Changing a culture of optionality to one of accountability

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by Bob Murphy, RN, Esq., FACHE

Would you consider allowing hand washing to be optional in your organization? No.

What about optional use of aspirin for a heart attack patient? No.

We all understand the absolute necessity of following evidence-based medicine protocols for providing good clinical care and are usually very prescriptive in what we do on the clinical side of our business. What about in leadership? Is the use of evidence-based leadership techniques mandatory in your organization? Do you require peer interviewing and 30- and 90-day questions to reduce turnover? Do you require that key words at key times be used to reduce anxiety? Or do you require postvisit phone calls to improve quality and service?

In most organizations today, the answer is no. If we are not deliberate in applying these techniques, they have the potential of becoming optional for leaders and staff members. Some leaders do not like the use of the word “mandatory,” so use “required.” There are some things we simply must do to get good results and provide good care.

Our research and work with hundreds of healthcare organizations and thousands of leaders and physicians have shown that a few simple techniques can help move a culture from one of optionality to one of accountability.

Objective evaluation system

The first component necessary in an accountable culture is that all leaders have an objective, measurable, weighted, and time-sensitive evaluation. The goals for each leader are tied to the organization’s goals.

Many organizations have evaluations that are subjective and competency-based, thus making it difficult to hold leaders accountable. Focusing on results, not activity, is what moves organizations forward.

The best way to use the objective evaluation is to require leaders to document progress monthly to reward meeting the required goals. Think about a personal example. If you balanced your checkbook once per year, how accurate would the result be? If you checked it monthly, it would likely be more accurate, and you could take quicker action to respond to changes. It is the same thing when you are measuring and reporting results monthly. If you find a negative variance in a monthly report card, you can react and change behavior much more quickly.

Leadership development

The second component of an accountable organization is providing regular leadership development and training. This training should be mandatory for all leaders. In many organizations, we evaluate the sessions. Excellent content and curriculums exist. The problem is that the courses are usually optional. So who do you think takes the classes? Typically, the leaders who need the training most are not likely to take an optional class.

A key leverage point in getting the most out of your leadership development is the use of linkage grids. A linkage grid is an accountability tool to help link training to behavior. Many training sessions are interesting or inspiring, but if the leaders who attended the training do not use what they have learned, if they do not behave in a new way, the training is in vain.

Before senior leaders and curriculum teams develop the topics and curriculum to be taught, they should decide the outcome intended. What new skill should be demonstrated by leaders following training? That becomes the linkage grid item. For example, in a training session for rounding for outcomes, the linkage grid item may say, “All leaders will round on their staff members as trained by x date.”

Keep in mind that giving leaders a linkage grid is only useful if we check compliance. Several methods of checking work well. One method is described below.

Supervisory meeting model

We have found that one of the most effective methods of reducing optionality is the use of the supervisory meeting model. This requires leaders to bring the following documents each time they meet with their boss for a supervisory session:

  • Annual goals
  • Current monthly report card
  • Current 90-day action plan
  • Most recent rounding logs
  • Most recent thank-you note log
  • Linkage grid to check compliance
  • Any other staff issues the leader wants to address

In this model of accountability, the senior leaders must set the tone. If senior leaders allow their direct reports to treat this as optional, it will have far-reaching consequences further down the ranks. I once canceled a supervisory session with a vice president because he did not bring all of the agreed-upon items to the session. It only happened once. Others get the message pretty quickly: bring the required documents. This is a powerful tactic and it is gaining traction with senior leaders.

Be careful not to assume that your direct reports are using this model with their staff members just because you are using the model. I was at a hospital recently where the vice president team was doing this perfectly, but the directors were not. It makes sense to routinely check by asking your direct reports for the logs and other verification tools of their direct reports as well.

Good verification systems

Former President Ronald Reagan is quoted as saying “trust but verify.” That is the theme of this tactic. We work with very talented people with wonderful integrity, but not all leaders prioritize the same way you do. We have found that although many of our leaders and staff members do exactly what we ask, 60% will not do some required tasks unless we check. Another 8%–10% may be thinking “this too shall pass.”

Therefore, it is possible that 70% of your staff will not complete the assignments you give, or not complete them on time, unless you check. If you are clear about expectations and check to see whether they are completed, you will find much greater compliance.

What should you verify? There are many systems being verified every day. We simply have to decide what is mandatory vs. what is optional. Collecting cash and copays: mandatory or optional? Doing a timeout in the operating room: mandatory or optional? Rounding for outcomes on staff members and patients: mandatory or optional? I know not everything can be mandatory, but it’s important to be clear about what is. Once decided, don’t make it complicated to measure and check.

For example, when rounding for outcomes, we originally created a single-page form that leaders filled out. Today, at the request of our partner organizations, we offer a computerized Rounding Manager. These tools allow the leader who is rounding to quickly document what he or she learns in order to follow up on promises made or questions asked. She can also share what she has learned with her boss, and her supervisor gets to verify that rounding occurred as expected. This is a win-win situation.

Reward and recognition

Finally, recognize that some leaders really get it and work very hard to meet all our expectations. For the leaders and staff members who consistently use the skills we teach or consistently implement the tactics of evidence-based leadership, reward and recognize them. Being consistent is difficult. We have so many things competing for our attention, so many distractions and pressures, that a leader who manages this well should be recognized. The use of thank-you notes, personal words of praise, and public recognition is critical. Tell others in the organization what is important and desired.

We know there are many things that are mandatory in healthcare today. There are zero-tolerance policies on theft, drug use, and violence in the workplace. In most organizations today, if you violate one of these policies, you are fired. There are mandatory behaviors that we cannot violate either. We have to decide as leaders what goes on that list of mandatory behaviors and how long we will tolerate noncompliance. The highest performing teams do not tolerate optionality for long.

Editor’s note: Murphy is a national speaker and coach for the Studer Group. He has more than 23 years of healthcare experience, including work as an RN, department leader of emergency/trauma services, quality leader, and chief operating officer. Murphy is also a paramedic, healthcare risk manager, attorney, and licensed forklift operator. He can be reached at