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© 2019 The Greeley Company LLC, Phone: (888) 749-3054 1

Dear Greeley Essential Conversations in Practice Participant,

We look forward to your participation in the course at Boca Raton Resort and Club-A Waldorf Astoria Resort on December 6, 2019.

Your program will start at 12:45 pm and end by 3:00 pm.

This program was inspired by the book, Crucial Conversations: Tools for Talking When Stakes are High. Attendees are encouraged to read the book prior to attending the afternoon session.

Attendees are welcome to stay for an additional 1-hour following the conclusion of the afternoon program to workshop crucial conversations in small groups led by Greeley faculty. Those who wish to participate are asked to bring 1 example of a crucial conversation that they would like to workshop.

Lunch will be served in the meeting room.

Boca Raton Resort and Club-A Waldorf Astoria Resort501 East Camino Real Boca Raton, FL 33432 888.543.1277In this PDF packet, you will find:

• The presenters' PowerPoint slides

We encourage you to bring your personal business cards to the event for networking purposes. In addition, we suggest that you bring a sweater or dress in layers as temperatures in the meeting rooms vary. Again, we look forward to seeing you in Phoenix!

Sincerely,

Lauren Belliveau Vice President Staffing and Education The Greeley Company

Additional Information:Please plan to attend our Networking Reception starting at 4:00 pm on Thursday, December 5, 2019 sponsored by Greeley Interim Staffing. Enjoy refreshments in a relaxing atmosphere while networking with our faculty and your peers. Dress is casual and guests who have traveled with you are welcome to join.

Please join us for an optional session for all attendees: Friday, December 6 at 7:00-7:45 a.m. “Controversies in Board Certification.” This session addresses MOC, alternative certifying boards, and the link between board certification and quality. CME/CE will be provided.

Copyright 2019 The Greeley Company LLC. All rights reserved. These materials may not be duplicated

without the express written permission of The Greeley Company LLC.1

Essential Conversationsin Practice

Presented By

Laura Rife, MD, MBA

David Tarantino, MD, MBA

Copyright 2018 The Greeley Company LLC. All rights reserved. These materials may not be duplicated without the express written permission of The Greeley Company LLC.

Textbook: Crucial Accountability: Tools for Resolving Violated Expectations, Broken Commitments, and Bad Behavior

Kerry Patterson, Joseph Grenny,David Maxfield, Ron McMillan, And Al Switzler

First edition published as Crucial Confrontations


How Do We Find Ourselves in an Accountability Conversation?

EXPECTATION

PERFORMANCE

= GAP




Take Corrective Action

Measure PerformanceAgainst Expectations

Set, Communicate & AchieveBuy-In to Expectations

Appoint Excellent Practitioners

Manage PoorPerformance

Provide PeriodicFeedback

The Greeley Performance PyramidHow to optimize practitioner performance

6

5

4

3

2

1

Accountability


Why is Crucial Accountability so Difficult?

▪ If I say nothing, I perpetuate a problem.

▪ If I speak up, I create a new problem.

▪ We feel trapped between two unattractive alternatives


Why is Crucial Accountability Important?

▪ Two-thirds of people the authors polled suggested that they can hardly stand going to family holiday gatherings because one or more of their relatives will do something offensive, yet nobody says a word

▪ Ninety-three percent of people they polled work with a person that they find hard to work with, but nobody holds the person accountable because other employees believe that it’s too dangerous

▪ What you permit, you promote!




Why is Crucial Accountability Important?

▪ January 13, 1982, a jumbo jet crashed into a bridge connecting Virginia to Washington

▪ The co-pilot was concerned about the ice building up on the wings and mentioned it, was ignored, and didn’t bring it up again for fear of being too forceful with the pilot.

▪ Seventy-four people died from a single case of silence


Case #1

▪ Dr. Leavemore has been having ongoing issues with the staff on the med-surg floor. His tirades and shouting at staff have resulted in a 38% turnover of floor staff in the last year. EMS (MIDAS) reports have been filed, and the department chair has met with him twice to discuss his bad behavior. Exasperated, the CoS has called him into the office for a Crucial Conversation. How should she prepare for their meeting?


