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Three Models for Having Difficult Conversations - Successfully
Lynne CunninghamStuder Group Speaker and Coach
Effective communications starts with trust
Our Objectives...
• Tie accountability for creating a great patient experience to setting expectations and holding each individual accountable for their actions.
• Identify three models for difficult conversations and learn how to select the best approach for a particular situation.
“When the music changes, so must the dance.”
Let me ask you some questions
• What are your organization’s key strengths?
• What are your organization’s greatest opportunities for improvement?
• What is creating a sense of urgency for you to do something different?
Do you suffer from cainotophobia or are you building the Choluteca Bridge?
DenialRationalizationBlameUniquenessUnwillingnessNot Skilled
Phases of Competency
Unconsciously unskilled
(incompetent)
Consciously unskilled
(incompetent)
Consciously skilled
(competent)
Unconsciously skilled
(competent)
Change ExerciseLet’s Have Some Fun!!
What’s more important than the words we say?
Clarity of message
Little omissions make big differences
Timeliness
Logical consequences
Communicate the “WHY”
Mixed messages
Mixed messages
Perspective
It’s about the filters you have
How do we spend our time communicating?
• Studies show that we spend:
• 9% of our time writing
• 16% of our time reading
• 30% of our time talking
And 45% of our time listening!
But are we really listening?
• We usually recall just 50% of what was said immediately after speaking with someone
• Over time we remember just 20% of what we hear
And it’s no wonder……Only 2% of us have had
formal educational experience with listening
Aspects of face-to-face communication
38%
55%
7%
Tone of Voice
Body Language
Words
Aspects of telephone communication
86%
7%
Tone of Voice
Words
Additional thoughts about listening
• Make listening your new default mode –replacing the “waiting for my turn to talk” mindset.
• The 12 second pause.• First, think about what you’re thinking.• Be interested; not interesting.
Be Quiet, Be Heard
• Trust is not a prerequisite for communications; trust is a byproduct of communication.
• The trouble with letting sleeping dogs lie is that we have to keep stepping over them.
• To foster a culture where praise becomes a norm, we must make it acceptable to receive praise as well as to give it. Like all communication, gratitude is a two-way street.
Ask transformational questions
• If you could change one thing about the direction of your company, what would it be?
• If there is one thing I can do to help you move more quickly toward your goals, what would it be?
• What’s the one thing you’d be proudest to accomplish?• If you did know, what would you do?• What about x seems impossible to change, yet if you
could change it, you would be much more satisfied?
Readers’ Digest version
If you only remember five things:1. It’s all about Coaching2. Reward and Recognize 3. Communicate Expectations4. Hold people Accountable – yourself and your
team5. Relate; don’t Compare
Connecting the dots . . .Aligning Difficult Conversations with:
•Rounding on your direct reports•Thank You Notes and other reward and recognition•Monthly Supervisory Meeting Model•Standards of Behavior/Anti-Disruptive Behavior
Results in improvements in:•Employee engagement•Patient experience•Patient safety
Having hairy conversations
We all have challenging interactions…
But where is the tipping point?
Where the conversation becomes destructive?
When we Compete vs. Complete
When I compete…
• Loss of trust occurs
• When it becomes unsafe to contribute
• Unsafe = less information
The Joint Commission Sentinel Events
No matter how advanced the technological system…
If humans are involved, error is inevitable.
Crew Resource Management by Drs. Gaffney and Seddon and CaptS. W. Harden
What’s at stake
• Better hand washing is one of the most effective ways to prevent the 2 million hospital-acquired infections that occur each year.
• However, research shows that caregivers only follow proper hand hygiene protocols about 40% of the time.
• If improved hand washing eliminated just 10% of these infections we would save 10,000 lives and $3 billion each year.
Scary messages respectfully
You forgot to wash your hands after that last patient. I’m reminding you because I’d want someone to remind me. I know you’re busy. Please do the same for me.
Teamwork =
Watching each other’s backs
Why don’t we speak up?
We don’t know howWe’re afraid
Difficult dialogues
It’s important to:1. Monitor motives
2. Practice presence
3. Clarify expectations
4. Plan and practice
1. Monitor Motives
What do I want?
Am I seeking to Complete or Compete?
Am I in this to WIN?
Compare
Yes, and…
Yes, but…
When I compete…
• It becomes unsafe for other people to contribute
• More information=Better decisions
• Better decisions=Better leadership
Critical ingredient . . .
Praise in public, criticize in private
RESPECT
Lack of respect impacts care
• 1500 nurses, 350 pharmacists and others:
• Intimidating behavior--common in healthcare
• Nearly half: experiences with intimidation changed how they handle questions about medication orders.
