Promoting employee voice and upward communication in healthcare: the CEO's influence.
Subject: Hospitals (Management)
Hospitals (California)
Chief executive officers (Management)
Organizational communication (Analysis)
Author: Adelman, Kimberly
Pub Date: 03/01/2012
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2012 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: March-April, 2012 Source Volume: 57 Source Issue: 2
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8060000 Hospitals; 9911434 Management-Communications NAICS Code: 622 Hospitals SIC Code: 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: California Geographic Code: 1U9CA California
Accession Number: 285087587
Full Text: EXECUTIVE SUMMARY

As noted by the Institute of Medicine (2004), a lack of critical upward feedback in the hospital setting has adverse effects on direct patient care and health outcomes. Employees are oftentimes reluctant to share information, as those above them might interpret the information to be negative or threatening. Leaders then may make important decisions based on assumptions or inaccurate feedback. The situation is especially significant in the healthcare setting, where hierarchical structures (Nembhard and Edmondson 2006), divisions between administrators and clinicians, and lack of collaboration across teams reinforce employee silence and undermine organizational learning (Ramanujam and Rousseau 2006).

Chief executive officers play a key role in developing a culture that fosters employee voice and upward communication (Ashford, Sutcliffe, and Christianson 2009). Hospitals winning performance excellence awards, such as those utilizing the Malcolm Baldrige National Quality Award Criteria for Performance Excellence, present a model of high performance with demonstrated results. The purpose of this study was to understand specific CEO behaviors and actions promoting employee voice and upward communication in performance excellence award-winning healthcare organizations.

Results suggested the award-winning CEOs facilitated employee voice by being approachable, mainly achieved through their regular presence throughout the organization. By being consistently visible and available to employees these CEOs fostered relationships, built trust, and promoted open communication. Leaders in the study created a cultural focus on continuous improvement largely built around transparency of information, particularly looking for the bad news from their employees. Voice invitation and positive voice response from leaders reinforced that critical upward feedback is not only welcome, but expected.

INTRODUCTION

In the healthcare setting, feedback from all levels of the organization is necessary to make improvements and prevent life-threatening errors (IOM 2004; Tucker and Edmondson 2003). While most leaders agree on the value of upward communication and its role in organizational effectiveness, many organizations still struggle with upward communication of both negative and positive information (Milliken, Morrison, and Hewlin 2003). Employee voice, defined in this study as the discretionary provision of information intended to improve organizational functioning to someone with the authority to act (Detert and Burris 2007), is necessary if leaders are to receive honest upward feedback from individuals throughout all levels of the institution.

Chief executive officers (CEOs) play a key role in developing a culture that fosters employee voice and upward communication (Ashford, Sutcliffe, and Christianson 2009). Having a culture of safety increases the chances employees will take positive risks and speak candidly. For organizational success, healthcare leaders must develop a culture in which employees realize that a sense of safety exists (Valadares 2004).

Findings from studies about psychological safety and communication in the healthcare environment have not articulated the actual leadership behaviors and practices necessary to create a culture of safety other than encouraging and training employees to speak up (Valadares 2004; Nembhard and Edmondson 2006). McAlearney (2006) notes that healthcare organizations pay little attention to improving management practices, which increases the likelihood of repeating previous mistakes. The purpose of this study was to understand CEO behaviors and actions that promote employee voice and upward communication in performance excellence award-winning healthcare organizations, addressing a gap in current literature.

The research questions guiding this study were: (1) How do CEOs of performance excellence award-winning healthcare organizations foster employee voice and upward communication of both positive and negative information in their organization? (2) How do CEOs of performance excellence award-winning healthcare organizations approach communication? (3)What can researchers learn from the CEO approaches?

METHODOLOGY

Study Design

A phenomenological collective, or multiple, case study approach (Moustakas 1994) was employed. Phenomenological research utilizes data collected from several persons who have familiarity with the phenomenon under study in order to capture their various points of view (Creswell 2007). The purpose of a case study is to obtain detailed descriptions and interpretations (Stake 1995). The lived experiences of hospital employees in regard to employee voice and upward communication within their performance excellence award-winning hospital was the phenomenon investigated in this case study.