The Pre-Work: Before the Conversation

Work on Me First




Focus on What You Really Want

▪ Have to first master your own emotions

▪ Break it down into left and right hand thinking

▪ Left Hand Column: What I was thinking or feeling but didn’t say

▪ Right Hand Column: What was actually said


Focus on What You Really Want

▪ Re-engage your brain when emotions are taking over

▪ What does it look like I want?

▪ What results do I really want?

▪ For myself?

▪ For others?

▪ For the relationship?

▪ For the Organization?

▪ How would I behave if I really did?


The Prework--What

▪ Signs that you are dealing with the wrong problem:

-your solution doesn’t get you what you really want

-you find that you are constantly addressing the same issue

▪ Delinquent charts, Patient complaints Late OR start times




Unbundle with CPR

▪ Content: This is the first time the infraction occurs—it deals with a single event in the here and now, and our response to it

▪ Pattern—This is the 2nd time this has occurred

-Problems have histories

-Pattern of Behavior over time

▪ Relationship—Concerns are bigger than content or pattern

-Trust is suffering

-Competence is in question


Master Your Own Stories

▪ We create our own stories

▪ Our stories create our emotions

▪ We see and hear = FACT

▪ We then create a STORY based on our interpretation of those facts

▪ We feel and act based on the Story we have created

▪ PROBLEM: we co-mingle fact and story as FACT


Mastering My Story

See and Hear

TellA

Story

Feel Act




Three Skills to Master Your Stories

▪ Separate facts from stories – stories are judgments, conclusions, and attributions

▪ Avoid the Three “Clever Stories”

▪ Victim Stories: “It’s not my fault”: Internalizing innocence

▪ Villain Stories: “It’s All your fault: Externalizing blame

▪ Helpless Stories: “There’s nothing else I can do”: Justifying inaction


Three Skills to Master Your Stories

▪ Tell the Rest of the Story

▪ Turn from Victim to Contributor:

▪ What am I pretending not to notice about my role in the problem?

▪ Turn others from Villains into Humans:

▪ Why would a reasonable, rational, and decent person do this?

▪ Turn yourself from helpless into Able

▪ What should I do right now to move toward what I really want?


Back to Case #1

▪ Pattern or Relationship?

▪ What is the list of what you do and don’t want?

▪ What was your story when you read the case?

▪ What was fact?

▪ Did you tell a clever story?

▪ How could you tell the rest of the story?




Master My Stories—Setting the Stage

▪ A person’s behavior during the first few seconds of an interaction sets the tone for everything that follows

▪ If leaders start out with strong emotions the outcome will turn out poorly for everyone, regardless of the cause

▪ The fallacy of “the Hazardous ½ Minute”


Mastering My Story

▪ How we get propelled to action

▪ Littered with good intentions, assumptions, and pitfalls

▪ We establish the climate of a conversation the moment we make an assumption about the other person.


Case #3

▪ In an effort to facilitate communication with floor staff and patient care, the Quality of Care Committee has implemented geographical rounds. While popular with the nurses and patient families, it has not been embraced by the hospitalists. Since they are not attending, care still appears fragmented with poor coordination. Questionnaires were sent via e-mail, with a poor response rate. As head of the Quality of Care Committee, you have been assigned the task of discovering why the hospitalists refuse to attend geographical rounds. What are your next steps?




Fundamental Attribution Errors

▪ Research from the 1950s-1960s

▪ Goal was to discover how normal people determine the root of a problem

▪ Conclusion: The research indicated that people’s behaviors are because of personality factors alone.

