Understanding your dimensions of agreement.

A community hospital, looking to the future, develops a new vision and implementation blueprint to lead its organization in a new direction. However, when the vision is presented to the hospital's medical staff, it is greeted with anything but enthusiasm.

The medical staff leadership makes it clear to the hospital administration that they do not agree with this vision and new direction. Are the physicians just being obstinate? How should have the hospital approached the change initiative with them? Could they have anticipated the medical staffs response?

A recent Harvard Business Review article titled "The Tools of Cooperation and Change" argues that there is a process for selecting the appropriate tools to bring about cooperation and change. (1) The process involves determining the level of agreement in an organization along two key dimensions.

The first dimension assesses the degree to which individuals or groups within an organization agree on what they want. This level of agreement is reflected in their values, priorities, and in the trade-offs they are willing to make to achieve a desired result. This dimension of agreement asks the question, "To what degree are people in this organization united around a common goal?"

The second dimension assesses the degree to which individuals or groups in an organization agree on cause and effect. It is a measure of the extent to which they agree on how to achieve what they want. It asks the question, "Is there agreement on actions which will lead to a desired outcome?"

These two dimensions may be graphed to create an "agreement matrix." (1) Organizations or programs in the left, lower quadrant represent those where there is little agreement on either what they want or how to get there.

Medicare is an example of a program where the level of agreement is in the left, lower quadrant of the matrix. The government, physicians, hospitals, patients, and all other stakeholders, both public and private cannot agree on what it is they want from the Medicare program. Likewise, none of them can agree on how to achieve any desired outcomes.

Organizations in the right, lower quadrant of the matrix have a high level of agreement on cause and effect, but not on what they want. The extent of agreement between many medical staffs and hospital administrators falls within this quadrant. Medical staffs and hospitals may have little agreement as to what they want as it relates to their respective futures, but may have a high level of agreement on certain actions that will lead to a desired outcome.

For example, both may agree that certain protocols and procedures, if initiated, may improve the quality and safety of care to patients, and as a result, will cooperate to follow those protocols and procedures.

The left, upper quadrant of the matrix represents high levels of agreement on common goals, but low levels of agreement on actions that will lead to desired outcomes. Hospital administrators who know they need to expand or start new service lines to increase volume and improve operating margin, but cannot agree on the areas in which to expand and grow, will fall into this quadrant.

Finally, organizations in the right, upper quadrant have high levels of agreement both as to what they want and how to achieve their desired outcomes. An example of an organization fitting into this quadrant would be a physician-owned and operated, ambulatory care center.

The right tools for the job

While one may be tempted to conclude that all organizations should aspire to be in the right, upper quadrant of the agreement matrix, this is not necessarily the case. There is no "best" position on the matrix. (1) The value of the matrix is that by understanding the level of agreement on these two dimensions, you can determine the appropriate tools to use to enhance cooperation and collaboration to bring about change.

Where an organization or group sits in the agreement matrix will determine the appropriate tools to use. Organizations in the left, lower quadrant will require what the article's authors call "power tools." (1)

Since there is neither agreement on what the organization wants nor how to get desired outcomes, tools such as mandates, fiat and coercion must be used to bring about change.

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Organizations in the right, lower quadrant will require "management tools" to improve cooperation and collaboration. (1) These include incentives, training, education and outcome measurements.

"Leadership tools" are required in the left, upper quadrant where the individuals or groups in an organization are united around a common goal. (1) These tools include vision, salesmanship and role modeling.

Finally, those in the right, upper quadrant require "culture tools" such as tradition and rituals. (1) In this quadrant, cooperation and change only will occur if they fit within the tradition and strongly held beliefs and culture of the organization.

Organizations may fail to achieve the cooperation and collaboration needed to bring about change because the wrong tools are utilized for where the individuals or groups fall in the agreement matrix.

In the community hospital example, it's not surprising that the medical staff would respond negatively to a new vision to bring about change if the hospital administration's level of agreement with the medical staff fell in the right, lower quadrant of the matrix.

The hospital would have been more successful achieving cooperation and collaboration through management tools such as incentives. Likewise, one could postulate that Medicare's impending pay-for-performance program, an incentive program, will not be successful since it is an inappropriate tool for where this program falls in the agreement matrix.

Could the community hospital have been successful using vision, even if its level of agreement with the overall medical staff was in the right, lower quadrant of the agreement matrix?

Fortunately, organizations can use the "tool of disaggregation" (1) to bring about collaboration and change. If the hospital had selected groups or individual physicians within the medical staff who shared a common goal that aligned with the hospital's new vision, it could have achieved cooperation and buy-in.

For example, if the new vision involved expanding cardiac care, it could have disaggregated the medical staff into a cardiac service line, including the cardiologists, cardiac surgeons and intensivists. By separating out those individuals who may be united around common goals of cardiac care (falling into the left, upper quadrant of the agreement matrix), vision would be an effective tool to use.

In order for organizations to bring about change, they must garner cooperation and collaboration from groups and individuals who work within their organization. By understanding where those groups and individuals fall in the agreement matrix, they can choose the right tools for the right time, and for the right individuals.

David P. Tarantino, MD, MBA, is executive medical director of Shock Trauma Associates, PA., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at [e-mail].

Reference

1. Christensen CM, Marx M, and Stevenson HH. "The Tools of Cooperation and Change." Harvard Business Review., October 2006.

By David P. Tarantino, MD, MBA

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