By Hilliard Jason, MD, EdD (as interviewed by Sarah Sherwood, M.A.)
SS: Thanks for agreeing to this interview, Dr. Jason. To begin, are there some generalities you want to share with us? What aspects of communication are important for having a clinical practice that achieves high standards?
HJ: Thanks, Sarah. Please call me Hill. Since contemporary clinical practices depend on the efforts of many people, creating and maintaining a high-quality practice begins with the task of establishing a harmonious, effective, collegial working environment. The senior leaders of the clinical practice need the understandings and skills required for creating and sustaining a team in which everyone strives toward the same high standards. We need highly motivated people who support the “culture” of the practice.
SS: Thanks, Hill. Can you say a few words about the culture of a practice?
HJ: Sure. The culture of a clinical practice includes the aspirations, values, standards and specific kinds of relationship patterns that dominate that practice. Successful practices have a coherent, consistent set of expectations that everyone understands and supports. Both management and staff should consistently represent the leaders’ guiding principles, and they should have clear ways of managing any questions or disagreements that may arise.
Most of us conduct our lives based on our beliefs and assumptions, which we may or may not recognize. Without effective orientation and communication, some members of an office’s team may behave in ways that are inconsistent with the leaders’ principles, goals and intentions. Inconsistencies, especially in key areas, can breed conflict and dysfunction in an office. As in health care, prevention is a critical part of ensuring that staff performance is as close to optimal as possible. Coherent, consistent, open communication, built on a foundation of trust among all members of the office’s team, are basic to preventing dysfunction and achieving high quality.
SS: Interesting points. Do you have some advice on how to have trust-based communication?
HJ: A foundational tradition in healthcare, shaping the actions of all good doctors, is being an effective diagnostician. We understand the importance of gathering relevant information before making decisions and acting. As clinicians, we begin by asking questions and making observations. The same principle applies to selecting and managing staff. Just as we have optimal health in mind as our goal when we diagnose and intervene clinically, we need an image of an optimally functioning office as our goal when we take actions as leaders of a clinical practice.
SS: Can you summarize these important ideas in the form of explicit steps you advise our readers to take?
HJ: This is an overview of some steps toward communicating effectively in a clinical practice.
- Being clear about our expectations: We can’t have others helping create and maintain an environment with consistent, high standards, including mutual respect and trust, until we have identified those standards for ourselves. How should patients be greeted? How do we want patients to be treated by everyone? How should we respond to questions and complaints? What are the procedures for expressing our own dissatisfactions? And more.
- Selecting and preparing an office manager: The office manager is your representative. Having a well-functioning office requires us to be clear about what sort of person we want to represent us when they recruit, hire, orient and supervise the staff.
- Recruiting and interviewing effectively: The process of selecting team members is the most influential time we have available for shaping our work environment. Any steps we take to try and change people who we’ve already selected aren’t likely to be as effective as selecting the right people in the first place. Our capacities for changing people in significant ways is quite limited. If an employee’s fundamental values or relationship styles are contrary to ours, we need to know that prior to making a hiring decision. Otherwise, we are virtually assured that there will be a continuous string of events we regard as problems. Making effective hiring decisions requires a specific set of “diagnostic” skills. When reviewing letters of reference, and during hiring interviews, we or our representative need to be perceptive observers. We need to look for clues that will answer such questions as: How needy is this person likely to be? Does she seem able to be collaborative? How much effort will it take to work with him? How is she likely to relate to colleagues and patients? Might he tend to lift other people up or drag them down? (Also, see Sidebar One)
- Optimizing everyone’s performance: People tend to do their best when they feel a sense of “ownership” of their work. Ideally, everyone on the staff will, or will come to, care deeply about the job that needs to be done. To be highly motivated and dedicated to achieving high quality, most of us need to be recognized and valued as individuals. Part of the task of senior leaders of a clinical team is taking the small amount of time needed for thanking people for contributions they make, and for getting to know enough about them and those close to them, to ask about their health and accomplishments. To do our best, most of us need to feel appreciated.
- Facilitating successful change: To remain effective, organizations need to evolve in response to changing circumstances and new opportunities. When we and our senior colleagues decide that some basic changes are needed in our policies or operations, we need to use our understandings of the change process to ensure that we achieve the improvements we’re seeking, without inadvertently causing damage. Everyone who will be involved in helping implement the desired changes, or who will feel the impact of those changes, needs to understand what is to be done and why. For significant changes to go well, we also need to be patient. Achieving lasting, worthy change takes time. We need to be patient with those who feel disrupted or excessively challenged by new expectations. As with so much else in achieving a high-functioning clinical practice, effective communication and trust-based relationships help make everything else easier and happen more smoothly.
- Preparing for emotionally-charged issues and events: Whenever two or more people work together for extended periods of time, under some pressure, events and issues can arise that cause disagreements, hurt feelings, or other forms of distress. Not all of us are equally adept at managing emotionally-charged situations. Part of being prepared for such events is reflecting on our own level of comfort and skill in managing such events effectively. If appropriate, a constructive step can be acknowledging our own limitations. Whether it is us or someone on our behalf, emotionally-charged issues must be recognized and dealt with as promptly as possible. An important step in ensuring high performance in a clinical practice is identifying, in advance, the person or people who are equipped and ready to take constructive steps when signs of conflict or other relationship difficulties first appear. As with most potential disruptions, emotionally-based difficulties are best managed by being prevented or by intervening as early as possible. Any office team that doesn’t have someone who is focused on, and well equipped to recognize and sensitively manage emotional difficulties and interpersonal conflicts can be a time-bomb waiting to go off.
SS: Thanks for that helpful set of recommendations. Is there anything else that you consider particularly important?