▪ The human tendency is to jump to conclusions and to make assumptions


Leadership Pearls

▪ We are more likely to make fundamental attribution errors when we are under strain ourselves

▪ We cast a “dispositional rather than a situational light on others”

▪ We assume that people behave the way they do because ‘it’s their nature’ rather than environmental influence

▪ Ironically, we are much kinder to ourselves: situation>disposition


Propelled to Action: Silence and Violence

▪ Silence: 3 potentially bad outcomes

1. Tacit approval (Permission?)

2. Playing favorites

3. Mounting evidence that you were always right about him/her (Can they really fix what they don’t know about?)




Propelled to Action:Silence and Violence

▪ Violence

▪ A sudden and unexpected (emotional) eruption

▪ Usually triggers surprise “Where did that come from?!?”

▪ Followed by an onslaught of dispositional opinions (about YOU)

▪ “out of touch”

▪ “evil”

▪ “drunk on power”

▪ “promotion turned him/her to the dark side”


Propelled to Action:Silence and Violence

▪ Violence

▪ Consequence of Silence?

“Rare is the sudden and unexpected emotional explosion that wasn’t preceded by lengthy periods of tortured silence.”

-Crucial Accountability

▪ As a leader, you never win with violence. “Violence takes the attention away from the real issue and places it upon you at a time that you may be showing your worst behavior.” -Crucial Accountabiity


How to avoid the pitfallsof Silence and Violence

▪ Tell the whole story (humanize the issue)

▪ Ask the right questions (moves us out of judgment mode)

▪ DON’T ask: Why are you bad?

▪ DON’T ask: What’s the matter with that person?

▪ ASK: Why are you different?

▪ ASK: “ Why would a reasonable, rational, and decent person do that?”

▪ What Sources of Influence are acting on this person?




The Six Sources of Influence

Motivation Ability

Self (Personal) Want to Can do

Others (Social) Peer Pressure (culture) Help from others (team)

Things (Structural) Carrots and Sticks Structures, Environment and Tools


Personal-Want to/Can do

▪ Acknowledges that people have personal motives—but must not be considered alone (FA error)

▪ Must add individual ability

▪ People not only want to do what’s required, they also need the mental and physical capacity to do it

▪ “lazy” “selfish” “unmotivated” “not engaged” “stubborn” “protecting the status quo”


Social—Motivation and Ability

▪ Peer pressure doesn’t disappear after middle school

▪ We warn our children but not our coworkers?

▪ Who are Solomon Asch and Stanley Milgram?

▪ “The presence of others who say nothing causes them to doubt their own beliefs, and their desire to be accepted taints their overall judgement.”-Crucial Accountability




Social—Motivation and Ability

▪ Other people can enable or disable you

▪ Coworkers can provide you with help, information, tools, materials, tacit knowledge, and sometimes permission

▪ “We all have an eyeballs problem: You’re on the wrong side of them if you want to notice the role that you’re playing”. –Crucial Accountability


Structural—Motivation and Ability

▪ It is not often obvious to look at the environment, organizational forces, institutional factors when trying to find what’s causing behavior

▪ Consider the impact of equipment, materials, work layout, internet signal, temperature, proximity to the printer, etc. may have on behavior

▪ Have you ever rewarded the wrong behavior?


Structural—Motivation and Ability

▪ Things can often provide a bridge or a barrier

▪ How have EHRs impacted motivation and ability in organizations?

▪ Are there physical aspects of the organization that would allow people to interact more easily and more often?

▪ Proximity has an invisible but powerful effect on behavior




Gadgets and Data

▪ Patient portals

▪ EHRs

▪ Wearable medical devices

▪ RFID encoded badges

▪ Cost transparency


Leadership Pearls

▪ When mastering our stories, avoid the natural tendency to assume the worst in others.

▪ Begin with curiosity so that our first words set the tone for the rest of the conversation.

▪ Seek to tell the whole story.


How to start an Accountability Crucial Conversation

Speak when you are angry and you will make the best speech you will ever regret.

--Ambrose Bierce




Step 3: Describe the Gap


Describing the Gap

▪ A gap: “a difference between what you expected and what actually happened”.