CEOs whose healthcare organizations had received either the MBNQA or state-level Baldrige award within the past seven years served as the four cases. Two national-level MBNQA and two state-level performance excellence award-winning hospitals participated in the study (see Exhibit 1 for case demographics). The focus on four cases allowed robust data collection and analytic conclusions (Yin 2008) while keeping the scope of the study manageable. Emphasis was on the quality of data collection and analysis versus the quantity, as more cases and more interviews would not necessarily mean the study is more scientific (Kvale 1996). Purposeful sampling (Passmore and Baker 2005) of only performance excellence award-winning health organizations specifically addressed the research questions, assuming that performance excellence award winners might be more effective at communicating than non-winners (Calhoun, Griffith, and Sinioris 2007; Griffith and Patullo 2009).

Data Collection

Document review of the participant's MBNQA or state award application and 20 semi-structured telephone interviews with members of the organizations provided data for the study. Information documented under the Senior Leadership and Workforce Engagement categories of the organization's award application (NIST 2009) was collected utilizing a document review summary form, specifically answering the following questions from the Health Care Criteria for Performance Excellence (NIST 2009):

* How do senior leaders communicate with and engage the entire workforce? (p. 7)

* How do senior leaders encourage frank, two-way communication throughout the organization? (p. 7)

* How do senior leaders foster an organizational culture characterized by open communication, high-performance work, and an engaged workforce? (p. 18)

In addition to document review, interviews were conducted with individuals at different levels within each organization, from the CEO to a frontline nurse, to capture perspectives from individuals throughout the organization. Interviewees from clinical service areas, particularly frontline nurses, were targeted to participate because the Institute of Medicine (2004) noted that silence of nurses contributes to medical errors and compromises patient safety.

Five interviews took place from each of the four participating performance excellence award-winning healthcare organizations, for 20 interviews in all. Interviewees included (a) the CEO, (b) the Baldrige lead for the hospital, (c) a director of a clinical services area, (d) a frontline manager or supervisor of a clinical services area, and (e) a frontline nurse. All interviews followed a semi-structured interview guide and were recorded for later transcription. Interviewees reviewed and checked their transcripts to ensure information in the transcript was an accurate representation of their perspectives.

Data Analysis

The intention of case study research is not generalization but rather addressing a particular case and knowing it well through an emphasis on uniqueness and understanding (Stake 1995). In a multiple case study, cases are purposefully chosen using replication logic to predict either similar or contrasting results. Quantitative sampling logic, such as that used when choosing multiple respondents in a survey or multiple subjects within an experiment, is not appropriate (Yin 2008). Because results from multiple cases are typically more robust than those from a single case, the study examined four cases, performing analysis and drawing conclusions first within each and then across all of the cases.

ATLAS.ti 6 analytical software was used to assist with qualitative coding and data analysis. In case study research, the search for meaning consists of identifying patterns in the data (Stake 1995). Similarly, phenomenological reduction organizes textural meanings and patterns into themes. Because participants spoke about their experiences, actions, behaviors, and perceptions using their own words, codes were assigned from words and phrases used by the participants. An a priori list of initial codes helped guide the coding process; however, inductive development of codes continued as necessary throughout the study to capture all relevant data (Creswell 2007). Coding and analysis of interview transcripts, field notes, and document review data was completed to identify salient categories, patterns, and themes.

RESULTS

Interview participants described important information they communicated upward to senior leaders in their organizations. Across all four cases, information communicated upward consisted of both positive and negative feedback. Exhibit 2 provides a complete list of topics generally communicated upward by interview participants and in which of the four cases the topic was identified as being present. Participants always spoke about first conveying concerns or issues with patients, employees, or physicians prior to relaying upward any positive feedback. This demonstrated an emphasis on patient care, physician satisfaction, and safety from the participants at these organizations.

