- Email: [email protected]
Cultivating the Citizenship and Culture You Want
Abstracts
Springer-Verlag London. Pages 1 – 515. ISBN: 978-1-4471-6586-6 (Print). 978-1-4471-6587-3 (Online). Published in 2014. 20. Barach P, Jacobs JP, Lipshultz SE, Laussen P. (Eds.). Pediatric and Congenital Cardiac Care - Volume 2: Quality Improvement and Patient Safety. Springer-Verlag London. 2015, Pages 1 – 456. ISBN: 978-1-4471-6565-1 (Print). 978-1-4471-6566-8 (Online). Published in 2014. doi:10.1016/j.ppedcard.2016.07.003
Cultivating the Citizenship and Culture You Want Kay Stewart-Hueya,, Cyrus Samai MDb a Children’s Healthcare of Atlanta, Atlanta, Georgia b Department of Pediatrics, Division of Cardiology, Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia ⁎Corresponding author at: Vice President, Sibley Heart Center, Children’s Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, Georgia 30322. E-mail address: [email protected] (K. Stewart-Huey) Background Cultivating the Citizenship and Culture You Want One of the benefits of a strong organizational culture that prioritizes trust and teamwork is employee citizenship. The purpose of this manuscript is to share a single institution’s experience in defining organizational citizenship and to provide recommendations for creating an organizational culture based in trust. Cultivating Citizenship A partner in your practice is suddenly called away to care for an ailing family member, leaving a clinic day without coverage. How do you react? You were looking forward to this day to catch up on emails, journal articles and to write that research paper due within a week. Instead, as the consummate team player, you cover the clinic for your colleague. This example is one of “citizenship” where you find yourself asking, “How can I help my fellow colleague for the greater good of the practice?” This scenario exemplifies is going above and beyond. This is citizenship. Creating, building, and maintaining a healthy organizational culture that fosters good citizenship is important to achieve success in a physician practice. A strong team culture may drive augmented efficiency, increased employee satisfaction, the ability to create better processes, and enable a practice to remain proficient in a dynamic health care environment. Conversely, poor team culture leads to a less engaged team, reduced productivity, increased staff turnover and may even impact the outcomes of patients. Some critics will argue that citizenship is about creating conformists who never challenge the status quo or develop creative solutions that push the boundaries of ordinary. The opposite occurs when true citizens are allowed to flourish. Organizations that embrace citizenship encourage employees, regardless of their seniority or level of expertise, to interact constructively to achieve a common goal: strengthening the organization to ensure its ongoing viability [21]. Before one can define good citizenship, one must first understand what fundamental elements are needed for a strong cultural foundation in which good citizenship can blossom. Many experts underscore that trust amongst all employees will promote constructive collaboration among the team members. Patrick Lencioni has promoted a theory that successful teams are founded on trust. Lencioni describes 5 dysfunctions of a team, which build upon one another (Figure 1). In summary, the foundation of a dysfunctional team is the absence of trust, defined as the inability to be vulnerable with one another about skill deficiencies, interpersonal shortcomings, or the need for assistance. Teams that lack trust avoid
39
constructive conflict, the discussion of pertinent data points critical for making the best decision. These teams lack commitment, and thus move forward with hesitation, if at all. They have no clarity around direction or commitment on priorities; therefore, these teams will not hold one another accountable to the same high standards and excessive bureaucracy results. Ultimately, dysfunctional teams cannot focus on collective results due to the lack of achievement orientation, and continued individualistic behavior, which destroys team morale [22]. Our Experience In an effort to gauge the health, culture, and commitment to citizenship of pediatric cardiology practices, a 10 question survey (with 2 comment sections) was sent to 122 Cardiac physician leaders around the country, achieving a 30% response rate (Figure 2). Survey results indicated more than 85% believe poor citizenship is detrimental to the team’s environment, and despite many groups not having a definition or code of expected behavior for citizenship, almost 80% of practices recognize acts of good citizenship. Nonetheless, most physician leaders did not believe quantifiable metrics for measuring citizenship existed. Our team felt it was important to evaluate and answer the following questions: why is citizenship important, how does one define citizenship, and how can we fairly measure citizenship? A colleague provided this analogy, “Citizenship was not only about everyone rowing in the same direction but also knowing everyone is pulling hard.” We worked to create a definition of citizenship for the practice by asking the questions of the physician group “Why are we successful at Sibley,” with the most frequent answer being team, (Figure 3) and “What do you see your Sibley colleagues doing that stand out to you as examples of good citizenship?” with the most common response being willingness to help others (Figure 4). Important in assessing your culture and level of citizenship, you may want to ask your team members, “Is our practice healthy enough to tackle the concept of