▪ Violated expectations

▪ Broken commitments

▪ Disruptive behaviors

▪ Gaps are often paired with the words “serious” “consequential” and “significant deviations”


Avoid the Pitfalls

▪ Don’t play games (no sandwiching)

▪ No surprise attacks (erodes trust)

▪ No charades (can’t document)

▪ Don’t pass the buck (good cop/bad cop)

▪ No “read my mind” (patronizing)

▪ Words that describe these techniques:

▪ “dishonest” “manipulative” “insulting” “disloyal” “ineffective” “cowardly”




How do Positive DeviantsDescribe the Gap?

▪ Honest

▪ Respectful

▪ Cautiously

▪ Completely

▪ Start with safety

▪ End with curiosity


Psychological Safety

▪ Hot topic and buzzword

▪ Is the foundation of every successful accountability discussion

▪ If individuals feel unsafe, they may resort to silence or violence

▪ Psychological safety relies on establishing mutual respect and mutual purpose


Mutual Respect and Purpose

▪ If you begin with anger, or presumed guilt, bad things may show in your tone of voice, facial expression, or in the words that you choose.

▪ May be subtle, raised eyebrow, sigh

▪ Person already feels judged to be incompetent, lazy, or worse

▪ Coping mechanism: silence or violence




Tool: Use Contrastingto Counter Disrespect

▪ Use to deal with a predictable misinterpretation

▪ Imagine what others might erroneously conclude

▪ Immediately explain that this is what you don’t mean (content vs. intent)

▪ Finally explain what you do mean

▪ The most important part is the “Don’t” part, it addresses what may put safety at risk


Establish Mutual Purpose

▪ Focus on the goal and set the stage for success

▪ Let others know your intentions are good, the goal is to solve a performance gap and make things better for both of you

▪ Ask for permission

▪ Speak in private


Avoid these Pitfalls

▪ Don’t keep others in the dark

▪ “Lack of clarity is accountability’s worst enemy”

▪ Avoid ambiguous expressions “shape up” “have a better attitude” “get your work done on time” “fix that”

▪ Don’t lead with judgments or stories




Describing the Gap

▪ Don’t lead with your story

▪ Stay external avoid dispositional conclusions

▪ Explain what, not why

▪ Gather facts—people will default to stories and not share facts. Ask them to share what they actually heard and saw.

▪ Tentatively share your story. Start with facts, share your story and conclusion, End with a question. (What happened?)


Case #4

▪ You are the new director of the medical informatics team. Part of your responsibilities include raising chart completion scores for the outpatient physicians

▪ The prior director had a “wall of shame” where all physicians were listed and had their number of outstanding charts listed

▪ One physician in particular had 247 charts listed as more than one week overdue

▪ How would you describe the gap?


Case #5

▪ Dr. Short has a long-standing history of minimal documentation in the medical records department. Although he is the busiest hospitalist, his charting has caused insurance companies to request partial refunds due to insufficient charting for discharge codes submitted to them.

▪ You are the new Internal Physician Advisor. You have been informed of his behavior and unwillingness to change his charting. His charting is costing the hospital at least $20,000 a month in reclaimed funds. How do you approach this physician?




Step 4: Make it Motivating


What if it is all about motivation?

▪ What are the most powerful motivators?

▪ Charisma?

▪ Power?

▪ Perks?

▪ Position?

▪ Fear?


Motivation

▪ Expectations

▪ Information

▪ Communication

▪ People are always motivated

▪ Motivation is brain driven

▪ People choose their behavior

▪ People have an infinite number of influences




Motivation

▪ In order to change behavior, you must give them adequate reason to do so

▪ If I do X, what will it give me?

▪ If I do Y, will it give me a better result?

▪ Any action will yield a combination of both good and bad results, it is the EXPECTED SUM TOTAL OF THE CONSEQUENCE BUNDLE THAT DRIVES BEHAVIOR.

