••Fall 2006/Vol. 10, No. 3

Health Systems

By Michael P Quirk, PhD

Today, organizational evaluation includes feedback on financial performance, quality of care, and customer service; staff satisfaction data must be considered as well. Staff satisfaction is measured through a variety of instruments like People Pulse and the Work Environment Assessment. Clinician managers and health care administrators typically meet with work groups to discuss these results, usually with the hope of improving them. However, conducting these group dialogues can be challenging. How does one keep the discussion open and constructive, avoid discouraging negativity, yet draw out engagement? With these dilemmas in mind, the following "Ten Tips" in brief and elaborated versions are offered to prepare for and conduct interviews with staff. The tips are drawn from the psychological literature about how to gather information, create behavior change, and achieve organizational outcomes.

Elaborated Version

1. Set the stage. Simply say: "Staff satisfaction is always an important issue. It is important in its own right and is also essential to fulfilling our organizational purpose to transform how health care is offered to our patients and communities."

2. Clarify the intent. "Yes, staff satisfaction assessment scores have recently come out, and now is a good time to check in with one another concerning what contributes to and interferes with our satisfaction. The intent is to have an open discussion on this topic so that we all can learn what things we can do to improve satisfaction--yours, mine, ours."

3. Ask open-ended questions. The best way to get to how people experience satisfaction is to ask open-ended questions. This is as straightforward as inquiring: "Please tell me about what it is that increases satisfaction with work?" Ask the alternative question: "What interferes with your satisfaction?" or "What haven't I asked that is important to you concerning satisfaction?" Throughout, make it safe, otherwise there is a limit to what you'll hear and learn. Address safety: "I can imagine there may be a hesitancy to answer these questions out of concern that some may not like what you say. I am open to and believe we will profit from as complete a dialogue as is reasonable for you." Staff will test your openness, and if they find you are true to your word, they'll say a lot. It is best to have hour-and-a-half meetings to get beyond the first 45 minutes of formality and mutual caution, and then on to franker discussions.

4. Keep as a backdrop the connection between what you hear and how it relates to specific staff satisfaction assessment questions. You might say: "We are holding these meetings right now because we have received staff satisfaction assessment results. They are a mix of strengths and concerns that vary from workgroup to workgroup." Jumping into the specifics can turn the assessment into an interrogation, and generates a lot of unproductive anxiety. Staying with open-ended questions lets you know what's up with most specific concerns and how they crosswalk to the satisfaction categories (ie, clarity of direction, recognition, etc). Yet, important material may not get covered. Often those are areas that are very close to and/or very far away from the people in the room. For example, if how well senior leaders have set directions, clarified priorities, and created engagements are concerns that have not been raised in the open-ended discussion, you might raise the question as follows: "I'm aware that our department/clinic/section was concerned that X issue was not going well, and I would like to learn from you what's going on there and what you believe would improve it." For concerns very close to home like relationships with immediate supervisors, people get nervous in a large group meeting--especially if there are outsiders in the room. It's better to handle these sorts of questions one-on-one or in smaller groups, and if the supervisor is viable, have him/her make the inquiries.

5. Establish who has control.^1,2 As you ask your questions, gently nudge the responders to give you their sense about who has their hands on the controls to improve satisfaction. What we are looking for falls into three buckets: what I control, what you control, and what is simply an inescapable reality that can only be controlled to the extent that people decide to accept it and come to peace with it. As for what "I" can control, those are the multitude of things that make up my work environment that are here for me to shape or organize as I see fit. The things that the collective "you/they" control includes work conditions that leaders may be able to modify in support of better organizational performance and improved staff satisfaction. ^3-6 Sponsorship of the Internal Collaborative (ie, rapid cycle team learning experience organized around the Plan, Do, Study, Act approach) has been a big success story of senior leaders moving from admonishing staff about access to creating an empowerment opportunity. Finally, for external control, it is helpful to hear what gets people to the acceptance part of the serenity prayer and what gets in the way. A controversial example is the cost of health care and the issue of premium sharing for health care employees.

6. Seek to understand which staff behaviors give a yield--however minimal--to satisfaction and resilience. In the mental health business, there is the solution-oriented strategy.⁷ Appeal to people's constructive sense of themselves. This is self-efficacy: it means being capable of coping--and sometimes of mastering the behaviors that, notwithstanding difficulties, get you through life successfully. Refine the locus-of-control question by drilling down into how individuals and groups manage the stress, complexity, and ambiguity of their work experience. For even the most downtrodden staff member, there is usually a nugget of self-efficacy that can go into your eventual sum-up of what contributes to satisfaction. Often, these discussions tell us about people's resilience, values, adaptability, and, quite frankly, their belief in the dream of what we aspire to through our organizational purpose.

7. Be aware of the factors that contribute to high performance organizations. Bernard Bass, PhD,⁸ did the groundbreaking work about what organizational practices result in high performance. To abbreviate a ton of research and several books into a few sentences, organizations are the most successful that have Rules and Reward people for following through (think performance agreements as an example), and engage staff via an Inspirational purpose (ie, to transform health care), with corresponding Intellectually challenging work, where there is an Individual opportunity to contribute. The organizing constructs described here are about management (the two Rs) and leadership (the three Is). All five constructs can be translated into what you can do and what staff can do. In an interview, you can use these constructs for filing away information you acquire with the goal of aligning our way of behaving organizationally with a further fulfillment of the two Rs and three Is.

8. Identify how people change and specify where we are in the process. James Prochaska, PhD,⁹ has documented the contemplative, cognitive, active, and reflective model of how people change. Its practical utility is in clarifying where people are in their "change readiness." If a person is just beginning to think (contemplation) about satisfaction with only preliminary interest in getting information (cognition), and there is an effort to move that person quickly into initiatives (action), they are likely to fall flat. If you are a year or two into reporting staff satisfaction scores and experimenting with improvement strategies, people are well into the change process. Being clear about the stage of change will also help keep expectations reasonable for all. Especially when satisfaction is related to being able to influence leaders, you'll get credibility by sharing that you gather information before taking action.

9. Paraphrase and eventually summarize what you heard for corrections, validation, and engagement. In its simplest terms, an interview as a conversation has its greatest impact when the interviewer conveys what s/he "got" from the discussion by way of understanding the other party. This is not a pass/fail test. Remember, leading is like learning a second language¹⁰--never completely natural--but you can acquire the needed skills and be reasonably fluent. If you misunderstood or missed information (because there was too much of it, or the message was not clear, or your/my biases interfered with getting to the other's sense of truth), the fact of calling that out in correcting your understanding helps you from a credibility perspective. It says to the other party that you attempted to capture what was said and when it got missed, you went back and extended yourself further to get it right. These shared understandings then become the bridge for building towards action steps.

10. Say "thank you" and foreshadow the move into action planning. There are many things as a manager you can require of others at work. You can hope for, but not dictate, cooperation during an interview where the goal is to get peoples' truth about what helps and hinders staff satisfaction. Therefore, express gratitude by saying thank you. However, it is not helpful to go into self-flagellation about what you did or didn't do that negatively impacted staff satisfaction. À la the paraphrasing tip, simply say that "you heard" that there were things you as a leader/manager could do to improve satisfaction. It is also important to conclude by saying that you will go the next step to get down on paper what you heard indicated could be done that would be helpful. Finally, tell people when they should expect the summary; how they can give you feedback about it; when the recommendations will be put into action; how the results will be measured and communicated; and when there will be an opportunity for a follow-up discussion like the one held today.

Appreciation is extended to Dolly Dixon-Payne for her assistance in the preparation of the manuscript.

References

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