Conversations Worth Having

Using Appreciative Inquiry to Fuel Productive and Meaningful Engagement

Berrett-Koehler Publishers, Inc.

Contents

Shifting Conversations

One great conversation can shift the direction of change forever.

– Linda Lambert

Alisha Patel, a senior administrator at a thriving medical center in New England, was surprised at the less-than-stellar patient satisfaction report that was sitting on her desk. Her surprise turned to understanding when she saw which hospital unit this was from. The director of that unit had recently quit because she felt frustrated with the new leadership model and refused to change. Alisha was filling in until a new director was hired.

She sent a copy of the patient satisfaction report to the nurse managers in the unit. She also emailed them an assignment for their next management meeting, which was a week away: Pay attention. Look for what staff members are doing that contributes to patient satisfaction. Come prepared to share a story of a best practice you've seen during the week.

The nurse managers were confused when they got the email; one even wrote back, asking if Alisha had made a mistake. "No," she replied, "please look for what's working well and bring your best story next week." This was a dramatic shift from what these nurse managers were used to, and it created quite a buzz. The former director usually read them the riot act, tried to find who was at fault, and demanded they do better, or else. They were glad to see her go!

When the nurse managers met, Alisha acknowledged the team for their quality of care and service to patients. Then she asked about their stories. They each shared a story of best patient care and then together analyzed the stories for strengths and replicable practices. They discovered several unique actions, but mostly there were consistent themes for what created high patient satisfaction. The nurses seemed excited about the ideas. "This was an amazing way to handle our problem, Alisha," one of them exclaimed. "I can't tell you how many meetings we've had that focused on this problem, and nothing ever changed. This was so effective. I know things are going to improve after just one meeting with you!" They left the meeting committed to sharing and implementing the best ideas. They were alive with possibilities!

Alisha smiled confidently as the staff left. She was thinking about the changes that had occurred over the last year. She remembered what it had been like working at the medical center before introducing their new leadership model. They had experienced steady growth in patient services over a three-year period, and, based on that growth, the demands on the staff were having a negative impact on performance, which was evident in their quarterly reports. Patient satisfaction had been steadily declining. Decreasing employee engagement was reflected in unplanned absenteeism and lower retention rates, which made matters worse for everyone. On top of that, patient "throughput" was not optimal, which meant the center lacked the beds they needed to serve the people who needed them most.

All of this negatively affected both the bottom line and employee morale. Everyone felt overworked and stressed. She knew the staff were always striving to provide a high quality of care, but the medical center's growth had become stressful, triggering short tempers, a lack of compassion, limited time for patients, and tension among staff and administration.

Alisha had not always been such an affirming leader. She was responsible for quality, and she lived by the quarterly performance reports. When performance stats were up, she didn't worry; it gave her a chance to focus on other responsibilities. She would send the reports to directors, but she never went out of her way to acknowledge them. She took good reports for granted. When performance stats started declining, it was a different story. She gave the reports all her attention. She spoke face-to-face with directors, and her tone was critical: "These reports are not satisfactory. Every quarter it's the same or worse. You've clearly done nothing to improve!"

The managers would defend the results, saying, "We have made changes, but we can't do anything when we are understaffed and people don't show up for work. Some of our staff are already working double shifts to cover for other folks!" "I don't want excuses, I want results," she snapped. "We are doing the best we can," a manager snapped back. "Well, you'll have to do better!" Alisha ended the conversation.

The managers always left demoralized and with no ideas about how to resolve the issue. Alisha's levels of stress and dissatisfaction grew over this period, and it became next to impossible to hide her frustration from her colleagues. Her stress rolled over into her family and nonprofessional life as well. She became short-tempered, negative, and quick to criticize both her kids and her husband. She had fast developed a reputation for being the kind of person she never wanted to be, as a manager, partner, or parent. She realized she was going to have to do something if she wanted things to change. So she began an online search. She was intrigued by the headline of an upcoming workshop she found, about something called Appreciative Inquiry (AI), which promised tools and strategies for strengths-based change at any level — personal, organizational, and community.1 What caught her attention was this headline:

The Best Healthcare Clinics in the World Are Strengths-Based; Their Performance Outpaces All Others!

