With the performance matrix in mind, the PACT Factors, which set a foundation for the creation and reinforcement of pride, accountability, commitment, and trust, are viable starting points for employing the PACT System. These four major themes can be applied directly in your workplace and underscored in your leadership strategy by examining the dipolar tendencies (first the right tendency in leadership style and strategy, the second listing the converse/negative tendency) for each of the four major PACT elements. The PACT Formula has a basic philosophy (Figure 2–2) that when encouraged by the physician leader can inspire increased performance and confident, progressive individual staff member action.
PACT knowledge and philosophy.
Moving from the general applications of the PACT Formula apparent in the preceding paragraphs to specific applications under its acronymic aegis, we will now put more PACT Factors into practice, starting with factors and strategies specific to the building of pride in an organization through strategic leadership communication. Pride is best defined for our purposes as a sentiment shared by the overall majority of the organization or team that
-We are here to perform a vital service.
-We believe that we do our jobs individually and collectively as well as anyone in our field.
-We will always do whatever it takes to take good care of our customers.
-We are in the game to win, not just to play.
This Is Now Versus That Was Then
With the continuing need to change within an organization, based on ever-escalating customer expectations, ever-emergent new technology, and ever-intensifying pace of action, it is easy for the nonplayers to lament current pressures and long for the good old days. As is always the case, they can often enlist the more pliable members of the steady group, and create a sense of doubt about current initiatives and organizational direction. It therefore becomes an intrinsic responsibility of the physician and healthcare leader to constantly educate his/her team about current objectives and future goals, all supplemented with a focus on current demands. Then or the good old days has relatively nothing to do with present-day demands, yet can be a wistful seditious inspiration for the nonplayers and their sympathetic listeners.
To do this, communication in department meetings should include at least one mention of a current event that is directly impacting the organization's current work. An example of this would be the latest government initiative to provide Medicaid and Medicare reimbursement based on patient satisfaction scores. A physician leader who uses an article from a local paper on this current miasma—and that would be readily available, given its prominence—can then link it to the requisites of a medical office to ensure that every action taken onstage in view of patients is customer friendly and provides the best effort to provide clear communication and compassionate care right from the patient's entry into the front office.
This Is Us Versus That Was Them
Closely related to the preceding facet, healthcare leaders must constantly affirm that they are satisfied with the construct of their current team and fully confident in their abilities. This is essential as the nonplayer will reference the past, in which budgets allowed larger staffs and, undoubtedly, more human resources in general that are available now in the era of doing more with less to the point of doing everything with nothing. Citing the wins and notable accomplishments of the current staff, both in a group context and with specific individual, positive recognition is an easy tool that is always available—but often not fully utilized—by physician leaders in their daily communication.
A good technique to ensure attention in organizational communication is to use a word that is not often heard in management parlance. This gets the staff's attention and can become a nice game among the superstars and steadies, as if the selection is interesting, which can in turn be used as a reference point in ongoing discussion. An example of this is the word, miasma, which generally can be defined as a deliberate, self-perpetuating foggy environment. Nonplayers love to create miasma through rumor, innuendo, and sheer mendacity. Focus on the current objectives of the team is the first step; however, the physician leader must strive to always frame the why of what the team means to achieve every day and at every opportunity. A simple cause-effect semblance is the best method for this.
For example, the practice of walking a new patient to not only the department that will provide primary service, but additionally introducing them to the first person in the continuum of care resonates maximum meaning to the patient entry process. It also eliminates the always-present potential of a new patient becoming confused and losing trust immediately by getting lost in a facility as they try to independently negotiate the miasma of paperwork and the often-vexing physical layout of a medical facility.
As depicted in Figure 2–3, superstars are selfless in nature and understand that by taking care of the customer/patient, their teammates, and the organization's objectives, they are in essence taking good care of themselves. The diagram provides an overview of the triad of their success strategy, which makes them natural leaders in conducting the action needed by the organization and directed by their physician leaders. Nonplayers, on the other hand, are self-centered and seek to create cracks in the overall structure—fissure—and particularly in the semblance of their assigned work team.
