Cascading improvements in communication: adopting a new approach to organizational communication.

Most large organizations are plagued by serious communication problems; the difficulties are especially prominent in large heterogeneous organizations where precise collaboration is critical.

Complex communication problems cannot be solved by merely never mentioning the distinction between specialists and support personnel, or physicians and non-physicians, or management and staff.

The real trouble is not caused by garden-variety problems such as simple misunderstandings, stylistic differences, disparities in training and pay or mismatched expectations.

The more subtle, pervasive and debilitating communication problems, we believe, stem from the fact that organizations inadvertently rely on simplistic and inadequate ideas of how communication works.

When we began working together three years ago to improve the organizational culture at Fallon Clinic in Worcester, Mass.--the largest group practice in central Massachusetts, with a national reputation for patient satisfaction and high quality care--we were both struck by the fact that communication problems were manifesting themselves with such variety that we barely knew where to begin.

For instance, an analysis of our e-mail system showed that we had about a dozen employees who routinely deleted important memos without reading them--in one case a full year after the memo was sent. We were also hearing complaints that meetings were too frequent, too long, and too ensnared by rumors--a habit that certainly did not bring out the best in the employees.

At one monthly staff meeting for Fallon Clinic managers three years ago, the new chief operating officer (COO) opened by introducing recent hires, and then audaciously asked for rumors to be voiced so that he could dispel or confirm them openly; there were almost a score of rumors called out and each one was met by loud murmurs of approbation, even applause.

We just had a conversation with an observer at another meeting in the same series and learned that when the COO asked for rumors this time, there was not a single one raised. Little wonder: Our annual employee survey had shown communication improving significantly over the last three years and reliance on rumors dropping steadily. These findings showed us the employees were becoming less troubled by (and less preoccupied with) rumors.

Finding communication solutions

Three years ago we hypothesized that the best course of action was to measure the corporate culture with a customized and focused diagnostic workplace survey and to adopt a new theory of communication based on four essential facts drawn from venerable work in sociology and new research on communication.

1. Addressees actively seek to determine the message's meaning.

2. Both the sender and addressee work to accommodate the other's point of view.

3. Good communication helps the addressee understand and more importantly, recall the message's content.

4. Effective communication in the workplace changes perceptions, opinions, attitudes, knowledge and behavior.

Our overall goal was to cascade information through the organization in a methodical manner that was conducive to clear understanding, accurate recall, and effective change.

Our approach marks a clear departure from the five common models of communication that we, and most corporate employees, typically encounter with distressing frequency.

Five over-utilized communication theories

Typical approaches to corporate communication are easy enough to identify:

1. The Marketing Theory of communication is especially prevalent in corporations today; it's based on the common belief that brevity, repetition, oversimplification and hyperbole are the key to good communication. This approach leads to a nearly constant flood of memos and meetings that sound as if something new is constantly being hawked again and again and again.

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2. The Legal Theory of communication stresses limitation of legal exposure, as if every act of communication was destined for litigation.

3. The Bureaucratic Theory of communication, much like the marketing approach, inundates recipients with an avalanche of information, but communicates without any attempt at novelty or perspective. The dull droning of this approach is what one former manager at IBM affectionately called "administrivia."

4. The Engineering Theory of communication portrays information exchange as a signal embedded in noise flowing over a single unidirectional channel between the sender and the receiver; it adopts the quaint notion that executives merely need to convey specifications and requirements, as if people were entirely devoid of their own perceptions, opinions, habits and desires.

5. The Family Theory goes to the other extreme, where nothing is written down and all communication is informal, off-the-record and emphatically private--just as it is in many family-owned businesses where privileged information stays within a tightly defined inner circle. Of course, things are not as two-dimensional as this outline seems to suggest; most of the time these different approaches coexist in changing combinations that depend on shifting exigencies.

Why is it helpful to understand the conventional theories of corporate communication? Because understanding them allows you to see where, how and why those theories cause subtle communication problems in the organization.

For example, by having different memoranda for physicians and non-physicians, we inadvertently adopted the Family Theory of communication and thereby exacerbated a counterproductive gap between physicians and non-physicians, making the latter feel as if they were second-class citizens.