citizenship by defining and creating our culture while setting the expectations that all of us will be rowing together? Does our practice value the concept of team-first? Are we willing to help others?” Cultivating a Healthy Organizational Culture All organizations are unique; however, by employing a collaborative process, an environment of trust can be established. First, you should assess the current state of your culture with a good understanding of your desired state. Next, determine the obstacles to reach your future desired state. Some organizations spend a long time to define their mission and values but neglect to critically evaluate the actions and behaviors of their team members. By defining your current culture, you can assess and develop values of importance. Engaging the physicians to define your culture allows them to evaluate the strengths and weaknesses of the practice and how they feel about them. Cultural fit affects job satisfaction according to the recent Physician Wellness Services/Cejka Search Organizational Culture Survey, 2013 [23]. The nationwide, multispecialty survey on organizational culture evaluated the responses of more than 2,200 physicians (82 percent of whom were in a hospital, group practice or academic medical center). The survey measured physician’s satisfaction in regards to 14 cultural attributes, which fell into four categories (work environment, organization, leadership and management, and communication) all measured on a 10-point Likert scale (Figure 5). The following were the most important cultural aspects from the survey: respectful and transparent communication, a patient-centered care focus, and supportive management approach to mistakes. If organizations focus on improving these three cultural aspects, the physicians (colleagues) will have higher job satisfaction and the practice will have greater employee retention. The Importance of Culture So why worry about cultural fit for physicians in the practice setting? Cultural fit affects not only a physician’s satisfaction, but also
40
Abstracts
their recruitment and retention. More than 50 percent of respondents understood that lack of cultural fit had a strong influence on their decision to leave their former practice. There are several key factors involved in building the culture that a practice desires and to make this process successful. Practice leaders must engage the physicians in crafting and defining their culture (early and often) and potentially have the physicians lead specific efforts. Consider the following suggestions for improving engagement: • Involve physicians in the overall organizational goals by fostering and soliciting their ideas into the strategic planning, budgeting process, and meeting frequently to discuss strategy and operations. • Keep the focus on the patient, rather than the hospital or doctors, during decision-making. • Provide IT support, other relevant resources and technology to help gain operational efficiencies. • Make behavioral expectations clear, and promptly deal with toxic behavior to avoid undermining good behavior. If necessary, consider developing a team compact outlining the desired team behaviors and if applicable, a mutually agreed-upon physicianhospital compact that delineates the physicians' obligations to the hospital and vice versa [24]. • Build a culture of trust by following through on promises, and not failing to communicate important information or make unilateral changes without explanation. Creating Trust Trust is essential and the foundation to creating an effective team and strong culture, because trust provides a sense of safety (Figure 6). When your team members feel safe with each other, they feel comfortable to be candid, to take appropriate risks, and to expose vulnerabilities. Without trust, innovation, collaboration, creative thinking, and productivity suffer. Simultaneously, employees protect themselves and their interests. Trust is essential for knowledge sharing. If team members trust one another, they are far more likely to share knowledge, and communicate openly [25]. As a leader, what can you do to create a culture of trust within your team? (Figure 7) Lead by Example If you want to build trust within your team, then lead by example and show your people that you trust others. Follow your own rules and do what you ask of others. Never forget that your team members are always watching and taking cues from you. Communicate Openly Open communication is essential for building trust. Define your group’s purpose and how you will work together with a defined group of core values. You need to get everyone on your team talking to one another in an honest and meaningful way. Meet regularly, so that all team members have a chance to talk about their challenges, successes and failures. This time spent faceto-face is an important part of relationship building, and creates opportunities for collaborative problem solving. Make sure that you "walk the talk". When you have important or relevant information to share, do so immediately with the group. The more you share with your team members, and thereby prove that you have no hidden agenda, the more comfortable the team will feel trusting you and each other. Provide transparency, not only with your internal team, but also with referring physicians and patient families. Get to Know People Personally One way to build trust is to encourage your team members to see their colleagues as people. Think about creating situations that help them share personal stories and bond. Consider outings with your colleagues (sports events, or special work events such as anniversaries, birthdays, and other special events).