The physician leader must therefore keep a focus on team objectives and goals and not allow inappropriate and disproportionate time to be spent on discussing individual problems and issues presented—and all too often, conceived in fiction in a fractious manner—by the nonplayer. Two specific strategies are needed herein. First, the physician leader should take the time in group meetings to provide the facts in the face of any prominent rumor in the interest of curbing further conflation by the nonplayer. This should be done crisply and resolutely, and be centered on the true facts, even if that means conveying that a decision has not been made (which is better, for example, than a rumor that a decision has been made that will negatively impact the work group) or simply confirming some bad news as fact. In the latter case, the physician leaders should provide action plans so that their group has an objective to work toward to deal with the bad news; that is, the physician leaders should give their group something to run toward, rather than run from various negative aspects, both real and perceived.
A second strategy is to implement a house rule that all staff members should provide solutions to all problems encountered by team. The staff should be tasked to innovate solutions, with the leader's guidance, that not only assuages the problem at hand but implements action which is proactive, progressive, pertinent to the situation at hand, and provides a definite, positive payoff for the customer, organization, and team. Naturally, the superstars and steadies of the group will be able to contribute, if not lead, this discussion and maintain a focus on shared direction and action. The nonplayer will be forced to enjoin that discourse positively, or in a very real sense, deal themselves out of the action.
Transformative Versus Trudging
It is unfortunate that politicians have embraced as part of their pedantic polemic the notion that they will be transformative leaders once they attain office, and all too often, become part of a trudging, status quo of inefficacy and mistrust. However, if taken from a more effective venue, a leader who uses a strategy, both in their communication and planning, that is transformative can garner the full support of all of their superstars and the overwhelming majority of their steadies. Transformative leaders are ones who can enact significant change that benefits the organization, customer community, specific work teams, and individual staff members. They can position all of these constituencies in a clearly improved position for the future while leading short-term change catalytically and with maximum outcomes.
As is the case with any sound leadership strategy, the foundation of planning at the team level should start with the staff members who are closest to the action and thus are a boundless front for new ideas that could translate into winning practical and pragmatic strategy.
The physician leaders who ask for the idea of the week at regular meetings and utilize a daily strategy of asking staff members a simple but very efficient question—“What do you think about (a given objective, new plan, or apparent need for action)?”—are those who are certain to have a ready lode of useful information in formulating new plans of action that will be transformative for their organization. Additionally, a natural level of commitment is at hand, as the genesis of the plan came from the staff that must now support the plan with action. Pride is engendered as results abound from the new action, each individual is assigned an accountability for specific action to support the group objective and results are realized from a smarter, better way of doing things—which, in reality, is a very credible application and definition of transformative action.
Superstars and steadies want their team to win. As simple as this seems, one only has to consider their devotion to selfless service, which in turn will ultimately provide a sense of satisfaction and achievement on their job. The nonplayer conversely wallows in multitudinous excuses and limitless reasons for why the organization and the team are not prepared, ready nor able to take care of business at a top level. The nonplayers unfortunately can take umbrage in the mass media depictions of the culture of complaint that exists in American society at large and has been aptly captured in several books and apparent on any talk show (Figure 2–4).
Being a victim is almost trendy, and most nonplayers have that role down to an art form. Unfortunately, their whining and inappropriate emotionalism can be a morale buster, and it must be arrested by the strategic healthcare leader forthrightly and resolutely.
Two strategies can accomplish this. First, the healthcare leader should think of teams that they have been part of which have been successful, as well as notable teams from the world of sports and other organizations that can be used as positive exemplars. This can be done most optimally as a group exercise with the team, as it would then be notable, resonant, and jointly owned when ratified and put into action. Three to five aspects of the winning team's composition should be aligned toward specific group's charter. An example of this approach would be to use the sports example of the underdog 2012 Super Bowl Champion New York Football Giants as a model, who succeeded through the employs of four criteria:
-Unconditional belief in their abilities rather than what the expert media believed
-Planning their work, and then working their plan
-Adjusting their plan as needed, but all while keeping the main objective in mind
-Knowing that the pressure would be on, but not getting on each other when the pressure was on
Taking a closer look at these factors, it is easy to see how an emergency room team in a community hospital, for example, could easily apply these tenets to their daily work. In doing so, the superstars and steadies would have a clear plan to victory (read: positive outcomes) and the nonplayers would be self-exempting if they decided to complain without merit, or bring up problems without solutions while the rest of the department dedicated itself to building an emergency services department that they could truly be proud of every day at work.