RQ1: How are CEOs of performance excellence award-winning healthcare organizations fostering employee voice and upward communication of both positive and negative information in their organization?

Visibility and Approachability

Visibility of the CEO and other senior leaders emerged as a theme in the study. All CEOs were visible and present in their organization on a regular basis, through rounding, employee-leader forums, or meetings with employees. Their presence allowed employees to know the person who was the CEO versus the CEO simply being a name or someone they read about but never saw. Face-to-face interactions with the CEO and other senior leaders helped develop relationships and trust. Employees appreciated seeing and knowing the CEO, and because employees saw the leaders on a regular basis they felt more comfortable talking to them.

Being present and interacting with employees gave the CEOs a chance to model their expectations with regard to frank, two-way communication. During face-to-face interactions with employees CEOs answered questions as honestly as possible, helping to set the tone for ongoing communication and building trust with employees. Being visible also gave the CEOs opportunities to actively listen to employees and invite feedback in the comfort of the employees' own work environments.

Interview participants in Case 4 emphasized the approachability of their CEO. Similar to visibility, approachability revolved strongly around regular face-to-face communication with the CEO; however, in this case, the CEO also placed emphasis on employees feeling welcome to come to administration and to approach any of the senior leaders at any time. He made himself approachable by connecting personally with individual employees; learning about their families, communicating his genuine concern for their well-being, and offering them his assistance. He also held other leaders accountable to the same standard of open, relational leadership behavior.

Culture

All CEOs in the study demonstrated a focus on their organization's culture. Similar in all four cases was a culture of continuous improvement, guided by the organization's mission, vision, values, and established employee behavior standards. The CEOs believed the organization could achieve improvements and excellence only by fully engaging employees for ideas and expertise. The concentration on continuous improvement gave employees permission to speak up about bad news, issues, or concerns. In fact, it was an expectation in all cases that employees would speak up to leaders with both positive and negative information. Leaders openly addressing bad news helped promote a transparent culture in which critical upward feedback was not only accepted but expected. As one interviewee described:

All CEOs were also cognizant about providing a response to all employees who asked questions or voiced concerns in order to encourage continued upward feedback. When employees saw actions or changes evolving from their input, they felt their voices counted, which reinforced speaking up. In all cases, the CEO initially set the expectation for employee voice at new employee orientation.

Formal Communication Strategies

All hospitals in the study utilized multiple formal communication strategies to promote two-way communication between employees and senior leaders (see Exhibit 3). The formal reporting structure of the organization was the foremost strategy used by employees to provide critical upward feedback to leadership. When asked how they communicated important information upward in their organization, all interview participants responded that they would talk with their direct supervisor first and then move up the hierarchy as needed. All CEOs were aware the hierarchy could potentially help or hinder frank, open communication. They respected the reporting structure but were also available for employees to communicate with directly.

Regular leadership and departmental meetings took place as a major means of information exchange across all cases. Steering committees, cross-functional teams, and process improvement committees were also used. All participants discussed using meeting and committee structures as a main avenue to voice concerns and to communicate upward to senior leaders.

The CEO was visible for all employees primarily through rounding in all four cases. Even though the tone and conversations during rounding were fairly informal, the schedule and structure was formalized to ensure compliance and accountability. Leaders used rounding logs in at least two of the four cases as a tool to track trends, track employee recognition, and follow up on issues. All CEOs discussed rounding as their primary means for soliciting upward feedback and made it a priority in their regular schedule.

All CEOs utilized employee-leader forums, sometimes called town hall meetings, to communicate directly with employees. The structure of the forums was nearly the same across all cases, with the CEO or other senior leader presenting information to the group first. However, the CEOs viewed as the most important part of the forum the last segment, in which the floor was opened to questions and comments from the employees. This was an opportunity to solicit critical upward feedback, address rumors and employee concerns, and answer questions in a transparent way. Secondary to rounding, employees high-lighted these forums as the main way they communicated face-to-face with their CEO.

