If the predominant management buzzword of the '90s was "empowerment," the past 10 years or so it's been "accountability." There are three levels of accountability — hierarchical, cultural and personal and each level has strengths and weaknesses.
In this article, I will share practical strategies for promoting cultural and personal accountability. This is especially important for hospitals and other health care organizations, because you cannot hold people hierarchically accountable for the things that really matter in the healing professions. You cannot promote caring and compassion, pride and loyalty, enthusiasm and fellowship by force.
The three levels of accountability may be illustrated best in the form of a pyramid. Higher levels on the Accountability Pyramid reflect the trust and maturity essential to being recognized as a great place to work, which, in turn, is a key ingredient to providing a great patient experience.
Hierarchical accountability is top-down command and control. It's what people typically mean when they use the word "accountability." It's rewards and punishments, looking over someone's shoulder, holding their feet to the fire (a term that originated from a medieval form of torture). The Internal Revenue Service requires hierarchical accountability to motivate people to pay their taxes on time; cultural and personal accountability motivate people to contribute to their favorite charities.
Hierarchical accountability is most appropriate for tasks that are highly complex, have significant potential for harm or both. People must be held accountable for administering the right medication to a patient, for performing a safety checklist prior to surgery, and for managing productivity and budgetary targets. People must be held accountable for behaviors that cause harm: theft, bullying, malicious gossip and the like must have consequences.
Managers often find to their dismay that trying to "hold people accountable" might achieve short-term gains in whatever it is that's being counted (the word accountable means "able to be counted") but, in fairly short order, there is backsliding. A customer service initiative gets off to a good start with employees being given a script and a happy face pin and then being held accountable for saying the words. But it soon becomes obvious to patients that some people are just parroting the script and not speaking from the heart (a point that's reinforced if the happy face pin is upside down!). What the manager is measuring — customer service training was completed and everyone got the script and the happy face pin — is very different from what customers are actually perceiving.
The two biggest problems with using hierarchical accountability to motivate performance are: (1) when you tell someone that you're going to "hold them accountable," it sends a subtle but unmistakable message that they cannot be trusted to hold themselves accountable; and (2) the managerial energy required to hold people accountable can be exhausting. (A recent article in my email newsletter covers six reasons why hierarchical accountability can backfire.)
Cultural accountability is peer pressure. It is far more powerful than hierarchical accountability, for better and worse. In many organizations, it exerts a negative pressure on productivity and performance, as when there is peer pressure to not be an overachiever, a quota-buster or a brown-noser. Attempting to impose hierarchical accountability for customer service excellence in a toxically negative culture requires far more energy, and is much more likely to fail, because of the inevitable passive-aggressive resistance. While trying to change culture is a lot harder than merely trying to impose rules, it is much more likely to achieve a sustained impact.
Perhaps the best example of the power of cultural accountability is the way that enforcement of nonsmoking policies has changed over the years. Hospitals no longer require no-smoking signs in every room, and managers almost never have to discipline employees for sneaking a smoke on the job. Why? Because cultural expectations have changed so profoundly over the past several decades. Anyone lighting a cigarette on an airplane today would not need to be arrested by an air marshal so much as they would need to be rescued from fellow passengers who no longer tolerate being poisoned by cigarette smoke.
One of the tools we use with client organizations is the Pickle Pledge (so-called because people who are always complaining look as though they're sucking on a dill pickle, at least metaphorically speaking). This promise simply says: "I will turn every complaint into either a blessing or a constructive suggestion." The Pickle Pledge has taken on a life of its own. In hospitals across the country we are seeing singing pickles, dancing pickles, pickle piñatas and pickle parties. We are seeing people bring pickle jars into the workplace and actually fining themselves and each other for toxic emotional negativity; every time someone complains or gossips about a co-worker, he or she is asked to put a quarter in the jar. The money can be used for a charitable cause or a departmental party (at one hospital, I was told they could fund a cruise!).
In organizations where people take this to heart, we're seeing the same sort of evolution in attitudes that not so long ago we witnessed with regard to smoking. As people realize how much more pleasant a pickle-free work unit is, they become increasingly intolerant of toxic emotional negativity. Most people appreciate and embrace the change — we've heard many stories from people who have achieved dramatic improvements in both their work and home lives simply by taking the Pickle Pledge to heart. And as the culture evolves in a more emotionally positive direction, the most irremediably negative people become marginalized and eventually leave (or are asked to leave).
This is the highest and best form of accountability. People who accept personal accountability don't need someone else looking over their shoulders or have co-workers pressure them into behaving in a certain manner — they do it because it's a reflection of their personal values. If hierarchical accountability is holding someone's feet to the fire, personal accountability is watching them voluntarily walk across hot coals.