She read further: "When we're unable to act with agility, speed, and unity, opportunities are missed and revenue is lost." It was as if these words were written just for her. In hospitals, she knew, agility and speed can mean the difference between life and death, and lost revenue seemed to lead to financial decisions that negatively affected quality. What convinced her that this was the workshop she needed was a quote from David Cooperrider: "We change best when we are strongest and most positive, not when we feel the weakest, most negative, or helpless." She realized she had become negative, focusing on everyone's weaknesses, including her own. Everyone was feeling helpless to turn things around. So she clicked on the registration tab.

During her online training, she learned about the practices and principles of AI. Somewhere in the midst of the week she realized she herself had actually been contributing to the problem at her own medical center. She had dug in her heels and had badgered the staff, without asking any questions or helping to find solutions. She vowed to be part of the solution when she returned.

The first thing she did was to create a positive framework for her next conversation: More and more, our patients feel highly satisfied with our care. Then she adopted an attitude of curiosity. She wondered if some of the patients felt highly satisfied. If they were, why? What were their stories? What was the staff who cared for them doing that made a difference? These were the questions she led with at her next staff meeting, and she noted a remarkable shift in the conversation and in more positive outcomes. Alisha felt in awe of how much easier and more effective this approach was. And the proof was in the reports. Quality improved in the next quarter!

A year later, after her recommendation, senior leadership, management, many of the nursing staff, and a handful of physicians had gone through a series of AI workshops that literally gave them the ability to turn their culture around simply by changing their conversations. Alisha thought about her own conversations with staff these days. They were appreciative and inquiry-based, focusing on what they did well and what mattered to everyone: best and heartfelt care, patient recovery, and a place where everyone thrived.

She also realized that her focus of attention had shifted. Instead of seeing the staff themselves as problems, she was seeing their actions as possibilities. Her conversations with them were very different from those she had had a year ago. These were conversations worth having, and the results they produced were creating positive change throughout the medical center.

For example, the Emergency Room staff engaged members of clinics and urgent care centers in productive conversations focused on getting people to use the ER only when needed. They mapped their clinical care strengths and specialties across the city. They asked questions to inspire possibilities and new ways of thinking, as well as ways to work together to help prospective patients choose the right location for care. Such questions included: What would have to happen for every citizen to know where to go to get quick and reliable care during the day and after hours? How do we make sure transportation is available to move people where they need to go? The result was a Right-Care, Right-Place plan to help patients learn over time where to go and how to get there. The staffs worked together and developed a system that was delivering right care in the right places. Ultimately, this meant the ER team was serving patients who really needed emergency care. It also meant less chaos and crowding in the ER.

What Alisha and most of the staff discovered was that conversations that were appreciative and inquiry-based fueled productive and meaningful engagement. These conversations were generating exceptional outcomes. The staff throughout most of the medical center had developed a sense of unity and commitment to one another because they intentionally engaged in these kinds of conversations. They routinely thought of innovative ways to improve care and consistently put patients — and one another — at the center of all they did. The results spoke for themselves. The work climate changed significantly. This positive vibe made the medical center a place where people wanted to work. Employee retention improved and staff absenteeism declined. Even when the patient census was high, staff received consistently high ratings that reflected outstanding performance and commitment to excellence.

For Alisha, these positive changes rolled over into her family and personal life just as her frustration had. Alisha found herself initiating more Appreciative Inquiry–based conversations at home, much to the joy of her partner and her children. She found her AI training was every bit as applicable at home and in her community service work as it was at the medical center.

Understanding how appreciation and inquiry enhance relationships as well as productivity and performance is a lesson that Alisha's whole team learned. In our next story about a struggling bank, you will see this point as something that Kamal Amari and Mary Wellington understood well and practiced in their leadership. Kamal and Mary had taken over failing banks and turned them around a number of times. Their success was, in part, due to their capacity for appreciative and inquiry-based conversations. Even when taking over Community One Bank didn't turn out the way they had hoped, great conversations still made all the difference to that bank's employees and customers.

Community One Bank stood as a refuge for the small business owner, first-time homebuyer, and teenager opening a first checking account. Located in the outskirts of Detroit, Community One never focused solely on making money. For the original owners, the goal was to provide quality service in a comfortable environment where people served their neighbors and friends. Early on, they had done well, but times had changed. The bank had been struggling financially for some time. One morning the owners gathered the staff to tell them the bank had been sold.

This news came as a shock to the staff. None of them had been privy to the bank's financial problems. Elizabeth Randall had been with the bank for thirty-eight years when the change in ownership occurred. She had longstanding relationships with her customers, who were more than merely deposit and withdrawal statements. For Elizabeth, her customers were like family. In response to the news, she declared sharply, "I'm not going to work for one of those big banks. They don't care about staff or customers. They only care about making profits!"