• 40 percent who reported having concerns about the safety of a medication: at least once in the past year they assumed it was correct instead of interacting with an intimidating prescriber.
Source: ISMP-Institute for Safe Medication Practice, 2004
New standards as of January 1, 2009
The Joint Commission warns that rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care. Intimidating and disruptive behaviors are such a serious issue that The Joint Commission is introducing new standards…to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior.
Silence kills
Source: Silence Kills: The Seven Crucial Conversations for Healthcare, 2005, AACN and VitalSmarts
• A national study of 1,700 nurses, physicians, clinical staff, and administrators concluded that it is “common” for providers to say nothing when they observe “troubling” performance by colleagues.
• 62% of nurses see coworkers taking shortcuts that may endanger patient care, and 48% of nurses believe coworkers show poor clinical judgment; however, fewer than 10% of nurses, physicians, and other clinicians directly confront colleagues about performance concerns.
The first step in taking ownership is asking
“How am I contributing to this problem?”
How do we show…
• Respect?
• Caring?
• “The average physician will interrupt a patient after approximately 17 seconds during the opening description of the principle patient concern.”
• Dr. Stephen Beeson, Practicing Excellence
• On average, a nurse interrupts a patient after one minute and 14 seconds
2. Practice Presence
Tell me about your weekend…
3. Clarify Expectations
Why don’t people do what we want them to?
In any critical communicationBefore you begin, ask how you want to end
And DON’TSend by email!!!
4. Plan and Practice
• Think of a difficult dialogue you…
• Should have
• Could have
• Would have
• Did have
• Deliver, get feedback, report to “one up”
Key Words
“You could be right.”
An Exercise . . .
What we permit…We promote
Cup of Coffee Conversation
Cup of Coffee Conversations
Based on Research and Curriculum Developed byCenter for Patient and Professional Advocacy, Vanderbilt University
What is a cup of coffee conversation?
• Informal conversation in which you bring your observation/experience of troublesome behavior to the awareness of your colleague… that’s it.
• Anyone can have the conversation with anyone… really! (department, role, position, don’t matter). There is no hierarchy…
Cup of coffee conversation: How to…
Before having the conversation:•Think about the experience and what you want to communicate - Intent•Have the conversation privately•Wait until emotion has passed
Cup of coffee conversation: How to…
During the conversation…•Offer appreciation
“I value you as a colleague…” or “I appreciate your skill, experience…”•Review what occurred/impact
“I heard, saw, experienced…”Be specific
•Pause Just listen to colleagues views (even if you disagree with the individual)Give reflection opportunity
Cup of coffee conversation: How to…
During the conversation (cont.)…•Empathize (carefully)
“I understand why you were frustrated and…”•Reminder
“Your comments/actions didn’t come across as professional or left a negative impression…”•Express appreciation/affirmation
“I care about you and wanted to make sure you are aware your words/actions weren’t consistent with our values.”
Pointers to make CCC most effective
• Avoid tendency to “fix it”• Stay on message• Avoid tendency to downplay or enable• Keep it short…
• If your chat lasts more than 4 minutes, you’re off track!
• It’s about the “pencil”; not the person
Recognizing troublesome behaviors•Abrupt, disrespectful •Passive or passive-aggressive•Complaining, gossiping•Talk “about” rather than “to” each other (triangle) •Incongruent words and actions•Focus on “being right” rather than “doing what’s right”•Others…
You know it when you see it…
Examples:
If I see/experience troublesome behavior…
Is it my place, my job, my responsibility to bring it to their attention?
Yes… we all have the responsibility
It’s all about EXPECTATIONS…
• Expectations of myself
• Expectations I have of my coworkers
• Expectations when my coworker or I “stub a toe”
It’s all about EXPECTATIONS…
“One of the best ways we honor people who do the right thing is to address those who don’t.”
~ Gerald Hickson, MDVanderbilt University Medical Center
Why is it important to address the behavior in each other?
• Breaks down trust – impairs team’s ability to function effectively
• Takes focus off the job• Decreases quality, increases risk of errors • Poor customer service• Negatively impacts support for our mission• Impacts job satisfaction• Examples:
• Standards infraction• Disruptive behavior• Missing expectations in a work setting• Others
What reaction might you get??
• Rationalization• Denial, finger pointing• “Look out the window” rather than “in the mirror”• Strive for control• Commonly… professionalism, appreciation, maybe
even remorse
• Whatever the reaction, it’s about them, not you
Impact Messages
• Describe the behavior • Describe the impact • Indicate the desired change• Get a commitment
Core Version:
• When you or When I see this happening…
• The result is…• I need (or, I want, would like)…• Are we in agreement . . .