At United Airlines, most flight attendants think they've done the job once they've parroted the script about seat belts and oxygen masks, whether or not people are actually listening (which, in most cases, they are not). They have passed the test of hierarchical accountability. At Southwest Airlines, on the other hand, flight attendants know the real job isn't just parroting the script — it's making sure passengers hear it. When David Holmes does it as a rap song or when Marty Cobb does it as a comedy routine, not only do people listen, they give the flight attendant a round of applause. When someone records the performance with a cellphone and the video goes viral, Southwest benefits from millions of dollars' worth of free advertising.
Nordstrom department stores are justifiably famous for customer service excellence, but it's not because they hold people accountable with policies. In fact, the entire employee policy consists of just two sentences, quoted here in their entirety: "At Nordstrom, we only have one rule. Use good judgment in all situations."
Most corporate call centers have a computer program that tracks how long employees have spent on each call and how many calls they've handled, and employees get busted if they don't hit their numbers. At Zappos, they're told to spend as much time as their customer needs and to talk about anything that's on that customer's mind (in his book Delivering Happiness CEO Tony Hsieh says the record call is more than seven hours — this is a company that sells shoes, but people call for psychotherapy!). Zappos has hundreds of people apply for every opening, making those jobs harder to obtain than a degree from Harvard University (how many hospitals would love to have a problem like that?).
The Key to Culture Change
Corporate culture is really the aggregate of attitudes and behaviors of the people working within the organization; culture doesn't change unless and until people change. And as Marshall Goldsmith emphasizes in his book What Got You Here Won't Get You There, people don't change unless they see it as being in their personal benefit as defined by their own core values.
One of the most effective tools we share with clients is the Self-Empowerment Pledge, which includes seven promises, one for each day of the week: responsibility, accountability, determination, contribution, resilience, perspective and faith. (You can download the poster for the pledge and each of the seven promises from the resources page of the Florence Challenge website.) When a critical mass of individuals within an organization make the commitment to hold themselves accountable for their attitudes and their behaviors, it cannot help but have a positive influence on culture. And the more personally accountable people are, the less managerial energy needs to be expended on hierarchical accountability.
The "Other" Health Care Crisis
Organizations that study employee engagement consistently find that on average about 25 percent of employees are engaged, 60 percent are not engaged and 15 percent are aggressively disengaged. In the culture assessment surveys we've conducted with our health care clients, respondents almost universally rate their organizations as being deficient when it comes to such cultural attributes as enthusiasm, pride and fellowship. In almost every case, their assessment is that 10 to 20 percent of all paid hours get wasted on complaining, gossiping and other forms of toxic emotional negativity, costing their organizations millions of dollars and deleteriously affecting employee morale, patient satisfaction, productivity and profitability.
We speak of the health care crisis as if it's all "out there," that is, what "they" are doing to us. But there is another more insidious health care crisis "in here" — how we respond to those pressures. If you look at any significant business turnaround of recent years — IBM, Ford, Starbucks, Delta Airlines, and so forth — an important element of that success was a resilient culture.
Former IBM CEO Lou Gerstner, in his book Who Says Elephants Can't Dance?, wrote that he learned culture wasn't just part of the game; culture was the game. In his book Onward: How Starbucks Fought for Its Life without Losing Its Soul, founder and CEO Howard Schultz described the essential resources in the company's turnaround as values, culture and trust. In each case, the key ingredient was a culture in which employees took ownership for the work instead of acting like hired hands who needed threat of punishment to perform.
Promoting Cultural and Personal Accountability
Hierarchical accountability rarely will foster a culture of ownership; it's much more likely to produce its opposite — a culture of dependence. Because cultural and personal accountability are more efficient and more powerful than hierarchical accountability, here are six strategies to help promote them.
Strategy 1: Make better use of your statement of values. Most hospital values statements are predictable (of course you value excellence, compassion and integrity — what hospital doesn't?), and I know from the experience of asking hundreds of people in dozens of hospitals that most employees (often including people with the word "chief" in their titles) don't know them by heart. A great statement of values that is actually integrated into how the organization does business is a powerful resource for recruiting and retaining great people. If you search for "Southwest Airlines Careers" in your browser, you are not taken to a page describing wages and working conditions but rather to a page that states: "Not just a career, a cause … . Our Employees value the opportunity to work hard, be creative, and have fun on the job."
Integrated DNA Technologies' recruiting Web page says: "IDT's Core Values form the foundation of who we are, what we believe and what we strive to be. They articulate what is expected of us; guiding our relationships and directing our decision-making. In our ever-evolving business, the Core Values are our constant. Our Core Values define our unique culture, shape our future and ultimately cultivate our success." One of the company's eight core values is "Be yourself — unless you're a jerk." Who wouldn't love working for a company that had the courage, and the sense of humor, to describe authenticity, respect, egolessness and being a team player in such a whimsical way?