When the transition occurred, the former owners introduced Kamal and Mary as experienced bankers with a long track record of turning around struggling banks. "I can't promise you this is going to be easy," Kamal told the assembled staff. "I can tell you that if we work together and do this as a team, we can save this bank and continue the tradition that Community One has established over the years. I want to be honest with all of you," Kamal continued. "Given the financial issues with the bank, we will be looking at staffing, overtime, and operating policies and procedures. For the bank to survive, we need to cut costs and meet revenue goals on a budget so that we are financially solvent to take care of you and our customers. This means that everyone will have to do more with less."

"I knew it," thought Elizabeth. "They're going to destroy everything we've worked so hard to build here." Kamal and Mary met with each employee individually, and when it was Elizabeth's turn, she prepared herself for the worst. However, the meeting was not at all what she expected. There were no closed doors, and no staff was fired. Elizabeth was completely caught off guard at how their meeting started off.

"Thank you so much for coming to talk to us, Elizabeth," welcomed Mary. "Kamal and I are excited to meet with you. We understand that you have the longest history with the bank and that no one knows this place better than you. We're hoping you'll share your best experiences with us about what makes Community One great. We also want to know: What gives life to this bank and community?"

Kamal and Mary smiled reassuringly in response to Elizabeth's "deer in the headlights" expression. Elizabeth stammered, "You want to know what makes the bank great? But I thought we were losing money!"

"The bank is losing money," said Kamal, "and we do need to make changes, but we don't want to change what it is about this bank that customers love. We want to learn about what you and the other team members have done to engender such loyalty on the part of this community. We need your experience and knowledge, Elizabeth, and we hope you'll partner with us to turn the bank around."

"Of course I will," Elizabeth agreed. She was stunned at the direction of the conversation. For the next hour, Kamal and Mary peppered Elizabeth with questions, such as: "What do you love most about your job? What wishes do you have for the bank to best serve its customers?" Elizabeth found herself drawn to the magnetic energy of these strangers. They laughed as she regaled them with stories of funny things that had happened over the years. Between their positive questions and these stories, Elizabeth began to remember why she loved her job. Elizabeth also found herself wanting to work with Kamal and Mary in whatever way she could to help the bank succeed.

Over the next eighteen months, the new management worked alongside the staff to make sure everyone was aware of the bank's financial situation and how the changes they were making affected their viability. Naturally, not all the interactions were problem-free. Some difficult conversations occurred. On one such occasion, Kamal asked Elizabeth and another account manager, Ram, to come to his office.

"Elizabeth and Ram," he began, "come in and have a seat. I have a couple of areas that we need to address together. You know we've been working on time management and new accounts over the last month. Elizabeth, it is still taking you too long to open new accounts, and Ram, you don't open many accounts." Elizabeth and Ram each felt a flush of embarrassment, but it vanished quickly because Kamal continued without blaming. Instead of focusing on what they were doing wrong, he acknowledged their strengths and asked them to team up. "Elizabeth, you open the most accounts every month. Ram, you are faster than anyone else at opening accounts. Would you two be willing to work together to combine your areas of expertise to create a fast and effective process for landing new accounts for the bank?"

This led to a great conversation between Ram and Elizabeth. They pooled their strengths and knowledge to develop a replicable process for opening accounts. Elizabeth learned some effective shortcuts on the computer, and Ram learned ways to engage customers and invite them to explore accounts that would be beneficial for them. When they presented their model to Kamal, he seemed quite impressed with their design. He asked them to introduce other staff members to their plan and bring them up to speed with their new process.

Kamal's leadership style had turned a problem into an opportunity to improve things for everyone at the bank, and also to strengthen the leadership capacity of upper-level staff. Elizabeth had come to understand that Kamal and Mary truly had both the employees' and the bank's best interests at heart. Their appreciative, open, and collaborative style of management had converted Elizabeth from skeptic to cheerleader. Things at the bank were now going extremely well. The bank was not completely out of the red, but they were getting close. Then the 2008 Great Recession struck. To make matters worse, the city of Detroit and all its surrounding communities were hit hard by problems with the automotive industry, the lifeblood of the local economy. This perfect storm negatively affected the bank, and almost overnight the bank went from "on the road to recovery" to "no longer financially viable."