Culture of Safety: How to Influence Accountability

August 12, 2013 ‐ Patton McGinley

July/August 2013

Culture of Safety

How to Influence Accountability

By David Maxfield, PhD

Editor’s Note: This Q&A first appeared on the official blog of the Crucial Skills Newsletter—a weekly online publication from the authors of New York Times bestselling books Crucial Conversations, Crucial Accountability, Influencer, and Change Anything.

Dear Crucial Skills,

I work as a nurse in the education department of a healthcare institution. I lead unit nurse educators whose role is to maintain the competence and educational skill level of the nursing staff on their units. They sometimes struggle with having a crucial conversation about safety or performance with a colleague who says, “It’s no big deal.”

How can I teach my nursing staff to hold their “friends” to a high standard without having the friend get defensive or tune them out?
Nurse Educator

A: Dear Educator,
Thanks for a great question. The issue you raise is relevant far beyond healthcare. Every organization has groups that are tasked with tracking and supporting best practices. Think of quality and safety departments in manufacturing, or human resources or IT departments in nearly every organization.

Here is what happens. Everyone knows that your group owns the issue. In your case, your education department owns competency and skill building. A natural human reaction is to conclude that if you own it, then I don’t. In their minds, you become an enforcer and they act like drivers on the freeway who slow down when they see a cop but then speed again as soon as they’re out of radar range. They don’t take responsibility for their behavior. That’s why you hear them say things like, “It’s no big deal.” It has become your issue, not theirs.

There is no way that enforcement alone can drive good behavior. Not only does it fail to produce positive change, it makes the enforcers feel ineffective, unwanted, and unappreciated. But there are solutions. I’ll share a few ideas that come from our Influencer approach and have worked with many of our clients.

Create an influence plan.
Begin by meeting with the unit educators. Describe the problem and get them on board. They can never really succeed as long as they are seen as enforcers. Your team needs to get employees in the units to own the problem. Then they can play a supportive role by coaching, building skills, and getting access to resources. Make sure your team knows how their roles will need to change.

Focus on measurable results.
Determine a handful of measurable results that you and the units can track. For example, you might focus on infection control, falls, and patient and family experience. Pick the few that will have the greatest impact. If you include too many result areas, units will lose focus.

Determine vital behaviors.
Vital behaviors are the two to three actions that will drive the results if they are consistently and reliably employed. Some of these behaviors will be unique to the result areas you target. For example, wash in wash out reduces hospital-acquired infections; quick screens reduce falls; and bedside reports improve patient and family experience.

Important to your case, a few vital behaviors span nearly every result area. One of these is 200% accountability, which means, “I’m 100% accountable for my own best practices, and I’m also 100% accountable for your best practices.” Instead of your education team members being the only ones to hold others accountable, everyone on the unit/team will hold everyone else accountable. This is the vital behavior that will fix the problem you describe in your question.

But this is a tough behavior to implement. Making it work will require all Six Sources of Influence™. I’ll suggest one idea for each.

Personal Motivation—Create a value frame.
Currently, employees in the units/teams are giving you and your nurse educators their compliance, not their commitment. They are focused on the enforcement of the rule, instead of the reasons for the rule. You could even say they are in a moral slumber. They aren’t attending to the very real personal impacts of their actions. For example, let’s say they are taking shortcuts instead of fully gowning up. When one of your staff reminds them, I bet they respond with “no big deal.” Your staff needs to make it personal by focusing on the patient, not the rule. For example, “Imagine your daughter was on this unit and you were doing everything possible to keep her safe. Wouldn’t you want people here to gown up to protect her from infections?”

Your goal is for employees in the units/teams to see holding each other accountable as watching out for each other. None of them wants to put their patients at risk and yet, we humans are all fallible. Despite our best intentions, we all make slips and errors. Team members need to give permission to (or request) their peers to watch out for them and to speak up when they see them slip.

Personal Ability—Use deliberate practice.
Team members need to decide how to remind each other. For example, “How would you like to be reminded if I see you forget to wash your hands?” They should compose the phrases they’d like to use to hold each other accountable. For example, “I’ll position the patient while you wash up,” or “The dispenser is by the door.”
Then teams need to practice using these phrases. Talking about holding each other accountable isn’t as powerful as practicing holding each other accountable. A fifteen-minute practice is all it takes to turn good intentions into actual action.

Social Motivation and Social Ability
Involve formal and informal leaders. You, as the manager of the education department, will want to meet with the unit managers to get their buy in. They need to understand that making their teams accountable for their own best practices is the best, most efficient way to improve performance.

There will be times when someone will object to being held accountable. Maybe it’s a more experienced employee or a high-status professional who doesn’t want to be reminded by a newbie. In these cases, you want to provide easy and immediate support for the newbie.

Having the formal leaders (the unit managers) on board is essential, but usually not enough. You’ll also want to reach out to informal leaders (the opinion leaders). Ask the manager, a physician, and a few other opinion leaders to play the champion role. They can explain why the issue (infection control, falls, etc.) is personally important to them. They can also provide that easy and immediate support when it’s needed.

Structural Motivation—Reward small gains.
This is where it gets fun. Instead of being enforcers, your team members become cheerleaders. Equip them with lots of ways to celebrate the improvements they see as units adopt 200% accountability and make progress on their results. You might give them gift certificates to use as recognition or provide funding for a few pizza parties.

Structural Ability—Be the bridge to resources.
This is another fun part of your new role. Your team members help units identify and bust through obstacles in their environment. For example, a team might complain that they don’t have enough hand-hygiene dispensers or that they aren’t always full and working. Your team takes on these kinds of challenges and gets to bring resources to the units.
You are starting in a strong position because you already have nurse educators embedded in the units. The challenge now is to move the enforcement part of their jobs from the nurse educators to the staff members in the unit. Once staff members take responsibility for holding each other accountable, you’ll see rapid improvements in quality of care, safety, patient and family experience, and even staff satisfaction and engagement.

David Maxfield is vice president of research at VitalSmarts, an innovative corporate training company that has trained more than 800,000 people worldwide. Maxfield’s research interests include the role “crucial conversations” play in the healthcare industry and how the ongoing failure rate within enterprise projects is consistently linked to the avoidance of a few key crucial conversations. He has also led research projects about diversity, leadership, and influence. Coauthor of three New York Times bestsellers, Maxfield did his doctoral work at Stanford University, where he studied personality theory and interpersonal-skill development.

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