All cases employed some form of computerized communication and feedback repository for employees to submit questions or concerns directly to senior leaders. The leadership team reviewed ideas, questions, or comments submitted electronically by employees through these systems regularly. In addition, all cases in the study used employee opinion surveys. However, Case 2 was the only one to specifically utilize employee cultural surveys as a method for soliciting employee feedback and monitoring staff satisfaction and engagement. The CEO had a goal of 75 percent employee participation in the employee opinion survey, with a component of the employee bonus structure linked to achieving that goal. The rationale behind the high participation target was that without enough employee input, the organization might work toward improving a small sample of items that were the concerns of only a few employees rather than addressing the concerns of the majority.

Informal Communication Strategies

Informal communication strategies also played an important role in facilitating employee voice by providing more relaxed ways for employees to express their ideas. All interview participants utilized e-mail or telephone calls to ask questions or convey important information to leaders. The CEO and leadership team members in all four cases had open-door policies, so employees could stop them in the hallway, drop by their offices, or schedule meetings when they needed to discuss something. Other informal approaches included meals that the CEO and leadership team members served staff, such as the grill days demonstrated in Case 2, or CEO-frontline employee breakfasts and luncheons utilized in cases 2, 3, and 4. Unique to Case 1 was the use of podcasts, blogging, and other social media, including Facebook and Twitter, to communicate in the variety of ways that people may prefer to receive or exchange information.

RQ2: How do performance excellence award-winning CEOs approach communication?

All CEOs highly valued employee voice and the knowledge that each employee brought to the organization. There was consensus among the CEOs that communication was a challenge in the healthcare environment that required ongoing attention and that new and varied approaches would always be essential. The CEOs believed employees were experts about what was happening in the organization and emphasized the need to tap into that information. They were relational and collaborative in their approaches and frequently solicited feedback from employees throughout the organization. The CEO from Case 4 summed up the overall approach when he stated, "And really, the employees have the pulse of the organization, and if as leaders we are not listening to them, we are missing the boat."

All CEOs modeled the communication behaviors expected from their employees. It was important to all of them to set an example, knowing it would set the tone for the entire organization, and they all spent significant time either rounding throughout their organizations or in small groups or one-on-one sessions with employees. This sometimes meant being in uncomfortable situations and hearing things they might not want to hear. As the CEO of Case 1 stated:

The CEOs attached extreme importance to having all employees know who they were, and it was crucial to answer employee questions truthfully to develop trust. As the Case 3 CEO articulated, "People may be a little reluctant to ask at the beginning, but if you answer the questions in the most transparent way possible, regardless of what [they are], then it builds over time." These CEOs used transparency and trust to create a culture of safety so employees would be comfortable speaking up.

In addition to their own behaviors, the CEOs understood the important roles of other leaders in the organization for hindering or facilitating frank, two-way communications. The CEOs focused on developing leaders all the way down to frontline supervisors through education and training, and they expected those leaders to develop open, honest communication with the employees for whom they were responsible. The CEOs' approach to communication focused on the entire leadership force through setting expectations and holding all leaders accountable to standards for communication.

RQ3: What can we learn from the CEO approaches?

A framework of key elements of leadership focus promoting employee voice and upward communication emerged from the data analysis (see Exhibit 4). Each of the four themes--establishing a culture of excellence, creating voice opportunity, reinforcing voice instrumentality, and the removal of risks and costs by leaders--positively influenced employee voice in the study.

Voice Opportunity

Leaders created voice opportunity (Ashford, Sutcliffe, and Christianson 2009) through visibility and approachability and the use of both formal and informal communication channels. Visibility-promoting actions included rounding and face-to-face conversations with employees via hallway conversations, open forums, or informal meals and celebrations. Modeling transparent communication and talking about things that were not going well reinforced the act of speaking up as welcome and expected.