By using the Bureaucratic Theory of communication during our patient referral process we were meeting requirements from health insurers, but unwittingly building a labyrinth of paperwork between specialists and primary care physicians, so that each had trouble getting a clear picture of the patient's experience from start to finish.

After mulling over these communication problems, and a few similar ones, we came to realize that the conventional approaches to organizational communication were causing a network of gaps and blockages throughout our organization.

In fact, we concluded that we had four distinctly different types of gaps and five types of blockages impeding communication; although the details of theses gaps and blockages were unique to Fallon Clinic, we believe their general features exist in many large corporations.

Gaps and blockages

Gaps fell into the following four groups:

1. Accountability gaps -- where the speaker and addressee misunderstand each other regarding their respective responsibilities associated with the communication

2. Expectation gaps -- where the speaker and addressee, often unbeknownst to either, have goals and assumptions that differ in critical respects

3. Standardization gaps -- where some parties in the communication are unaware of, or unwilling to follow, the organization's standardized routing path for communication

4. Culture gaps -- where miscommunication is caused by culture-based differences in implicit meaning or connotation 

We classified blockages into five groups:

1. Technology blockages -- where some but not all recipients are connected to a communication source

2. Access blockages -- where managers explicitly or implicitly refuse to release "their" information, or where they function as gatekeepers by denying access to all employees

3. Schedule blockages -- where time constraints impede quick information flow

4. Interaction blockages -- where personal conflicts, turf battles and the like prevent communication between people who would otherwise communicate openly

5. Compliance blockages -- where employees actively or passively refuse to participate, so that memos remain unread and meetings are consistently missed

To mend these blockages and gaps we adopted a new approach to communication and built a model showing how we wanted communication to cascade through the organization.

Closing the gaps

We began by making Fallon Clinic's management council (composed of the chief executive officer, chief financial officer, chief medical officer, chief operating officer, and chief human resources officer) responsible for improving communication flow and communication content simultaneously.

We discussed what we wanted communication to be like and provided a working outline of what we called the Cognitive Theory of Communication, which stresses:

1. Construction of meaning

2. Accommodation of perspective

3. Facilitation of memory

4. Communication with the explicit purpose of creating change

We made it clear that our goal was not instant transmission of every message, but communication accommodating the cognitive processes required for effective action. We envisioned that the end result would be a controlled, step-wise flow of information that would be integrated into each component of the organization before it passes to the subsequent level.

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Next, the council constructed a diagram of how we wanted communication to cascade down and across the hierarchy to every division, department, clinic, team and individual employee.

The council also did a comprehensive analysis of several important communication tasks such as making a referral to a specialist, handling a patient complaint or compliment, etc., and approached each as if the slate were clean.

This allowed the council to see the common elements of exemplary communication within our organization, and that naturally led to a list of common

features (in essence, a template) so that all communications could share headlines, structure and formatting.

The Cognitive Theory includes a straightforward but powerful notion that is often overlooked in large corporations: Every communication should be designed to induce change.

Because the initiative to improve communication came from the top of the organization and penetrated to all of its levels, it was possible for us to insist that communications be altered to fit the corporation's strategic plans.

Specifically, we established six strategic themes for Fallon Clinic, knowing that the themes covered the entire domain of strategic goals for the organization as a whole during the current fiscal cycle, and that the themes were important enough to be relevant (admittedly, to varying degrees) for every employee regardless of position.

All internal communications had to appear under the heading of a specific strategic theme:

* Business development & growth

* Profit

* Technology & process improvement

* Excellence in customer service & access

* Improve clinical quality & patient safety

* Strengthening the identity of Fallon Clinic

Templates made it easy for managers to organize meetings, minutes and memoranda so that they would be consistent and informative.

All executives provided their managers and committee chairs with a standard agenda for departmental meetings that included discussion of corporate and local performance using previously defined key metrics. Communication training sessions were held where managers learned how to conduct effective meetings and communicate more effectively.

A template for recording meeting minutes in tabular form included topic, report/discussion, conclusions/recommendations and, most importantly, expected follow-up. Because the council also had access to the list of participants and individuals receiving a record of the minutes, it was relatively easy to monitor company-wide progress on an ongoing basis.

The templates provided unusually high alignment of content, form, documentation and delivery across the entire organization; they also brought the virtual elimination of superfluous memos and meetings.

