Building trust through promises and performance: Can your organization achieve the stellar results and employee loyalty found at southwest airlines? (Leadership).

"All the physicians ever do is complain. I can't get them to come together and agree on what we should accomplish or how we should do it."

(Hospital CEO)

"The information the administration gives us is so sanitized by the time we see it that I don't know where we are going or what we are really doing to get there."

(Hospital physician leader)

"The hospital administrator told us we would begin to get our money back when the PHO we invested in was profitable. The organization has a revenue stream and it is profitable, but now they tell us we have to leave the money in the organization as an investment in the future. I don't trust them."

(PHO physician leader)

These people don't trust each other.

Trust is confidence in the integrity, ability, character and truth of a person or thing. (1) It is a faith based on integrity, honesty and honor. It cannot be demanded or required. Conditions must be created to allow trust to be born, flourish and grow.

Those conditions include the absence of disloyalty and deception.

Trust is possible when a person or a thing does what it is represented to do. It is a natural outcome of consistency between promises and performance.

For this consistency to exist, both parts of the equation must be present. There must be promises and there must be performance.

We all experience deceit by the time we're adults.

We learn to be careful, particularly when dealing with people who seem to have agendas different from our own. Physicians and administrators frequently fit in this category. They often have agendas that, at least in the short run, seem to be quite different.

* The foundation for physician behavior is the Hippocratic oath that emphasizes each physician's moral duty to do what is best for the individual patient.

* Administrators, on the other hand, are trained to focus on collective costs and benefits while seeking to maximize aggregate health care outcomes over time.

Both views are important and yet the differences can make trusting relationships difficult.

Short-term trust in similarities

All the parties were present -- physician leaders, administrators and trustees-- for the annual hospital retreat.

Much work needed to be done, but little constructive conversation was occurring. Each group seemed committed to defending itself and pointing out what others did wrong during the past year.

* The physicians claimed their input was screened by the CEO on the way to the board and not given serious consideration.

* The administrators defended themselves and pointed out that none of last year's physician promises -- a new scheduling system and reduced utilization -- was met.

* Board members were confused and frustrated by both groups unwillingness to work together for the well-being of the hospital and its patients. They were also upset by not receiving the information they requested from both groups on the values and visioning process they were undertaking.

Rather than continuing to referee the onslaught of accusations, a hired facilitator for the retreat asked the three groups to hold separate meetings. The task for each group was to specify the 10 top priorities they had for patients, the hospital and the community.

Not surprisingly, when the groups shared their lists there were differences. But there were also significant overlaps.

Instead of wasting valuable time disagreeing about their differences, the groups agreed to begin by focusing on their similarities. This resulted in several joint follow-up projects that allowed them to produce mutually valued short-term outcomes and enhanced trust in their ability to work together.

Difficult issues separating the physician leaders, administrators and trustees still had to be addressed. However clarifying mutual interests that could be advanced by working successfully together provided a firmer foundation for addressing the remaining challenges.

Building long-term trust

Small short-term wins in mutually important areas provide a beginning. What really needs to be addressed, however, are ways to build enduring success.

Research and practice show that long-term success demands building a foundation of agreements about values, purpose, vision and goals. (2)

This is not new information. The relevant question is: Have you done the hard work necessary to clarify and successfully instill unifying values, purpose, vision and goals throughout your organization?

While goals, strategies, and tactics often change as the environment shifts, agreements regarding values, purpose and vision provide a backdrop for establishing new goals while maintaining trust in joint physician/administrator values, purpose, and vision commitments.

Without this foundation, changes in goals, strategy and tactics demanded by the environment are easily interpreted as dishonesty, disloyalty, and infidelity. A movement in this direction breaks trust, destroys collaboration and wastes energy and resources.

Health care organizations can no longer afford to operate without a solid foundation of stable promises on which trust can be built. Articulated and instilled values, purpose, vision and goals provide this foundation.

Enduringly successful organizations in a wide range of industries have repeatedly demonstrated the long-term payoff reaped from relentless adherence to the foundation provided by thoroughly instilled values and purpose.

* 3M is known for innovation.

* Mary Kay is focused on giving unlimited opportunity to women.

* Merck is dedicated to preserving and improving human life.

* Disney makes people happy.

* Southwest manages costs, service and availability in a manner consistent with their commitment to democratizing air travel.

What is your organization committed to? Do your people know? Have you developed a common dream and demonstrated your relentless commitment to pursue it? Is that dream inspiring? Does it produce the rallying point for the extraordinary effort, committed contribution and joint achievements evident in enduringly successful organizations?

Promises alone are not enough

A wide variety of investments are required for long-term health system success.

Like information systems, clinical technologies or new buildings, investments in people create strategic assets.

Investing in physical assets provides obvious advantages. Information systems, for example, cannot quit, move to a competitor, demand higher wages, reject your authority, express dissatisfaction or be unmotivated.

However, investing in your people can lead to a sustainable competitive advantage typically not available through technologies or other physical assets. While your competitors can rapidly replicate technology advantages, powerful, collaborative relationships among your people cannot be imitated easily.

Southwest sweeps the competition

As the airline industry reeled under billions of dollars of losses during the early 1990s, Southwest was the only airline that produced consistent profitability. (3) In fact, Southwest is the only airline to earn a profit every year since 1973.

Its average profit margins have been the highest in the industry. Its steady growth, conservative balance sheet, outstanding stock performance and market dominance are the envy of many of its competitors. Southwest has a young fleet of airplanes, high customer service ratings, low turnover and the lowest fares in almost every market it serves.

What is the competitive advantage that allows it to achieve such unprecedented outcomes?