[ILLUSTRATION OMITTED]

Culture and Voice Instrumentality

A high degree of voice instrumentality (Ashford Sutcliffe, and Christianson 2009) was achieved through a culture of voice invitation and positive voice response. The CEO and other leaders interacted with employees often to actively solicit comments, and because leaders asked employees for input on a regular basis, employees felt comfortable voicing their concerns. Positive voice response from leaders included taking action on employee suggestions and also providing feedback to employees when leaders did not act on suggestions. The consistent response from leaders demonstrated employee voice had an impact on decisions and patient care.

Risks and Costs

According to Chiaburu, Marinova, and Van Dyne (2008), employees must experience a sense of psychological safety before they will consider exercising their voice and speak up to leaders in the organization. A climate of safety was constructed by the CEOs through building relationships and establishing trust and by advancing the expectation that every employee's job was to speak up with concerns or ideas for improvement. Relationships and trust develop when people work together over time. The hospitals studied demonstrated relatively high average tenure across their employee population. Hiring and retaining the right employees was an area discussed by the CEOs, who pointed out that as people worked together longer they became more comfortable communicating negative or bad news to each other. The climate of safety created in the study cases allowed individuals to take interpersonal risks with regard to communicating information to leaders.

DISCUSSION

Patient care concerns, safety issues or events, and physician satisfaction issues were the most frequent items communicated upward to senior leaders in the study. Common communication of negative issues was somewhat unexpected, as it conflicted with Tourish and Robson's (2003) findings in which upward feedback in the healthcare setting was mostly absent and when it did occur was overly positive. Earlier, Milliken, Morrison, and Hewlin (2003) also indicated that most employees were afraid to speak up about problems with organizational processes and performance or to offer suggestions for improvement. The current case study found the opposite, with employees comfortable speaking up with negative news or issue-focused information to leaders in their hospitals. Employees in the study felt they were supporting leaders by giving them notice of any bad news or current issues. Participants attributed their comfort speaking up to the organizations' cultures of continuous improvement and the ease from routinely seeing and interacting with the CEO and other senior leaders.

Consistent with the findings of Valadares (2004) and Nembhard and Edmondson (2006), employees in the study emphasized the importance of the CEO and senior leaders in setting the culture of safety for communication. The positive response to voice exhibited in all cases reinforced to employees that they were safe in speaking up with bad news as well as good news. Because the CEOs were transparent and actively solicited employee voice, employees regularly provided critical upward feedback. Employees felt listened to and respected, especially when the CEO proactively sought out their input.

CEOs in the study found great value in being visible, present, and available for all employees. The CEOs pointed out it would be easy to stay in their offices, isolate themselves, and not hear things that might be difficult to hear; however, they emphasized the need for feedback from employees as necessary for organizational success. Similar to prior research describing the benefits of managing by walking around (Peters and Austin 1985), CEOs and other leaders spent a significant amount of time out in the hospital soliciting input from staff. In an extension of managing by walking around, providing timely feedback to each employee who asked a question or provided a suggestion was the utmost priority to the CEOs in the study. It was important for senior leadership to take action or provide feedback on employee suggestions to demonstrate that the employee's voice had an impact.

The goal of each CEO was to build relationships with employees, find out what was going on in the organization, and identify opportunities for improvement. Through their routine presence, employees knew the CEO and other senior leaders. Knowing the CEO made it easier for employees to speak up with ideas. The finding was consistent with a recent study by Liu, Zhu, and Yang (2010), which found employees more likely to voice their thoughts toward a target with whom they strongly identified. Sobo and Sadler (2002) also described how regular face-to-face interactions with the CEO built trust and opened a flow of information to which the CEO might not have otherwise had access.