Resonance Versus Dissonance
Pride can be built on having a credo—that is, a set of beliefs—that the entire work group can embrace and employ through action. This credo must resonate—echo positively—through the entire work group. The fracturing of communication known as dissonance can be destructive in any work situation, and in some healthcare situations, can actually be dangerous if it leads to miscued action, inaction, or mistakes in treatment. The nonplayer can often create dissonance that can lead to miscommunication deliberately just to get attention in a despicable manner; regardless of the motivation, dissonance over time can lead to a schism within a work group, which ultimately can lead to abject failure.
A basic credo should therefore be forwarded by the physician leader, ideally with easy-to-remember phrases, to have a resonant communication of the basic mission and philosophy of the work group. The use of alliteration, repetition of phrasing, and other communication devices helps to facilitate reference and recall of the credo. The following is an example of a credo that the author helped create for a Veterans Administration Medical Clinic in Appalachia:
-The Veteran Patient has served our nation with high distinction, now we have an opportunity to respond in kind.
-The Veteran Patient drives our clinic, not vice versa.
-The Veteran Patient is a neighbor of ours and from a family like mine, so only the best possible care will do.
-The Veteran Patient can do without a lot of noise, hassle, paper chase, or waiting.
-The Veteran Patient will appreciate all that we can do and will be eternally grateful if we can get it all done.
The use of argot familiar to the team, as well as the service community, is essential to making certain that the credo resonates at full force. Furthermore, a well-conceived credo can have long-term usage for a team and act as a long-term warranty of pride in the workplace for the superstars, steadies, and for the person at the top of the organizational chart—the customer.
Garnering Maximum Commitment
Understood/Respected Versus Liked/Accepted
This particular factor is one that finds its fulcrum in the physician leaders themselves as opposed to being a group calculus. Starting with the counter component with any leader wanting to be liked and accepted, it is easy to see the fallacy of action relative to nonplayers, whose favorite response to a negative performance evaluation is to say to their physician leaders, you're doing this to me because you don't like me! While all of us would want to be liked in general and accepted by those we encounter in a given day, physician leaders charged with the responsibility of moving others toward good work cannot aspire to being socially popular or perceived as being a good egg as a primary goal. The bad news is that the nonplayers, who are usually socially manipulative if nothing else, will use the physician leaders' penchant for being liked as a munificent opportunity to ply that brand of manipulation. The good news in this case is that the superstars and steadies will like the physician leader on an interpersonal basis if the leader seeks to be understood and respected in their job.
There are four steps that a physician leader should take to make certain that respect and understanding take precedence over being liked and accepted.
Get bad medicine done quickly. New physician leaders should make all of the necessary but somewhat painful actions that are needed in a new department to be done quickly and within the first 3 months on a job. This signals clearly to their staff that they have the fortitude to get the job done and will make tough call as needed.
Bad news doesn't get better with age. Sitting on bad news doesn't make it go away, nor make it less deleterious, nor give fate and fortune an opportunity to magically revert its circumstances. Using the preface, “I have to tell you something, cold and true,” and then delivering the message conveys to a staff member or group that we will get upset about the bad news, get over it, devise a plan of action together and then as a team, get on with it.
Keep the small talk small. In the New York Metropolitan area, believe it or not, office places can become communicatively hostile during any occasion in which the Yankees find themselves playing their crosstown neighbors, the Mets. Television shows baseball, the stock market, and politics are all avocations and areas of interest which in proper context can be stress relievers on the job, ideally on coffee breaks and at lunch time. The leader who overindulges in conversation on these topics can be seen in the wrong light and cause unneeded discordance and adversity. For example, a Mets fan in a group of Yankee fans, or a conservative working with a bevy of MSNBC viewers could make personal preferences a source of discord if those affiliations became more of a topic of conversation than the work mission at hand.