Don't Place Blame When people work together, honest mistakes and disappointments happen and blame comes easy. However, when everyone starts pointing fingers, an unpleasant atmosphere escalates. This behavior lowers morale, undermines trust, and is ultimately unproductive. Instead, promote a “Just Culture” mindset. In the Just Culture mindset, a learning culture is promoted over a punitive one. Encourage honesty and accountability, and understand that anyone is capable of error. Discourage Cliques Sometimes cliques can form within a team, often between team members who share common interests or work tasks. However, these groups can inadvertently make others feel isolated. Cliques can also undermine trust between group members. Only by addressing the issue openly can you discourage this damaging behavior. Discuss Trust Issues If you manage an established team that has trust issues, it is imperative to find out how these problems originated. Understanding the root of the problems allows you to devise strategies to overcome them. Consider giving team members an anonymous questionnaire. Ask these team members about their perceived level of trust within the group, as well as why they think there is a lack of trust. Once you have read the results, convene the team to talk about these issues and respect the anonymity of the survey. Nurturing the Culture It is not enough to define and build your organizational culture, but culture must also be reinforced and nurtured. Starting with recruitment is a good way to build the foundation. Developing assessment tools and processes, and using behavioral interviewing techniques to evaluate candidates about conflict management, teamwork, and communication is essential to ensure they fit your cultural expectations. Creating onboarding programs will educate and reinforce cultural norms for newly hired team members. For existing staff, choosing physician leaders who exemplify the desired cultural attributes will assist in reinforcing the cultural standards of the organization.
Figure 1
Figure 2
Abstracts
41
Figure 3 Figure 7
Ultimately, achieving cultural fit is about setting expectations, and changing behaviors and attitudes — not just those of physicians, but all stakeholders who work alongside them. Achieving cultural harmony will benefit the practice by creating a stronger sense of engagement with its physicians while improving satisfaction with their jobs and careers.
Figure 4
References 21. Bolino, Mark C., and William H. Turnley. "Going the Extra Mile: Cultivating and Managing Employee Citizenship Behavior." Academy of Management Executive (2003): 60-71. Print. 22. Lencioni, Patrick. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco: Jossey-Bass, 2002. Print. 23. Research and News. "Physician Wellness Services Organizational Culture Survey.” Web. 21 Aug. 2015. 24. "Creating Strong Team Culture - STEPS Forward." STEPSforward.org. Web. 20 Aug. 2015. 25. Ferrara, J. (2015, September 4). Trust. Workshop lecture presented at Children's Healthcare of Atlanta, Atlanta, GA. doi:10.1016/j.ppedcard.2016.07.004
Figure 5
Figure 6
Creating an Organization of Leaders: A Positively Deviant Approach Lynn Perry Wooten PhD Ross School of Business, University of Michigan, Ann Arbor, MI, USA ⁎Clinical Professor of Strategy, Management & Organizations, Ross School of Business, University of Michigan, 701 Tappan Street, Ann Arbor, Michigan 48109-1234, USA. E-mail address: [email protected] (L.P. Wooten) Creating an Organization of Leaders: A Positively Deviant Approach The notion that you can lead from any position in an organization is often a novel concept. Many individuals associate leadership with a specific title or think of a leader as the person who has the highest position or rank in an organization. Yet based upon both research and the observation of actual practices, we know that in highperforming organizations, leadership is everyone’s business. When leadership is everyone’s business, organizational members recognize that leadership is a skill and way of being that can be learned through self-development and collaborative processes [26]. Moreover, with this mentality, organizational members invest their time and energy in creating a work environment in which others can contribute their best self and flourish as they collaboratively work toward shared aspirations and exceeding performance expectations.