Moreover, because templates had a specific slot for local information, communications could maintain relevance without losing their fidelity on corporate issues. By establishing the strategic goals and building them into templates, our communications had more focus, greater efficiency, more business utility and less construction time--elements that (as all the research on communication shows) made them eminently more memorable and actionable.

Using this approach, we were able to reduce the number of committees, their size, and the frequency of their meetings. Because meetings and minutes are standardized, it is now easy to lighten the burden on managers and executives even further by rotating memberships on many committees.

Principles of effective communication

After building templates for memos and meetings, it became clear to us that we should move from the realm of theory and talk simply about the guiding principles behind our approach. They are:

* Communicate no faster than the speed of comprehension and integration.

* Communicate in a cascade that follows a planned step-wise process.

* Use the corporation's strategic goals as the organizing principle for every meeting and every memo.

* Communicate in context, with every meeting and every memo containing both organizational elements and local elements, so that addressees know how the new information will affect them.

* Specify the desired change that is being sought in attitude, opinion, perception, knowledge and/or behavior so addressees know how to follow through.

* Build in systems that monitor progress and generate documentation, so that both senders and addressees can stay apprised of the changes created by a communication.

* Communicate collaboratively, using the sender's name and contact number, so that memos or meetings can be part of a larger communicative exchange.

We are obviously not advocating that fire alarms and birthday greetings follow this same model; our approach is really designed to facilitate the kind of communication that changes the corporate culture.

Embodying the principles is a relatively straightforward task. For example, in our case the council formulated a communication plan that ran in two six-month cycles. Each executive was required to send a company-wide communication at regular intervals (not more than once every other month) incorporating specific themes of the strategic plan and the operational progress report of each current initiative.

Managers were reminded of the principles promulgated in the communication training sessions, especially stressing the fact that the meetings are to be participatory and collaborative, rather than a mere bucket brigade moving corporate policies and information down the line.

If appropriate follow through was not shown in the meeting minutes, the responsible manager and physician leader were contacted so they could close the loop with a written communication or an agenda item at the next group meeting.

Our process for improving communication between primary care physicians (PCPs) and specialists provides a fairly typical example:

* The responsible physician leader and his or her team created a telephone message system that compelled the PCP to complete a brief questionnaire regarding the consultation request.

* Accordingly, the PCP's request for a referral was always accompanied by a concise and explicit rationale for the requested consultation; correspondingly, the specialty care physician was compelled to use a similar system to outline his or her treatment plan.

* As the last step in this newly streamlined and standardized process, the electronic medical record system automatically sent the PCP and the specialist a written treatment record showing the rationale for the referral, the treatment plan, test results and the specialist's final summary.

Other communication problems were handled similarly. Though each problem was different in scope, mechanics, impact and etiology, all could be handled well with a common set of principles.

Building commitment

After the first year of the program we knew we had good reason to believe that improving communication at Fallon Clinic was critical. However, we also recognized that we would have to build commitment to making the necessary improvements. We did this by showing managers four things:

1. Internal benchmarks from the employee survey that identified communication as one of the organization's weakest points

2. Anonymous comments from survey respondents describing what was good and bad about communication

3. External benchmark scores comparing communication at Fallon Clinic to scores from the National Benchmark Study--a nationwide research project surveying a stratified random sample drawn from 22 million employees in 1,000 of the nation's largest corporations

4. Results from a linkage analysis conducted at Fallon Clinic in the previous year showing that communication had a strong causal linkage to patient satisfaction and profitability

Even skeptical managers were convinced about the importance of improving communication when they learned that last year's communication scores predicted this year's profits, and, moreover, that the greater the improvement in communication during the last year, the greater the improvement in profitability.

Baltej S. Maini, MD, is president of Fallon Clinic and Fallon Clinic Foundation in Worcester, Mass. He can be reached at 508-754-9981 or [e-mail]

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Palmer Morrel-Samuels, PhD, M.Phil, MA, is an expert witness (www.expertwitnesspsychology.com) and CEO of Employee Motivation and Employment Assessment, Inc (www. surveysforbusiness.com) in Chelsea, MI. He can be reached at 734-433-0344 or [e-mail].

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By Baltej S. Maini, MD, and Palmer Morrel-Samuels, PhD