Manage off-time wisely. A new manager at a hospital decided to use Facebook as a communication forum for a number of social activities—and unfortunately became friends with many of his/her staff. The nonplayers, as you probably already surmised, used this as a prime opening to bring personal lives into the workplace inappropriately. A wealth of precious communication and work time was then dedicated to resolving and remedying some of the prattle from that banal, numbskull source of social media than an upcoming commission inspection of his/her healthcare team's facility. Short answer—stay off of social media, as well as oversocializing with staff members. The superstars and steadies aren't really interested—the nonplayers are interested only to the extent that they can use it against their (in this case, soon to be erstwhile) physician leader.
A pernicious undercurrent can exist in any work group in which gossip takes precedence over more substantial communication. Nonplayers can often be sardonically artful purveyors of gossip, and as lead gossip mongers, they can find any number of steadies willing to give their babble a hearing. Unfortunately, human nature is predisposed to the prurient and as we all know, bad news sells in all forms of the media. Taken together, gossip can find a disproportionate place in the workplace, as people want to know the latest dish regardless of its relative validity or the veracity of its communicator. This is especially true when a workplace has experienced a tremendous amount of change or a significant downturn in business; in health care, for example, gossip around the facility can feature pending layoffs, closing of units, and an assortment of many other doom and gloom scenarios. The worst impact of this type of communication is the manner in which it promulgates fear among staff and customers; in the former, the steadies can be prime victims of this gossip/fear mongering, and with the latter, a direct loss of business can occur as people wonder, “Will this organization stay in business?,” or perhaps worse, “How does this place stay in business?,” as that sentiment goes directly to an at least perceived lack of integrity within the organization. Taken as a net effect, it is difficult to be proud of an organization that rivals the worst in reality television relative to contrived subplots and character exploitation.
To combat this undertow that can undercut the essence of their team, the physician leaders can incorporate the smart address and disposal of rumors at their staff meetings at least once a month. In this as a special item, The Rumor of the Month, the physician leader should select a topic which has been apparent gossip fodder, and discuss whether the rumor is true or more likely, why it is not true. By taking the lead in acknowledging that the rumor exists and then minimizing its impact by presenting an action plan, if there is an element of truth, the steadies are provided with a clear choice on who to believe between their physician leaders and the gossipmongers. Additionally, it demonstrates to all of the staff that the physician leader is clued in to what the concerns of the staff might be and is willing to take on the nonplayer, who is usually also a verbal bully in addition to being a mendacious, disingenuous communicator. The physician leader should crisply address the rumor, confirm its relative truth or counter it with the facts, and then move on to the next topic at hand in the meeting. He/she should not address additional questions specific to the rumor, nor address additional rumors if asked by the nonplayer, but instead say, “I think that most of us agree that we have too much work to do around here without wasting time on every single rumor that is concocted by a few people.”
Trust—Encouraging the Individual as the Nucleus of Action
Cascade of Commitment Versus Niagara of Negativity
The nonplayer loves to dwell in negativity; it has been often noted that most nonplayers would not be happy in heaven; they would likely complain that their cloud was too hard, their wings too tight, or that St. Peter asked too many questions when they entered the Pearly Gates. They have a natural proclivity for finding the worst in any situation, are expert of immediately deducing the problems inherent to a proposed action, and identify quickly where and how a plan will fail once enacted. Over time, they can erode not only pride, but also create a doubt in the steadies' collective consciousness about how strong the organization really is, which in turn causes this middle majority to question the organization in general and the physician leader specifically relative to competence and direction. Furthermore, the superstars, who want to be part of a successful team positioned and dedicated to growth and development, will tire of the perpetual and unabated negativity, and eventually seek employment at an organization with a more positive perspective.
To ensure that a positive posture of communication is positioned as a daily expectation, the physician leader should implement a series of house rules for all staff members. These house rules can be posted, or as is the case at many healthcare organizations, printed on the back of the employee's name badge to signal clearly that they are not only job expectations, but work requisites.