Springer-Verlag London. Pages 1 – 515. ISBN: 978-1-4471-6586-6 (Print). 978-1-4471-6587-3 (Online). Published in 2014. 20. Barach P, Jacobs JP, Lipshultz SE, Laussen P. (Eds.). Pediatric and Congenital Cardiac Care - Volume 2: Quality Improvement and Patient Safety. Springer-Verlag London. 2015, Pages 1 – 456. ISBN: 978-1-4471-6565-1 (Print). 978-1-4471-6566-8 (Online). Published in 2014. doi:10.1016/j.ppedcard.2016.07.003
Cultivating the Citizenship and Culture You Want Kay Stewart-Hueya,, Cyrus Samai MDb a Children’s Healthcare of Atlanta, Atlanta, Georgia b Department of Pediatrics, Division of Cardiology, Sibley Heart Center Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia ⁎Corresponding author at: Vice President, Sibley Heart Center, Children’s Healthcare of Atlanta, 1405 Clifton Road, NE, Atlanta, Georgia 30322. E-mail address: [email protected] (K. Stewart-Huey) Background Cultivating the Citizenship and Culture You Want One of the benefits of a strong organizational culture that prioritizes trust and teamwork is employee citizenship. The purpose of this manuscript is to share a single institution’s experience in defining organizational citizenship and to provide recommendations for creating an organizational culture based in trust. Cultivating Citizenship A partner in your practice is suddenly called away to care for an ailing family member, leaving a clinic day without coverage. How do you react? You were looking forward to this day to catch up on emails, journal articles and to write that research paper due within a week. Instead, as the consummate team player, you cover the clinic for your colleague. This example is one of “citizenship” where you find yourself asking, “How can I help my fellow colleague for the greater good of the practice?” This scenario exemplifies is going above and beyond. This is citizenship. Creating, building, and maintaining a healthy organizational culture that fosters good citizenship is important to achieve success in a physician practice. A strong team culture may drive augmented efficiency, increased employee satisfaction, the ability to create better processes, and enable a practice to remain proficient in a dynamic health care environment. Conversely, poor team culture leads to a less engaged team, reduced productivity, increased staff turnover and may even impact the outcomes of patients. Some critics will argue that citizenship is about creating conformists who never challenge the status quo or develop creative solutions that push the boundaries of ordinary. The opposite occurs when true citizens are allowed to flourish. Organizations that embrace citizenship encourage employees, regardless of their seniority or level of expertise, to interact constructively to achieve a common goal: strengthening the organization to ensure its ongoing viability [21]. Before one can define good citizenship, one must first understand what fundamental elements are needed for a strong cultural foundation in which good citizenship can blossom. Many experts underscore that trust amongst all employees will promote constructive collaboration among the team members. Patrick Lencioni has promoted a theory that successful teams are founded on trust. Lencioni describes 5 dysfunctions of a team, which build upon one another (Figure 1). In summary, the foundation of a dysfunctional team is the absence of trust, defined as the inability to be vulnerable with one another about skill deficiencies, interpersonal shortcomings, or the need for assistance. Teams that lack trust avoid
39
constructive conflict, the discussion of pertinent data points critical for making the best decision. These teams lack commitment, and thus move forward with hesitation, if at all. They have no clarity around direction or commitment on priorities; therefore, these teams will not hold one another accountable to the same high standards and excessive bureaucracy results. Ultimately, dysfunctional teams cannot focus on collective results due to the lack of achievement orientation, and continued individualistic behavior, which destroys team morale [22]. Our Experience In an effort to gauge the health, culture, and commitment to citizenship of pediatric cardiology practices, a 10 question survey (with 2 comment sections) was sent to 122 Cardiac physician leaders around the country, achieving a 30% response rate (Figure 2). Survey results indicated more than 85% believe poor citizenship is detrimental to the team’s environment, and despite many groups not having a definition or code of expected behavior for citizenship, almost 80% of practices recognize acts of good citizenship. Nonetheless, most physician leaders did not believe quantifiable metrics for measuring citizenship existed. Our team felt it was important to evaluate and answer the following questions: why is citizenship important, how does one define citizenship, and how can we fairly measure citizenship? A colleague provided this analogy, “Citizenship was not only about everyone rowing in the same direction but also knowing everyone is pulling hard.” We worked to create a definition of citizenship for the practice by asking the questions of the physician group “Why are we successful at Sibley,” with the most frequent answer being team, (Figure 3) and “What do you see your Sibley colleagues doing that stand out to you as examples of good citizenship?” with the most common response being willingness to help others (Figure 4). Important in assessing your culture and level of citizenship, you may want to ask your team members, “Is our practice healthy enough to tackle the concept of citizenship by defining and creating