HJ: There are two large categories that I’d like to emphasize: 1) the importance of being an effective Role Model, and 2) let’s return to the process of Earning Trust, since it is so fundamental to almost everything else.
Role Modelling. Among our many ways of communicating, the most influential messages we convey to colleagues and staff can come from our own consistent behaviors. Our role modelling, the examples we provide, can have a powerful impact on the atmosphere, standards, priorities, and quality of everyone else’s work. Intentionally or not, we tend to be living illustrations of what we consider acceptable and desirable. As a leader of the office team, we need to be aware of our own communication and relationship style. Our ways of relating to others are likely to be reflected in what others do.
Earning Trust. To make good decisions about our organization, as in making good decisions about the patients we care for, we need access to good information. That information needs to be as accurate and as complete as possible. Staff members may have access to far more information than they convey to their supervisors, which leaves those supervisors handicapped. If we and other senior staff are to make the best decisions, everyone in the office needs to feel fully comfortable sharing their observation without hesitation.
Optimal leaders work consciously at creating an atmosphere in which everyone feels safe communicating their relevant perceptions and concerns, even if some of that information seems negative or worrisome. We can’t solve problems that we don’t know exist.
Some steps toward having an open, supportive, trust-based environment
Being non-judgmental gives you access to the best information from your staff. How do you show that you are a non-judgmental, employee-supportive leader?
- Consider being called by your first name: Senior leaders who are comfortable being on a first-name basis with their staff (at least when away from patients) tend to find that they are told more about important events, developments and problems in their office than they were when their hierarchical status was being emphasized with the use of titles. I must emphasize that this step is only likely to be of help if it is accompanied by other considerations, as follows.
- Being non-judgmental: Deemphasizing status and hierarchy, as the use of first names can help accomplish, tends to work best in teams where everyone feels valued, respected and supported. Such an atmosphere doesn’t imply lowering or eliminating standards. We don’t need formality, titles, or harsh judgments, to achieve high standards. In fact, the relationship between standards and judgmental relationships tends to operate in reverse. Standards are usually highest when everyone feels “ownership” (responsibility for) those high standards; when they are pursuing those standards as much for themselves as to please a “boss” or supervisor, or to get a good rating. Non-judgmental supervisors are not those who have low standards. Rather, they convey their expectations of high standards without causing others to feel judged, put down, or at risk.
- Being diagnostic, with “open” questions: Bringing the open mindset of the good clinician to our work with colleagues can take practice and explicit effort to form new habits. Those of us who are inclined to relate harshly to others, to be controlling, can need help and patience to change our relationship style. Anyone who is inclined to express dissatisfaction quite quickly when hearing about or witnessing something unwanted, is at risk of preventing growth opportunities and closing off potential sources of important information. Many of us need reminders from others and repeated practice to replace hasty judgments with neutral inquiries. What were you thinking? can be conveyed harshly or supportively. The question: Why are you doing that?, delivered with a harsh voice, needs to be replaced by the same question being conveyed as a simple question, with a neutral voice. The more we begin explorations by asking questions that are “open” not “judgmental”, the more we contribute to having an atmosphere of trust and comfort, which can help everyone grow and the practice thrive.
- Empathic Communication: Learning to be an empathic means perceiving the world from other people’s point of view. As doctors or administrators, it means adjusting our speech to those with whom we are communicating; to a pace and vocabulary they will find easy to understand, while not being patronizing. Empathic communication involves being diagnostic: observing and listening carefully, and being reflective about those perceptions. With staff, as with patients, we need to ask ourselves such questions as: What is this person able to understand? Am I helping her feel sufficiently comfortable to tell me private information that is important to my being helpful? Have I double-checked to be sure he understood what I’ve suggested?
- Some negatives to avoid: Gossip, Complaining, Dogmatism: Having a productive staff involves both what we do and what we avoid. Good morale, a sense of safety, and optimal performance can all be undermined by behaviors that are hurtful or counter-productive. Gossip involves the sharing of opinions or (possibly inaccurate or hurtful) information about a group member behind their back. It can lead to the formation of an in-group and an out-group in an office, destroying morale, collaboration, and trust. Complaining tends to involve repetitive assertions that there are problems, without constructive efforts to solve those problems. Like gossiping, it can be destructive. Dogmatism reflects rigidity and an insensitivity to alternative points of view. All 3 of these signs of negativity are symptoms that require quick action. They are danger signs, requiring information gathering and appropriate interventions. Sometimes, it is traceable to one person whose behavior may be changeable with supportive guidance, or it may indicate some personal difficulties that are beyond our capacity to resolve. The only solution may require that she/he be terminated as an employee.
Clinical groups do important work, usually under pressure. Creating an environment in which all team members are performing at their best, and the total contribution of the team is as close to optimal as possible, rarely happens spontaneously. Helping make sure that happens takes awareness, perceptive observations, and persistence over time. Ensuring a culture of excellence is a most worthy and achievable goal, but that task is never done.
I hope that you and your colleagues have already established the trust-based, collegial, supportive working and personal setting that enables everyone involved to be at their best, especially those for whom you make this special effort: your patients. I wish you well in achieving the standards of quality you want.
Sidebar 1: Additional Interview Questions
By asking these and similar questions you can get indications of how collaborative a candidate is likely to be.
Have you worked in a patient-care setting? (If so) Please describe that experience.
Have you worked with a difficult patient or colleague? What was that like? How did you respond?
At your last position, what kind of decisions did you make? What was it like to make those decisions? Please describe anything you would do differently if you needed to make those decisions again today.
In a prior job, have you worked with outside vendors? Please describe that experience.
Sidebar 2: Earning Trust with “HAIL” (See this link)
Honesty: Being straight and trustworthy
Authenticity: Being truly ourselves
Integrity: Being consistently dependable; Following through
Love: Wanting and doing our best for our staff and patients