Do not raise a problem unless you are ready to propose at least two solutions.
When you make a suggestion and suggest a solution to a problem, make sure that the solution is realistic in scope and capable of being implemented readily without undue expense of time, energy, or other precious resources.
Noise annoys; keep personal problems and opinions away from the patient and visitors, and preferably, away from the hospital.
Anytime is a good time to ask for help, especially if you feel overwhelmed.
These precepts can prevent the steadies from falling into the Niagara of negativity promoted by the nonplayers while conveying clearly the expectations for work performance beyond the specter of the job description to the nonplayers. It also reflects standards which the superstar already exemplifies, which not only reinforces their work behavior but also provides additional empowerment, as it encourages them to act as leaders in the workplace in providing assistance to steadies as needed and requested.
Priorities Versus Preferences
All employees have their own notions on what is the most important part of their job and definitely can detail their favorite parts of the job. In some cases, their preferences are in accord and alignment with the organization's need for their work contribution, and thus a fusion exists with their strengths and interests as the organization moves forward. However, the organization will invariably expect more from an employee than just their personal favorite parts of their job, and as a result, nonplayers and some steadies can be justly evaluated poorly due to not doing the whole job.
The physician leader needs to constantly calibrate performance based on the priorities of the organization, namely
The needs, expectations, and demands of the customer: This can include the basic reason why the customer exists relative to the organization, as well as new trends, emerging demands for new services, and the often-overlooked but ultimately important human touch always sought and constantly evaluated by the customer. In essence it is the organization taking good care of business vis-a-vis their customer that is the most important evaluator in the process.
The goals, objectives, and strategy of the organization: The organization's original charter is as important as its current mission statement in this regard and often can be concordant. For example, many metropolitan hospitals on the East Coast were opened in the late 1890s and forwarded a charter of using all of their organizational strengths—mental and physical—in the pursuit of excellence in the interest of taking care of their neighbors who were in pain and need. Newark Beth Israel Medical Center, opened in 1899 with a charter statement which embraces this tenet fully, now has over 4400 employees across the largest medical campus in the nation's most densely populated state, New Jersey. Its strategy is still centered on its original charter, and despite myriad changes in medical technology, constant restructuring of nonprofit healthcare finance, and varied eras of change and competition in urban health care, the mission remains the same and each employee's second priority—next to taking care of the patient, as per our first standard above—is supporting the organization's almost sacred charter in taking care of the healthcare needs of the state's largest city.
The operational imperatives of the work team: It is the responsibility of the team leader to ascertain the best work flow and assignment of responsibility to each team member in a manner that both utilizes the individual talent of the employee while garnering maximum return on investment relative to the organization's goal. The sometimes elusive value proposition of each employee should be appraised by the physician leader and then used in concert with the whole team to provide maximum contribution to the organization's mission.
The individual daily action of the employee: The duality of the employee's action being the fourth priority is the epitome of a double-edged sword proposition. On one hand, the employee should think of the patient's needs, the organization's mission and contribution to the team's success progressively—in taking care of those three objectives, he/she is in essence taking care of himself/herself. On the other hand, if the employee does not meet the demands of all three of these dimensions, the entire operation can fail in some regard, as the employee represents the nuclear strength of the organization. Accordingly, the strategic leader should use all four dimensions in this sequence in all communications:
What is the best action needed individually to meet a customer's expectation?
What course of action would reflect the best credit on the organization's mission?
How does this particular employee make the optimum contribution to the team?
How do I best play to the strength(s) of this employee, based on the three factors above?
Inspiration Versus Obligation
Motivation is a topic which has filled tomes of management literature since people tried to figure out what made Adam bite that apple. From Maslow to the late Steven Covey, the topic has fascinated psychologists in general and management scholars alike. This PACT Factor can easily be interpreted as another attempt to gild the basic concept of the carrot (inspiration) and the stick (obligation), but the idea here is more rudimentary than grandiloquent. Relative to accountability, the mediocre performer works from a reactionary perspective and has limited opportunity for personal growth and professional development. Their sole motivation at work is a paycheck, which in turn pays for obligations such as rent, food and transportation, and maybe a disposable income item or two which make them forget that they are bored in their job and essentially unfulfilled professionally.