Participants in the study used the formal reporting hierarchy of the organization as their primary means of communicating information upward. Challenges with power and status differences (Morrison and Rothman 2009) or divisions between clinicians and administrators (Ramanujam and Rousseau 2006) were not strongly evident in any of the cases. Bidirectional information flow among different levels of the organization was facilitated through the hierarchy, through either conversations with direct supervisors or formal meeting structures. CEOs respected the reporting structure but offered employees opportunities to speak directly with them and other leaders as needed. Realizing every manager and supervisor within the hospital could either foster or hinder open communication, CEOs provided ongoing support and leadership development in the areas of conflict resolution and communication for all supervisors. The CEOs set expectations for speaking up at new employee orientation and held all leaders, down to the frontline supervisors, accountable for creating a culture of safety.

Argyris (1986) noted that consistency within leaders' espoused values, words, and actions reduced defensive routines. Ashford, Sutcliffe, and Christianson (2009) described the constancy of leader behavior and leaders doing what they say they will do as reducing communication barriers caused by power and status differences among individuals in an organization. Findings from the current study were congruent with the previous literature. The CEOs were keenly aware of the importance of modeling expected behavior, especially through consistency of their words and actions. Fostering of frank, two-way communication occurred mainly through transparency when answering employee questions.

LIMITATIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH

The stated research questions bound the scope of the study to address only CEO behaviors facilitating employee voice and upward communication. No questions addressed specific leadership style of the studied CEOs, leaving an opportunity for future research. The small number of cases studied may limit the ability to generalize results across the larger population of all performance excellence award winners, other healthcare organizations, or organizations outside of the healthcare industry. However, the use of multiple cases was put into place to produce more compelling and robust results than would a single case study design (Yin 2008). A similar study with non-award-winning hospitals could be conducted to compare CEO communication approaches found in this study and to determine if there is a positive correlation between the CEO's encouragement of employee voice and organizational performance.

While the study identified four themes of CEO approaches to promoting employee voice, it is unclear if all four areas influence employee voice to the same degree, if they all need to be present, or if each area can individually influence employee voice alone. Research specifically examining the relationships between CEO approaches toward culture, voice opportunity, voice instrumentality, and risk and costs affecting the psychological processes of employee voice may provide additional insight and implications.

Interview participants may not have been representative of their entire peer group as they were chosen to participate in the study by the Baldrige lead and CEO of the hospital. Results might have been altered with a different sample of interview participants. The average tenure for participants was 14 years, with only one employee interview participant being at the current organization less than three years. Employee interview participants who were new employees might have produced different results. Studies to determine if employees in their first year of service feel safe speaking up with ideas and concerns could produce valuable results, as could investigating what helps employees in their first year of employment feel comfortable communicating both negative and positive information upward, especially for organizations with high turnover rates.

The importance of senior leaders' presence in new employee orientation to set the expectation for open, upward communication was touched upon in the findings of the study. However, additional research into specific practices during the orientation and new hire process, such as how expectations for speaking up and voicing concerns are established, might result in more specific findings.

Employees consistently used the hierarchical structure of the hospitals to communicate information upward to senior leaders. Research exploring this avenue of communication could provide answers to important questions such as the following:

* Do direct supervisors consistently communicate employee feedback upward to senior leaders, or is employee feedback filtered?

* What actions and behaviors are the supervisors taking to facilitate employee voice?

* What communication strategies, formal or informal, are most effective for supervisors to receive information from below and to relay information upward?

CONCLUSION

Patterns and nuances of CEO behaviors and actions promoting successful upward communication appeared in this study. Findings provided detail to assist scholars and practitioners in better understanding how to address the challenges surrounding upward feedback and systematic communications in the healthcare setting, highlighting the importance of CEOs being approachable and physically present throughout the organization as a key factor of facilitating employee voice.

ACKNOWLEDGEMENT

The author would like to thank Dr. Toni Buchsbaum Greif, Dr. Cortis (Mac) McGuire, and Dr. Karen Bammel for their contributions to the study.

REFERENCES

Argyris, C. 1986. "Reinforcing Organizational Defensive Routines: An Unintended Human Resources Activity." Human Resource Management 25 (4): 541-55.

