Community

Do you have an action plan?

My last JHS Focus post introduced the Waterline model as a guide to providing clarity regarding the root causes of team conflict and/or underperformance. I suggested that, more often than not, a system or process issue may be the basis for the problem even though we, as emotionally driven team members, may attribute underperformance to an individual or to an interpersonal conflict, missing the opportunity to productively develop an appropriate action plan to change the current reality.

We have all witnessed situations where change is necessary, but we infrequently expressly agree on a vision of what the perfect reality would look like, and too frequently observe a “shoot from the hip” approach towards change. For example, I recently consulted with a young spine surgeon in the first decade of his practice about a mandate from the President of the medical staff at his hospital that he receive professional coaching. This young surgeon was Ivy League trained from college all the way through his fellowship, was very driven, very talented, and very busy. He found the mandate baseless and of no value. As he interpreted events, two nurses in the 4 OR hospital complained that he was too demanding, and when he went to them to discuss their allegation, they perceived him to be threatening. He disagreed, of course. In fact, he dismissed the conflict all together because the two nurses who complained about him had subsequently moved on to new jobs—problem solved he thought. When I asked if the team ever discussed the issues at hand, what the objective of the coaching was, what metrics would be used to assess whether the coaching was successful, and whether there had been any other analysis involved in determining the action plan, he was in the dark.

Perhaps his style in the operating room was autocratic, or as a pacesetter he was not viewed as collaborative and there was a disconnect between his intention and impact. Or, perhaps the processes in place at this small hospital may have been inadequate to accommodate the demands of a busy spine surgeon. So, point # 1 is that too little analysis of the problem occurred, and it occurred in a silo that did not leverage understanding the differing, perspectives of the team members. And point #2 is that there was seemingly little if any process that went into the action plan for effective change.

Enter the relevance of Logic modeling—a change process template of sorts. The Kellogg Institute has published a great PDF about this (https://www.bttop.org/sites/default/files/public/W.K.%20Kellogg%20LogicModel.pdf);  a typical template includes the following categories: 1. Resources required (inputs); 2. Planned activities; 3. Outputs (desired conduct, interaction, process improvement); 4. Outcomes (short and long term), and 5. Impact.

Any logic model begins with a “vision” of what the situation would look like ideally, and what changes need to occur. For the above scenario the vision might include a more harmonious team climate, in which intention and impact are well-aligned, false narratives are replaced by honest communication and mutual understanding, and conflict is leveraged to facilitate team development. Inputs/resources may include scheduled time for team meetings, leadership/institutional commitment to the processes required to enable team dialogue and feedback, and individual willingness to share accountability for performance improvement, which includes self-awareness and self-management. Planned activities might include daily briefs prior to the start of each day to facilitate a shared mental model and debriefs (after action reviews) at day’s end to assess how the day went and whether any perceived conflict or suboptimal performance requires attention. The outputs may involve, better communication and more trusting and respectful relationships. The outcomes and impact, at the end of the template, may include a safer environment both in terms of task and people—the latter meaning improved psychological safety to provide feedback to each other about feelings.  And then of course there need to be metrics to assess if the activities occur and the outputs are happening—that is, is the model effective?  This might include assessment of whether meetings occur and whether team behavior is changing; to this end, instruments have been published by the Agency for Healthcare Research and Quality (www.ahrq.gov) as part of the Team Stepps initiative to assess team climate and effectiveness.

With respect to the surgeon mentioned above who was sent to coaching, this may have been a warranted planned activity to address intrapersonal barriers to improved performance aka “the vision”, but the narrative underlying the mandate was inchoate, and the method used to communicate the basis for the mandate was thoughtless.

Utilizing a logic model to effectuate change is likely to be more effective in the long-term that any knee jerk reaction/response to a situation requiring change. A shoot from the hip approach commonly underestimates the complexity of a successful change initiative and reflects an incomplete assessment of root causes. An effective action plan develops only after understanding the multitude of potential causes as well as well as a compelling, and shared vision of what the ideal reality would look like. Lastly, effective leadership is one of the most critical factors in this change process.

So, the question is: “Are you part of the problem or part of the solution?”

Article written by:

Matt practices in Rochester, NY where he focuses on treating hand, shoulder and elbow problems. He has been in practice since 1994 and spent his first 15 years at both the University of Pittsburgh and the University of Rochester. In 2008 he started his own practice and works closely with his wife, who is his nurse practitioner. As a Team Stepps instructor, he is currently interested in the subject of high performing teams and the importance of improving physicians’ nontechnical skills to enable improved collaboration on teams as well as more effective connections with patients.

Leave a Reply

Your email address will not be published.