The primary component in this couplet, inspiration relates to four concepts which can be utilized positively by the strategic leader with their staff and indeed are likely part of the work orientation of the physician leaders themselves.
Work interest: If an employee enjoys about 70% of their job responsibilities, they will contend with the 30% that is less interesting and engaging. If that quotient is higher, the employee will become even more motivated. If it is less, the employee's performance will either erode, as would likely be the case with a steady, or the employee will seek new employment, as would be the case with the superstar (Figure 2–5).
Knowledge: Many clinical specialists in health care found their way into their profession based on a passion for science that was apparent early in life. Likewise, many human resource professionals in health care consider themselves not only people persons, but individuals with a deep interest in figuring out what makes certain people tick—a good interest base for someone who interviews job candidates. However, these established interests and passions must be augmented with formal education and training to fully develop their acumen in their profession. Knowledge must be an accountability shared by leader and staff member alike as a continuous and constantly evolving process.
Intrinsic drive: Put simply, the employee must want to do the job. For a team of high potential students at Asbury Park High School, to cite an example of the work of the Stevens Healthcare Educational Partnership, the drive to attain a good career through the opportunity to go to a good college and have a career in health care is the drive for this cadre to come to SAT prep classes in the middle of July. For a team of physicians at nearby Monmouth Medical Center, the drive is derived from wanting to see how much healing can be accomplished with the resources at hand in a hospital which was opened nearly 150 years ago as a railroad workers' hospice. This facet of motivation might be nebulous in definition, but apparent immediately by just observing the intensity of work demonstrated by a particular staff member. And among all four of these tenets, it is probably the one that sparks performance in the other three tenets and therefore which must be brought to the workplace from Day 1 by the employee.
Innate ability: This factor is centered on the employee's ability to be able to do the job—the can do element which can vary widely among performers, even in the same job category. The lexicon of professional athletics and the world of music is replete with stories of individuals who were born with talent considered average in comparison to their peers, but was maximized by outsized innate drive, attainment of more knowledge than their competitors, and a work interest that was close to the 100% level.
The physician leader should evaluate each employee and provide guidance and support not only through communication, but action in accordance with all of these interdependent and synergistic tenets.
If eyes are the window to the soul, then words are the key to action. Physician leaders must make every effort to demonstrate that their words do have meaning, and in essence, that they say what they mean and mean what they say. In a world that seems synthetic with mass media and Internet communication seeming more insouciant and dissonant every day, a leader who makes the tough calls exhibits the small decencies and knows that there is no such thing as conditional integrity cuts a strong swath among their staff and goes a long way to establishing trust.
While no tenet of human behavior can be considered an absolute, the establishment and maintenance of trust might be the one exception. If an individual trusts a friend, coworker, or family member and then witnesses an episode in which they feel that trust was compromised—that is, they were burned by the person they trusted, either perceptually or in reality—it will be difficult if not impossible for the offending party to completely regain the complete trust of the offended party. Try as they might, there will always be a shadow of doubt and 100% trust will never be recovered.
To establish trust among their charges, physician leaders should demonstrate not only through words but more importantly, through actions resonant of the bromide talk is cheap, five essential values that are held in high esteem by right-thinking staff (read: the superstars and steadies). While values are typically classified as verbs, consider the application of these values in a predicate sense—that is, as verbs (Figure 2–6). For example, either physician leaders value integrity or they do not. The physician leaders value the attainment of meaningful, purposeful knowledge in the workplace as a common objective or they do not.
Defining values of a superstar—DFIIK Formula.
Decency: The desire to do the right thing in every given situation
Fortitude: Fighting the good fight
Industry: Working hard and equally important, working smart
Integrity: Unfailingly honest and forthright in every communication
Knowledge: Striving to learn something new every day at every opportunity
In addition to being leadership standards, these five values can be communication guides that should be the norms in a progressive workplace. As a refreshing contrast to the bloviating and obfuscation of the nonplayers, these standards represent the most appropriate way to communicate in a progressive workplace.