For Example
• When you interrupt me when I’m talking…• The result is that I don’t feel as if I’ve been able
to explain myself adequately• I need you to let me finish before you respond• Do you agree that you can do this?
For Example
• When you are consistently late to meetings• The result is I feel you don’t value the time of either
me or the others on the team• I need for you to be on time or let the team know you
can’t participate• Do you agree that you will let us know if you are going
to be late?
Addressing highmiddlelow® Performance
Performance Curve
Definition of High Performer
• Proactive• Trusted• Brings solutions• Teaches/precepts• Good attitude• Problem solver• You relax when you know they are on
an important process improvement team
• Good influence• Use for peer interview• Five Pillar ownership
• Role models Standards of Behavior
• Manages up . . . not down• Loyal to customers/patients and
the organization• Makes tough decisions• Does not make excuses• Knowing what you know today,
would you hire this person again? ABSOLUTELY!!!
Definition of Middle/Solid Performer
• Responsive• Tells you about a problem• Solid performer• A few developmental needs• Good attendance• Loyal most of time• Influenced by high and low performer• Wants to do a good job• Could just need more experience
• Role models standards of behavior• Manages up . . . not down• Loyal to customers/patients and the
organization• Requires coaching to make tough
decisions• Makes excuses occasionally• Knowing what you know today, would
you hire this person again? YEH, AND!!!
Definition of Low Performer
• Unaware/unwilling• Blames you for a problem• Advocates for the status quo• Even complains about free food• Points out problems in a negative way• Positions leadership poorly• Master of “We/They”• Passive/aggressive• Thinks they will outlast the leader
• Does not role model standards of behavior
• Manages down staff, peers, or the organization
• Loyal to staff rather than customers/patients
• Avoids making tough decisions and taking action
• Makes excuses to rationalize lack of results
• Knowing what you know today, would you hire this person again? NEVER!!!
An Alternate View of highmiddlelow®
Low Performer - Up or Out
• Do not start meeting out on a positive note• D: Describe
Describe what has been observed.• E: Evaluate
Evaluate how you feel.• S: Show
Show what needs to be done.• K: Know
Know the consequences of continued same performance
Summary . . .
• Complete vs. compete• Monitor motives: do I want to win?• We contribute more information when we feel safe
• We all get spinach in our teeth• We have to admit mistakes; we have to help teammates
• Watch your “but’s”• Never underestimate the power of negativity
And More Summary . . .
• Practice presence• Listen with your body; remember eyes
• Clarify expectations• Sometimes people don’t do what we want them to not
because they don’t want to, but because they don’t know
• “I Messages”: when you, the result is, I need
• Plan and prepare• Complete vs. compete
And Document
• In your planner• Verbal• Written• Final• Discharge
Three Models For Having Difficulty Conversations Successfully
Model Impact Message Cup of Coffee Low Performer
Key Steps When you . . . The result is . . . I need/I want . . . Do I have your agreement?
I value you as a colleague . . . I saw/heard something that’s
inconsistent with our standards, values, or policies.
I wanted you to know this because I value you.
D – describe E – evaluate S – show K – know the consequences
With Whom Colleague Co-worker Employee Another member of a
committee, task force, etc. Leader above you Physician
Same as Impact Message plus: Cascade to all staff so issues can be
resolved at the most appropriate level High or Middle/Solid performer who
“stubs their toe”
Employees in your hierarchy who fit the definition of Low Performer
Follow-up As appropriate if agreement isn’t kept
As appropriate if behavior doesn’t change.
Escalate to Low Performer if performance doesn’t change.
Action Plan with weekly meetings until behavior/performance conforms
Move to advanced forms of discipline as appropriate and in concert with your HR rep
Situations When Appropriate
Persistent, repeating behavior that is disruptive to team performance, functioning of teams or committees.
Peer or someone above you in organization who is exhibiting behavior inconsistent with leadership standards.
Behaviors which are inconsistent or contrary to standards, values or policies.
Behavior is the exception – not a regular occurrence.
Employee demonstrates characteristics of a Low Performer.
Pattern of behavior is persistent.
Behavior is detrimental to patient or employee safety.
Other resources Spinach in your Teeth http://www.studergroup.com/thoughts/archive/spinach_in_your_teeth.dotThree Models of Difficult Conversations https://www.studergroup.com/thoughts/archive/difficult_conversations.dotDiscouraging Disruptive Behaviors - It starts with a Cup of Coffee!
http://www.studergroup.com/wrihc2009/video/cup_of_coffee.dot
Those who say it cannot be done should not interrupt the person doing it.
-Chinese Proverb