▪ Change the consequence bundle and the behavior will follow


Avoid these Pitfalls

▪ Charisma—we love the movies with the inspiring coach, or the pep talk that saves the world, but it isn’t real motivation

▪ Raw power—may move bodies, but doesn’t change hearts and minds

▪ Avoid excessive use of perks—could rob people of intrinsic reward. Not everything gets a trophy.


When/How to use Discipline

▪ Know the mechanics (follow your procedures)

▪ Partner with people in authority

▪ Be appropriately somber

▪ Explain the next step

▪ Be consistent

▪ Don’t back off under pressure




Step 5: Make it Easy


Make it Easy

▪ “The best leaders don’t simply inspire people to continue to do the gut-wrenching, mind-boggling, and noxious. They help people find ways to ease the gut-wrenching, simplifythe mind-boggling, and nullify the noxious.

-Crucial Accountability


Case #6

▪ Your hospital has recently had a series of unexpected deaths from alcohol withdrawal. As a result, administration has appointed you, a physician champion, to write a protocol that includes a clinical scoring tool along with the suggested medications for each score.

▪ After an intensive literature review, you create an alcohol withdrawal protocol that utilizes a CIWA score coupled with escalating benzodiazepine doses for escalating scores.




Case 6 continued

▪ Medical informatics informs you that after 6 months, the protocol is not being used.

▪ Nurses say that the doctors are not following the protocol and ordering their own meds.

▪ Doctors say that the nurses are not scoring patients correctly, forcing them to change the dosing regimen.

▪ How would you approach this problem in order to make it “easy to do the right thing, and harder to do it differently”, in your institution?


The Six Sources of Influence

Motivation Ability

Self (Personal) Want to Can do

Others (Social) Peer Pressure (culture) Help from others (team)

Things (Structural) Carrots and Sticks Structures, Environment and Tools


Step 6: Stay Focused and Flexible




How to handle curve balls, what ifs, and this is the way we’ve always done it…

▪ Crucial accountability is not designed for a multiple-front war

▪ If a new and emergent issue surfaces during a conversation: Be Flexible and Focused.

▪ Broken trust: always worth the battle. Without trust, there is no accountability.

▪ “Something came up”—response is “if something comes up, let me know as soon as you can”.

▪ Changing topics midstream: pause the original conversation, discuss the new issue, bring it to resolution, and decide whether or not to return to the original issue


Leadership Pearls

▪ Only deal with one issue at a time. If something more pressing comes up, select the right problem, resolve it, and return to the other issue.

▪ Make a decision to choose to deal with a new issue. Don’t allow a new issue to be forced upon you during a crucial conversation.

▪ Avoid “arbitrary accountability”, if you allow people to choose which promises they will and will not keep, life becomes a buffet line of commitments

▪ “Something came up.”? “If something comes up, let me know as soon as you can.”


Four Rules for Dealing with Anger

▪ 1. Ensure your Safety

▪ 2. Dissipate the Emotion

▪ 3. Explore the Other Person’s Path to Action

▪ 4. Take Action




Step 7: Agree on a Plan and Follow Up


Establishing future accountability: The follow up plan

▪ The way you finish is as important as the way you begin:

▪ WWWF

▪ Who

▪ Does what

▪ By when

▪ Follow up


WWWF:WHO

▪ There should be a name attached to each task

▪ “We”, “Let’s”, “Us”, “Team” are nebulous terms

▪ Important tasks, large jobs require a named individual responsible for success or delivery

▪ It may also be helpful to have an administrative champion to help, especially in team-based interactions




WWWF:What

▪ Be specific

▪ Be detailed

▪ Define the exact behaviors or products you are seeking (particularly important to intergenerational work forces)

▪ Ask for feedback and don’t take it for granted that their competency or experience guarantees a clear understanding

▪ Example: wrong site surgeries


WWWF: When

▪ Time is a human construct

▪ It is specific, exact (atomic clock)

▪ “I need it by next week”

▪ “Get this to me ASAP”

▪ “STAT”

▪ “Don’t be late”

▪ “I’ll be there shortly”


WWWF: Follow Up

▪ Decide when and how to follow up

▪ Who follows up with who

▪ Use Risk/Trust/Competence to determine the type of follow up necessary

▪ How high is the risk? Riskier projects need closer follow up

▪ How strong is the trust? Does this person have a track record of being reliable?

