, Kosnik continues. "For example, 3M sends several people to England each year. We send ours to conferences — not only to attend but also to present. There are lots of ways to get them in [as presenters]; conferences are always looking for panelists. Our staff love that."
Horizontal communication
Steger says that one of the keys to effective communication is that it must be spread horizontally across the system or facility. "Every member of the staff must understand what the change means for him or her," she explains. "We are an integrated delivery system, with a hospital, an HMO, and a medical group practice. If change starts in one area, the natural tendency is for the others to think it’s not for them. So they must understand our integrated approach. It has to be driven from the CEO level through management and linked through individual staff."
This year, Heartland Health introduced an initiative designed to reinforce this message. "Every one of the 2,600 individuals in our organization has a simple developmental plan, related in some way to our larger developmental plan," Steger explains. "At the time of their annual appraisal, they decide what their developmental pieces are."
This year, Heartland also developed a behavioral standards document around customer focus. "We conduct an evaluation of everyone from the CEO to the staff and come up with a mutually agreed upon development plan along those standards: what they want to do better this year," says Steger. "Everything flows back to the developmental plan."
Kosnik agrees that communication is essential to keeping the change process fresh. "You can call it communication or diffusion of an imperative. The key is diffusion to the last third of your population — the ones who don’t want change, who ignore your mail. If you have all the other players in line, this one-third will be your watchers — or your barriers — so you must communicate with them. Everyone must feel he is being communicated with, [whether he is] staff, patient, or a member of the community."
She adds that it’s important to constantly educate, re-educate, and provide fresh fodder for the next idea. "Allow [staff] to see best practices; try to stimulate their minds."
"Otherwise, when you get the same people in the same organization for their whole career, how can you expect them to have new ideas or to be excited? They need to see other people generating enthusiasm; then, maybe they’ll become the ones to come up with ideas," Kosnik says.
Steger concurs. "There are 100 leaders in our organization and 2,500 other individuals. If it’s only us singing the song, the change process won’t go any further," she says.
Lead by example
As powerful as these strategies are, none of them will be successful if you don’t lead by example, the experts say. "If you’re going to ask others to change, you need to be willing to change yourself," says Steger. "Leading a group always involves self-exploration; in fact, that’s the difference between managing and leading," she says.
"How do you make your staff innovation-hungry? First, start with yourself," says Rohe. "The way to do it is to be an innovation freak yourself; hop out of the mindset that change should be delegated to your staff, and let them know that change is so important to you that you’ll fight for their ideas."
This approach "started a flood of change" at St. Luke’s Hospital in Houston, Rohe recalls. "People came to know me as the change bug,’" he says. "It was such an innovative environment that people would run up to me with their ideas. Part of the quality manager’s role is to come out and be supportive, and draw out the great ideas the staff have."
An effective leader also must understand the difference between coaching and disciplining, says Steger. "The first thing you have to do is train a group of leaders who, in turn, will be able to coach others and who understand the difference between coaching and discipline," she says.
"When you are in a coaching environment, everything must relate back to the developmental plan. You give feedback around the plan, but that feedback is never attached to disciplinary repercussions. The attitude you must have it that it’s OK to make mistakes. You can’t expect everyone to get it right the first time — or even the second time," Steger explains. "Look for movement toward the ideal state, and reinforce all the positives. If there is negative feedback to be given, ask the staff members to tell you how they might do something differently in the future. Let them drive the change process while you facilitate and point out where the holes are."
This way, Steger says, staff become invigorated about doing the right thing. "That’s the leadership component. The only time you can lead is if someone is willing to follow you."
Another key to effective change leadership is to recognize the informal leaders who exist throughout any organization, people who can stimulate others to change. "We try to recognize them and help them become part of our critical mass," Steger says. "We try to find people who are, or who could be, champions around the process. Once you find them, you need to make sure they have skills around facilitating process, that they are inclusive of others, and that they have some kind of charisma.
"We believe these people are the keys to success. If you don’t engage them, they will go underground and end up sabotaging your efforts." (See Learn to watch out for roadblocks to change," in this issue.)
Staff should expect change
Finally, says Kosnik, your staff should come to expect change as an ongoing reality. "I don’t agree that a fix-of-the-month’ mentality is necessarily bad," she asserts. "You need to have your employees expect change. I believe in rapid-cycle change; you constantly re-evaluate until you achieve the change you want. Make sure your goal and your ultimate change are the same.
"You want your staff to be saying, OK, are we adding something today?’ If someone went to a conference, everyone should be curious about what he has learned that we can implement. Employees should expect that change will become part of their lives and make it better. No change should make it more difficult for staff to function or hamper their work flow; it should make it easier and improve work flow."
For Rohe, the more change the better. "People need to be kick-started," he says. "Through dig-out, a manager can help the staff person to think further. The Japanese used to look for 24 ideas per employee per year; now, they look for even more. The key is to continually look for new ideas — small or large. If you do enough small changes, they will lead to large ones."
Finally, if management merely delegates change to the staff, the initiative will be self-defeating, he says. "Unless you can show how to operationalize the change, all you have is a flavor-of-the-month. Unless you can drive it, don’t push it down on people."
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