our culture while setting the expectations that all of us will be rowing together? Does our practice value the concept of team-first? Are we willing to help others?” Cultivating a Healthy Organizational Culture All organizations are unique; however, by employing a collaborative process, an environment of trust can be established. First, you should assess the current state of your culture with a good understanding of your desired state. Next, determine the obstacles to reach your future desired state. Some organizations spend a long time to define their mission and values but neglect to critically evaluate the actions and behaviors of their team members. By defining your current culture, you can assess and develop values of importance. Engaging the physicians to define your culture allows them to evaluate the strengths and weaknesses of the practice and how they feel about them. Cultural fit affects job satisfaction according to the recent Physician Wellness Services/Cejka Search Organizational Culture Survey, 2013 [23]. The nationwide, multispecialty survey on organizational culture evaluated the responses of more than 2,200 physicians (82 percent of whom were in a hospital, group practice or academic medical center). The survey measured physician’s satisfaction in regards to 14 cultural attributes, which fell into four categories (work environment, organization, leadership and management, and communication) all measured on a 10-point Likert scale (Figure 5). The following were the most important cultural aspects from the survey: respectful and transparent communication, a patient-centered care focus, and supportive management approach to mistakes. If organizations focus on improving these three cultural aspects, the physicians (colleagues) will have higher job satisfaction and the practice will have greater employee retention. The Importance of Culture So why worry about cultural fit for physicians in the practice setting? Cultural fit affects not only a physician’s satisfaction, but also
40
Abstracts
their recruitment and retention. More than 50 percent of respondents understood that lack of cultural fit had a strong influence on their decision to leave their former practice. There are several key factors involved in building the culture that a practice desires and to make this process successful. Practice leaders must engage the physicians in crafting and defining their culture (early and often) and potentially have the physicians lead specific efforts. Consider the following suggestions for improving engagement: • Involve physicians in the overall organizational goals by fostering and soliciting their ideas into the strategic planning, budgeting process, and meeting frequently to discuss strategy and operations. • Keep the focus on the patient, rather than the hospital or doctors, during decision-making. • Provide IT support, other relevant resources and technology to help gain operational efficiencies. • Make behavioral expectations clear, and promptly deal with toxic behavior to avoid undermining good behavior. If necessary, consider developing a team compact outlining the desired team behaviors and if applicable, a mutually agreed-upon physicianhospital compact that delineates the physicians' obligations to the hospital and vice versa [24]. • Build a culture of trust by following through on promises, and not failing to communicate important information or make unilateral changes without explanation. Creating Trust Trust is essential and the foundation to creating an effective team and strong culture, because trust provides a sense of safety (Figure 6). When your team members feel safe with each other, they feel comfortable to be candid, to take appropriate risks, and to expose vulnerabilities. Without trust, innovation, collaboration, creative thinking, and productivity suffer. Simultaneously, employees protect themselves and their interests. Trust is essential for knowledge sharing. If team members trust one another, they are far more likely to share knowledge, and communicate openly [25]. As a leader, what can you do to create a culture of trust within your team? (Figure 7) Lead by Example If you want to build trust within your team, then lead by example and show your people that you trust others. Follow your own rules and do what you ask of others. Never forget that your team members are always watching and taking cues from you. Communicate Openly Open communication is essential for building trust. Define your group’s purpose and how you will work together with a defined group of core values. You need to get everyone on your team talking to one another in an honest and meaningful way. Meet regularly, so that all team members have a chance to talk about their challenges, successes and failures. This time spent faceto-face is an important part of relationship building, and creates opportunities for collaborative problem solving. Make sure that you "walk the talk". When you have important or relevant information to share, do so immediately with the group. The more you share with your team members, and thereby prove that you have no hidden agenda, the more comfortable the team will feel trusting you and each other. Provide transparency, not only with your internal team, but also with referring physicians and patient families. Get to Know People Personally One way to build trust is to encourage your team members to see their colleagues as people. Think about creating situations that help them share personal stories and bond. Consider outings with your colleagues (sports events, or special work events such as anniversaries, birthdays, and other special events).