Ashford, S. J., K. M. Sutcliffe, and M. K. Christianson. 2009. "Speaking Up and Speaking Out: The Leadership Dynamics of Voice in Organizations." In Voice and Silence in Organizations, edited by J. Greenberg and M. S. Edwards, 177-201. Bingley, UK: Emerald Group.

Calhoun, G., J. Griffith, and M. Sinioris. 2007. "The Foundation of Leadership in Baldrige Winning Organizations." Bulletin of the National Center of Healthcare Leadership. Supplement to Modern Healthcare 37: 379-99.

Chiaburu, D. S., S. V. Marinova, and L. Van Dyne. 2008. "Should I Do It or Not? An Initial Model of Cognitive Processes Predicting Voice Behaviors." In Citizenship in the 21st Century, edited by L. T. Kane and M. R. Poweller, 127-53. New York: Nova.

Creswell, J. W. 2007. Qualitative Inquiry and Research Design: Choosing Among Five Traditions, 2nd ed. Thousand Oaks, CA: Sage.

Detert, J. R., and E. R. Burris. 2007. "Leadership Behavior and Employee Voice: Is the Door Really Open?" Academy of Management Journal 50 (4): 869-84.

Griffith, J. R., and A. Pattullo. 2009. "Finding the Frontier of Hospital Management." Journal of Healthcare Management 54 (1): 57-73.

Institute of Medicine (IOM). 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press.

Kvale, S. 1996. Interviews: An Introduction to Qualitative Research Interviewing. Thousand Oaks, CA: Sage.

Liu, W., R. Zhu, and Y. Yang. 2010. "I Warn You Because I Like You: Voice Behavior, Employee Identifications, and Transformational Leadership." Leadership Quarterly 21 (1): 189-202.

McAlearney, A. S. 2006. "Leadership Development in Healthcare: A Qualitative Study." Journal of Organizational Behavior 27 (7): 967-82.

Milliken, F. J., E. W. Morrison, and P. F. Hewlin. 2003. "An Exploratory Study of Employee Silence: Issues That Employees Don't Communicate Upward and Why." Journal of Management Studies 40 (6): 1453-1476.

Morrison, E. W., and N. B. Rothman. 2009. "Silence and the Dynamics of Power." In Voice and Silence in Organizations, edited by I. Greenberg and M. 8. Edwards, 11134. United Kingdom: Emerald Group.

Moustakas, C. 1994. Phenomenological Research Methods. Thousand Oaks, CA: Sage.

National Institute of Standards and Technology (NIST). 2009. 2009-2010 Health Care Criteria for Performance Excellence. www.nist.gov/baldrige/publications/ upload/2009_2010 _HealthCare_Criteria.pdf.

Nembhard, J. A., J. A. Mexander, T. J. Hoff, and R. Ramanujam. 2009. "Why Does Quality in Health Care Continue to Lag? Insights from Management Research." Academy of Management Perspectives 23 (1): 24-42.

Nembhard, I. M., and A. C. Edmondson. 2006. "Making It Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams." Journal of Organizational Behavior 27 (7): 941-66.

Passmore, D. L., and R. M. Baker. 2005. "Sampling Strategies and Power Analysis." In Research in Organizations: Foundations and Methods of Inquiry, edited by R. A. Swanson and E. F. Holton, III, 45-55. San Francisco, CA: Berrett-Koehler.

Peters, T., and N. Austin. 1985. "MBWA (Managing by Walking Around)." California Management Review 28 (1): 9-34.

Ramanujam, R., and D. M. Rousseau. 2006. "The Challenges Are Organizational, Not Just Clinical." Journal of Organizational Behavior 27: 811-27.

Sobo, E. J., and B. L. Sadler. 2002. "Improving Organizational Communication and Cohesion in a Health Care Setting through Employee-Leadership Exchange." Human Organization 61 (3): 277-87.

Stake, R. E. 1995. The Art of Case Study Research. Thousand Oaks, CA: Sage.