When leaders at Memorial Hospital of Converse County in Douglas, Wyo., revised its statement of values, they went from a simple-minded acronym, CARE (which no one knew even existed), to a robust document with seven core values defined by 35 statements of behavioral expectation. One of those seven values is integrity; one of its definitional statements is, "I will talk with, and not about, others." Another value is ownership; one of its definitional statements is, "I will not say ‘It's not my job' or ‘we are short-staffed.'"
Strategy 2: Define your ideal culture. An exercise I often conduct in leadership workshops is asking people to work in small groups to define their organization's culture in just six words. There is typically a significant lack of consistency between groups. At one large health care system retreat, for example, managers' responses ranged from "We Love Patients and Each Other" to "Entitled, Victimized, Hating It, and Staying." Organizations that are recognized for having a great culture, on the other hand, can clearly state the essence of that culture in just six words. The six words at Southwest Airlines are "Servant's Heart, Warrior Spirit, Fun-Loving Attitude." At Cypress Semiconductor they call themselves "The Marine Corps of Silicon Valley." In both cases, being crystal clear about who they are helps to prevent hiring people who would not fit with their culture.
Strategy 3: Make better use of new-employee orientation. This is your first and best opportunity to clarify expectations regarding cultural and personal accountability. For example, most hospitals have an active rumor mill; but if they were serious about integrity as a core value, then new-employee orientation would provide guidance on how to deal with a situation in which two people were talking about a co-worker behind his or her back (for example, by pulling out a cellphone and putting the person being gossiped about on speaker).
Strategy 4: Be explicit about your zero-tolerance behaviors. If you are in any health care–related LinkedIn groups, you probably have seen discussions on bullying and lateral violence in hospitals. You no doubt have heard the hideous metaphor "nurses eat their young" (and quite likely have seen it in practice). The emotional environment of your organization will be defined by what you expect and what you tolerate and, over time, what you tolerate will dominate what you say you expect. Having a representative group of employees from throughout the organization define behaviors that are not to be tolerated is often the first step to eradicating those behaviors from your culture.
Strategy 5: Use visual reminders. One of the most powerful public health tools ever devised was the simple No Smoking sign: Instead of having to confront a person lighting a cigarette, someone could just point to the sign. One of our client hospitals reminded emergency department staff to treat every patient — no matter what they look like, talk like, act like or smell like — with greater respect and dignity by posting a sign with the letters MMFI, the acronym Mary Kay Ash used to remind her beauty consultants that everyone wears an invisible sign saying, "Make me feel important."
At another hospital, the surgery department manager posted a sign outside every operating room saying, "Your patient could be awake," as a reminder that no one should act or speak in ways that would be inappropriate were the patient listening. And in hospitals taking the Pickle Pledge, we've seen so many people posting signs declaring their workspace a "Pickle-Free Zone" that we actually created a PFZ door hanger.
Strategy 6: Use the power of ritual to shape cultural expectations. Rituals are one of the most powerful forms of shaping cultural accountability — which, in turn, strongly influences personal accountability. In a growing number of hospitals, groups of people are gathering for each day's promise of the Self-Empowerment Pledge in staff meetings, nursing unit huddles or other settings. If you watch this two-minute video of a group at Tri Valley Health System in Cambridge, Neb., you will notice that many of the people in the group are not reading the promise — they know it by heart.
In a previous H&HN Daily article, I described a dozen other strategies for promoting a culture of ownership.
A Culture of Ownership
Demographers long have been predicting the mother of all staffing shortages when the baby boom generation begins to retire in earnest. The subtitle of Roger Herman's book Impending Crisis is "Too many jobs chasing too few people." One of the most effective ways to recruit and retain a loyal workforce is to work your way up the Accountability Pyramid, wherever possible by replacing hierarchical accountability with cultural and personal accountability. This is an essential step in the journey from a culture of accountability toward a culture of ownership.
A culture of ownership will thrash a culture of accountability in the competitive marketplace. Companies like Southwest Airlines, Zappos, Hubspot, Rackspace and Integrated DNA Technologies are out-recruiting and out-competing rivals by fostering a culture in which employees think and act like owners instead of people renting a spot on the organizational chart. No one ever checks the oil in a rental car, but you don't have to hold a homeowner accountable for mowing the lawn.
Joe Tye is the CEO and head coach of Values Coach Inc., an Iowa-based company that provides training and consulting on values-based life and leadership skills and cultural transformation. He is also a member of Speakers Express.