Don't Place Blame When people work together, honest mistakes and disappointments happen and blame comes easy. However, when everyone starts pointing fingers, an unpleasant atmosphere escalates. This behavior lowers morale, undermines trust, and is ultimately unproductive. Instead, promote a “Just Culture” mindset. In the Just Culture mindset, a learning culture is promoted over a punitive one. Encourage honesty and accountability, and understand that anyone is capable of error. Discourage Cliques Sometimes cliques can form within a team, often between team members who share common interests or work tasks. However, these groups can inadvertently make others feel isolated. Cliques can also undermine trust between group members. Only by addressing the issue openly can you discourage this damaging behavior. Discuss Trust Issues If you manage an established team that has trust issues, it is imperative to find out how these problems originated. Understanding the root of the problems allows you to devise strategies to overcome them. Consider giving team members an anonymous questionnaire. Ask these team members about their perceived level of trust within the group, as well as why they think there is a lack of trust. Once you have read the results, convene the team to talk about these issues and respect the anonymity of the survey. Nurturing the Culture It is not enough to define and build your organizational culture, but culture must also be reinforced and nurtured. Starting with recruitment is a good way to build the foundation. Developing assessment tools and processes, and using behavioral interviewing techniques to evaluate candidates about conflict management, teamwork, and communication is essential to ensure they fit your cultural expectations. Creating onboarding programs will educate and reinforce cultural norms for newly hired team members. For existing staff, choosing physician leaders who exemplify the desired cultural attributes will assist in reinforcing the cultural standards of the organization.
Figure 1
Figure 2
Abstracts
41
Figure 3 Figure 7
Ultimately, achieving cultural fit is about setting expectations, and changing behaviors and attitudes — not just those of physicians, but all stakeholders who work alongside them. Achieving cultural harmony will benefit the practice by creating a stronger sense of engagement with its physicians while improving satisfaction with their jobs and careers.
Figure 4
References 21. Bolino, Mark C., and William H. Turnley. "Going the Extra Mile: Cultivating and Managing Employee Citizenship Behavior." Academy of Management Executive (2003): 60-71. Print. 22. Lencioni, Patrick. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco: Jossey-Bass, 2002. Print. 23. Research and News. "Physician Wellness Services Organizational Culture Survey.” Web. 21 Aug. 2015. 24. "Creating Strong Team Culture - STEPS Forward." STEPSforward.org. Web. 20 Aug. 2015. 25. Ferrara, J. (2015, September 4). Trust. Workshop lecture presented at Children's Healthcare of Atlanta, Atlanta, GA. doi:10.1016/j.ppedcard.2016.07.004
Figure 5
Figure 6
Creating an Organization of Leaders: A Positively Deviant Approach Lynn Perry Wooten PhD Ross School of Business, University of Michigan, Ann Arbor, MI, USA ⁎Clinical Professor of Strategy, Management & Organizations, Ross School of Business, University of Michigan, 701 Tappan Street, Ann Arbor, Michigan 48109-1234, USA. E-mail address: [email protected] (L.P. Wooten) Creating an Organization of Leaders: A Positively Deviant Approach The notion that you can lead from any position in an organization is often a novel concept. Many individuals associate leadership with a specific title or think of a leader as the person who has the highest position or rank in an organization. Yet based upon both research and the observation of actual practices, we know that in highperforming organizations, leadership is everyone’s business. When leadership is everyone’s business, organizational members recognize that leadership is a skill and way of being that can be learned through self-development and collaborative processes [26]. Moreover, with this mentality, organizational members invest their time and energy in creating a work environment in which others can contribute their best self and flourish as they collaboratively work toward shared aspirations and exceeding performance expectations.