The answer is simple: It has the most productive workforce in the industry. (4)

The company has consistently served twice the number of passengers per employee of any other airline. It gets more daily departures per gate and more productive hours out of airplanes than anyone else does. As a result, it has the lowest cost per available seat mile.

These outcomes are the direct result of its unusual culture and extraordinary work force, and this work force is the result of consistent investments that support people in their relentless pursuit of the organization's articulated dream--the democratization of air travel.

Making and keeping promises

Compare Southwest to health care, where feelings of loss, a sense of powerlessness, confusion and hopelessness abound.

The absence of clear values, purpose, vision and goals drive many important contributors to withdraw their commitment to extraordinary results. Given that the primary responsibility of senior executives is to create, articulate and energize people in their pursuit of a vision, it is time for leaders to make and keep the promises required for trust, collaboration and extraordinary results.

But does anybody really keep their promises? After all, the environment is changing rapidly and adjustments have to be made.

"Sure, we have a double-digit profit margin, great retained earnings and we really do want to share these out- comes with the people who have created our success" the hospital CEO told us. "But we have not yet been able to work out the details of how to do so and it is important to retain earnings in case conditions become more difficult."

After hearing similar stories repeated over time, the people who produce the success for the organization lose trust in the integrity of their leaders and withdraw their commitment.

Predictably, conditions become more difficult. People who have been told that they are the organization's most important asset question these words as they watch their colleagues leave during mergers, re-engineering initiatives and cost reduction efforts as their health systems attempt to grow or shrink their way to success.

There are exceptions to this pattern.

Excellent organizations across diverse industries have demonstrated alternative paths to success. For example, while most corporate mergers fail, (4,5) most of Cisco's don't. (6) This helps explain why Cisco is currently one of the most valued companies in the world, third on last year's Fortune 100 Best Companies to Work For (7) and fourth on Fortune's list of America's Most Admired Companies in the Year 2000. (8)

They have a well-articulated dream and they use acquisitions to relentlessly shape themselves and their product line in a manner consistent with their vision. Their well-conceived and implemented acquisition processes are designed to reduce uncertainty, quash fears, reward people who produce results and remove surprises from the process.

And then there's Southwest Airlines.

Ranked number two on last year's Fortune's 100 List of Best Companies to Work For (7) and sixth on Fortune's list of America's Most Admired Companies (8) list, the organization's people rally around their trust in their senior executive.

Southwest president Herb Kelleher is renowned for his commitment to his employees and for keeping his word. Union leaders have acknowledged that his verbal word is better than anything written on a piece of paper. (3)

Kelleher's reputation for integrity built up over years of relentless consistency, a pattern that makes it safe for Southwest's' people to trust their leadership and collaborate as they move toward their vision.

Options for health care leaders

Physicians control the care given to patients. Administrators control organizational resources required to support patient care.

Working together in an environment of trust and collaboration, they can minimize wasted energy and resources, while maximizing value to be equitably distributed among those who have created it.

Working against each other, they doom everyone to a downward spiral of accusations, mistrust, wasted resources and lost control of their own futures. For those truly committed to recapturing control, it is time to partner with those who must also succeed if you are to reach your goals.

Building collaborative physician/organization partnership requires trust-- the trust that results from making and keeping commitments. Is your organization and its leadership deserving of that trust?

While most people feel they deserve trust, some have consistently demonstrated the behaviors required to build it while others have not. Covey, for example, tells us that trustworthiness demands conceptual and technical competence as well as the integrity and maturity required for effectively manifesting these skills. (9)

How would you know if these conceptual and technical competencies are present in your organization?

You can recognize conceptual skills -- the ability to see the big picture -- in the presence of well-articulated values, purpose, vision and goals. Similarly, the presence of technical skills is evident in the degree to which the systems and structures are in place to thoroughly instill these throughout your organization.

Figure 1 provides a short set of questions that lets you evaluate the degree to which your organization demonstrates the behaviors and outcomes worthy of the trust required for collaboration.

We suggest collecting candid, untraceable information from different perspectives (physicians, top, middle and lower level administrators, nurses and a cross section of additional employees).

Unless the results are consistently positive, take steps now to make the transitions necessary to model yourself after today's winning organizations.

Edward J. O'Connor, PhD is a principal with the Implementation Institute, a professor of management at the University of Colorado at Denver, a courtesy professor of management at the University of Oregon and a member of the faculty for the American College of Physician Executives and the Kaiser Consulting Network.

Michael H. Annison is president of The Westrend Group in Denver, Cob., a member of the Kaiser consulting network and co-author of Trust matters -New Dimensions of Health Care Leadership and author of the award-winning Managing the Whirlwind - Patterns and Opportunities in a Changing World.

References:

(1.) The American Heritage Dictionary. (Second college edition) Boston, Houghton Muffin Company, 1985.

(2.) Collins, JC., Forms, J.I. Built To Last. New York, Harper Business, 1994.

(3.) Freiberg, K., Freiberg, J. Nuts! Southwest Airlines' Crazy Recipe For Business And Personal Success. Bard Press, Austin, Texas, 1996.

(4.) Hoskison, R. E., Hitt, M. A. Downscoping. New York, Oxford University Press, 1994.

(5.) Colon, G., Gupta, A., Mango, P. "M & A malpractice." The McKinsey Quarterly. 1999, 1, 62-74.

(6.) Bunnell, D. Making The Cisco Connection. New York, John wiley & Sons, Inc., 2000.

(7.) Levering, R., Moskowitz, M. "The 100 Best Companies to Work For." Fortune. January 10, 2000, pp. 82-110.

(8.) Colvin, G. "America's most admired companies." Fortune. Feb. 21, 2000, p. 141.

(9.) Covey, S.R., Merrill, Merrill PA., First Things First. New York, Simon and Schuster, 1994.

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