▪ How competent is the individual? Does this person have experience/skills to complete this project?




Leadership Pearls

▪ Perils of micromanagement: If colleagues believe that they’re being watched too closely, they will become “good soldiers” and fail to think independently. They will perceive follow-up as criticism. The consequence is a loss of initiative or creativity. (loss of trust and respect from boss)

▪ Perils of hands-off approach: rarely interpreted as a positive. “My boss is too busy to care about my project”.

▪ The intention of follow up is to be helpful and supportive—not to micromanage.


Step 8: Put it All Together


The Crucial Accountability Checklist

▪ Choose “what” and “if” (internal discussion)

▪ Master my stories (internal discussion)

▪ Describe the gap (external discussion)

▪ End with a question (external discussion)

▪ Is this a motivation or an ability issue?

▪ Consider the Six Sources of Influence

▪ Communicate and jointly work towards resolution

▪ WWWF




Tough Cases

▪ What if my crucial conversation is with my boss?

▪ If your boss is narcissistic or authoritarian, control may be their only motivation

▪ Tough decision may be to cope or to cut out

▪ Most bosses will respond to the creation of a mutual purpose

▪ Many of these issues will be a polarity to manage, not a problem to be solved


Tough Cases

▪ Everyone else is doing it, so why can’t we?

▪ Risks of violation of a procedure, bylaw, or standard practice can lead to risk exposure or high stakes consequences

▪ Example: hand-washing, stopping at red lights, insider trading

▪ This is an issue of doing things “right” vs. doing the Right Things.

▪ Ask: Why are reasonable, rational, and decent people doing this?

▪ Do: Make it easy to do the Right Things (remove barriers)


Tough Cases

▪ My team has a false harmony. We never talk about the real issues.

▪ If one part of the team needs to discuss something and the other one doesn’t, no real or deep work can ever take place.

▪ Silence or avoiding conflict eliminates routes of resolution.

▪ Conflicts compound

▪ When people resort to silence, it’s usually because they feel verbally oppressed or dominated, allow for safety and appropriate times to allow for healthy discussion




Tough Cases

▪ How do you handle opinions and the rumor mill?

▪ “Don’t trust that guy” “She’s like talking to a wall” “No one can work with him”

▪ “If others are not willing to talk to the person themselves or own up to negative feedback, you have no right to talk with that person on the basis of secondhand information.”

▪ When you adopt other people’s stories as your own, you surrender control.

▪ Unless safety is at risk, gather information for yourself.


Tough Cases

▪ He can’t handle the truth. It would break his heart…

▪ If this is a competency issue, this has been an ongoing disservice to the company and to the employee

▪ Fellow employees either learn to live with the mediocrity, or develop resource-intensive work-arounds.

▪ Be objective, and provide clear, direct and detailed feedback on that topic alone. Talk about raising the bar on the current work instead of discussing his current shortcomings


Tough Cases

▪ What if the employee can’t be fired, and he holds the entire department hostage?

▪ Often threaten litigation if confronted

▪ Outsiders routinely ask why that person is allowed to continue working in the department

▪ Solution: Use The Greeley Pyramid

▪ Document, collect data, and use discipline if appropriate




Tough Cases

▪ One of my hospitalists does consistently marginal work, but she never crosses the line…

▪ Must do research, homework, and connections

▪ Must be able to provide examples of mediocrity vs. excellence

▪ Must be able to demonstrate how the changes also link to her own goals.


Tackling your own Crucial Accountabiity

▪ Describe some scenarios in your own organization that may need crucial conversations.

▪ Master your story (situation>>disposition?)

▪ Share with the group, or work in pairs.

[email protected]

888.749.3054greeley.com



Thank you for joining us!

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