Management by walking our talk.

An old friend and colleague, a cardiovascular surgeon, became the CEO of a large multispecialty group practice. My work with the organization involved aiding the board in its efforts to create an excellence-oriented culture. In the course of talking with people from all levels--from Board members to housekeepers--I was impressed with an intriguing pattern. Discussing the climate in the organization, people spontaneously mentioned how much my colleague, I'll call him Dr. Bob, "really cared about people."

Dr. Bob had a wonderful habit. He would not allow a single week to pass without sending a personal note to at least one individual, complete with a copy to the person's supervisor, saying that he had seen them doing something well and expressing his appreciation. Most of the people I spoke to had not received such a note, but because sincere recognition has a positive ripple effect, they knew of his habit. It did not surprise me that the clinic's reputation in the community slipped badly upon his retirment. Increasingly now, people refer to the clinic as a place that seems "not to really care about people."

I discussed this pattern with my friend several times while he was CEO. It took a while to ease him over his initial embarrassmeent: "It's no big deal. It doesn't take much of my time, and it seems to really make people feel better about themselves." The more he talked about the habit he trivialized, the more I realized that he was using a tightly knit theory of excellence vis-a-vis high-quality, patient-centered care--every health-care organization's espoused mission.

"If I don't observe someone doing something exceptionally well," he commented, "it's because I'm not paying careful attention." The practical implications of this single element of his theory of management are incredibly profound . First of all, he assumed that, somewhere in the organization, someone was behaving in an excellence-oriented way all the time. This element of his belief system is consistent with McGregor's famous Theory Y. [2] Second of all, he presumed that observance was his responsibility as a manager. He had to notice what was already there, and he had to do it at least once every week. By noticing excellence and rewarding it, he cultivated more excellence within his clinic. It was like watering a tree, providing nourishment for it to bear fruit.

As modern managers not only espouse Theory Y principles but also put them into action ("walk their talk"), organizational excellence will become common. Theory Y predicts two likely outcomes of Dr. Bob's walking his talk. By habitually taking the time to be sure he was attentive enough to notice behaviors he expected and to take action to write a note, he was creating a self-fulfilling prophecy, a "Behavioral Quality Assurance" effect. [3,4] As others have noted, creating new habits is at the core of the business of patient-centered quality care. "When staff and employees experience acknowledgement, ressect, and support for their work, they tend to reflect this in the manner in which they care for and respond to patients." [5] This is a common-sense theory but an uncommon occurence. We believe in the talk, but we do not walk it regularly.

All managers have theories of effective managerial behavior. Our theories influence what we notice in a world flooded with information. Like lenses on sunglasses, they filter certain light rays. Managers with Theory X glasses will see employees as lazy and unmotivated; they will notice the brown leaves on the tree. Managers with Theory Y glasses will see employees as productive and creative; they will see--and enjoy--the fruit. It is in this sense that all theories become self-fulfilling over time.

We cannot prevent havits. We develop them early, and they serve us well. What we can do is take the steps to alter thenature of our habits by:

* Becoming aware of our habits.

* Having a clear idea about the chain that links our habits to patient-centered quality care.

* Putting our beliefs (our theories) into action.

Having a habit means that you don't have to remind yourself. Without much forethought, some managers take a few moments at the close of every staff meeting for a quick around-the-table response to the question "How do you feel about meeting today?" For shorthand purposes, we'll label this FFF, face-to-face feedback. The managers' logic might sound like this: "FFF in staff meeting is a health maintenance measure. Pinches that develop during the meetings can be remedied before they fester. People are less likely to leave the meeting feeling bad about me or about one another, or thinking that it wasted their time today. There may be less grumbling in the hallways or less putting people down behind their backs. Maybe more energy will be available to focus on our jobs, and the climate here will be a little more friendly. It's no big deal, and, who knows, it might make some patients feel better about themselves if they encounter an employee who's smiling."

Another person's logic could also begin with FFF but follow a different path to a similar bottom line: "I believe that all growth--and healing is a growing toward wellness--depends on feedback. FFF in my staff meetings sets a norm for my people. It tells them that, as their boss, I expect there to be opportunities for improvement (no matter how good we are); I expect them to have ideas about how we can improve, including most specially, me and my behavior; and I expect people to be unafraid to speak their minds. Maybe if they see me engaging in regular FFF, they will do the same with their people. Maybe this habit will trickle down to an examination room, and FFF will take place between a patient and a provider. Who knows, the feedback might even be praise! Feedback is the lifeblood of excellence."

To achieve this level of awareness for yourself, you need to reflect on the following three questions:

* What specific habits do you bring to your job?

* Which two or three of these do you believe contribute to the quality of care that patients receive in your institution? In other words, which of your habits contribute to people feeling better?

* What is the logic that links your habits to the bottom-line of patient-centered quality care? How does your habit trickle its way to making patients feel better?

A Call to Action

Take a few moments to translate your awareness of your management habits onto paper. Please write your answers to the questions above, and mail them to:

Irwin Rubin, PhD Temenos Foundation P.O. Box 37130 Honolulu, Hawaii 96837

Please include a brief description of your role (surgeon, department head, COO, etc.) and type of institution (hospital, group practice, HMO, etc.). Names, while welcome, are not necessary.

In a future article, we will create a composite theoretical model of the behaviors that health care professionals put into day-to-day practice because they believe that these habits affect the bottom line of helping people to feel better about themselves.

References

[1] Peters, T., and Waterman, R. In Search of Excellence. New York, N.Y.: Harper & Row, 1982.

[2] McGregor, D. "The Human Side of Enterprise." First published in Adventure in Thought and Action, Proceedings of the Fifth Anniversary Convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, April 9, 1957. Cambridge, Mass.: M.I.T. School of Industrial Management, 1957, and reprinted in Management Review 46(11):22-8,88-92, Nov. 1957.

[3] Rubin, I., and Inguagiato, R. "Behavioral Quality Assurance: A Transforming Experience." Physician Executive 16(5):30-3, Sept.-Oct. 1990

[4] Rubin, I., and Fernandez, C. My Pulse Is Not What It Used To Be: The Leadership Challenges in Health Care. Honolulu, Hawaii: Temenos Foundation, 1991, pp. 99-103.

[5] Eichborn, S., and others. "Changing the Way We Work." Healthcare Forum 34(2):45, March-April 1991.

Irwin M. Rubin, PhD, is President of Temenos, Inc., Honolulu, Hawaii.