Tourish, D., and P. Robson. 2003. "Critical Upward Feedback in Organisations: Processes, Problems and Implications for Communication Management." Journal of Communication Management 8 (2): 150-67.

Tucker, A. L., and A. C. Edmondson. 2003. "Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change". California Management Review 45 (2): 55-72.

Valadares, K. 2004. "The Practicality of Employee Empowerment: Supporting a Psychologically Safe Culture." Health Care Manager 23: 220-24.

Yin, R. K. 2008. Case Study Research: Design and Methods, 4th ed. Thousand Oaks, CA: Sage.

PRACTITIONER APPLICATION

Charles D. Stokes, BSN, MHA, FACHE, chief operating officer, Memorial Hermann Healthcare System, Houston, Texas

When healthcare leaders are asked why they got into healthcare, most respond by saying they wanted to help people and make a difference. Frequently, CEOs climbed the corporate ladder by starting their careers at the department director or manager level, in which frequent interaction with hospital staff was essential for them to be successful in career progression. Successful executives mastered their communication and engagement skills with the staff. They learned how to be approachable and motivational and how to hold their staff accountable for performance. A common phenomenon is that the further executives progress in their leadership responsibilities, the less feedback they receive about how they show up in the organization. Even those closest to the CEO are at times reluctant to give candid feedback to the top executive for numerous reasons: fear for job security, allegiance to their boss, and sometimes just being uncomfortable giving feedback. Many executives say that at times, they feel very isolated at the top and unsure of how they are perceived by governance, hospital, and medical staff.

In order for leaders to truly know what is going on in their organizations, they must validate their feelings through feedback. CEOs and senior executives can no longer delegate organizational culture development to directors and managers. They must lead cultural transformation by developing a deep personal involvement with hospital staff.

Clinical and financial excellence can only happen with an engaged workforce. The following are several suggestions to improve employee engagement and therefore enhance organizational performance.

1. Weekly senior leadership rounding. Rounding should be required and documented for accountability.

2. "Ideas for Excellence" program. Leaders should actively solicit employees' suggestions on how to improve organizational performance. When ideas are implemented, leaders should reward and recognize these employees.

3. Employee recognition programs. Leaders should routinely recognize employees and medical staff at board meetings and monthly department meetings, during senior leadership rounds, and through other hospital communication tools. Personal handwritten thank-you notes are one of the most effective forms of recognition. Senior leadership should send at least five handwritten notes per week to hospital and medical staff.

4. Town hall meetings. Candid discussions about key organizational issues around patient safety, clinical performance, and financial issues enhance transparency and trust in leadership. Leaders recognize there are very few "secrets" in the organization. Therefore, leaders should use the town hall meetings to state the facts regarding issues and dispel rumors that are disruptive and detrimental to organizational culture.

5. A mandatory 360 evaluation process. Such evaluation processes should be developed and implemented for all leaders in the organization. The evaluation elements should be tailored to be consistent with the organization's mission, vision, and values. This process should be completed annually for all leaders, and when issues surface, the leader should be required to develop a corrective action plan to address the feedback.

Most healthcare organizations have four to six strategic initiatives, critical success factors, or pillars, usually articulated as people, physicians, service, quality, financial, and growth. These are inextricably related to each other through leadership engagement. The formula for success goes like this: Engaged and motivated people and physicians, delivering an exemplary level of service (patient satisfaction) and quality (clinical outcomes) will produce sustainable financial results, which allows the organization continued growth.

It all starts with an engaged hospital and medical staff. Without an engaged and self-aware leadership team, the first two initiatives, around people and physicians, are difficult to achieve.

Kimberly Adelman, PhD; project manager, Stryker Performance Solutions; adjunct faculty, Colorado Technical University

For more information on the concepts in this article, please contact Dr. Adelman at ksadelman@gmail.com.
Through solicitation of adverse events
   each week and reporting adverse or
   negative information upward to the
   board ... that we are comfortable taking
   something we don't perform well at,
   putting it on a system scorecard and
   looking at it every month and talking
   about it every quarter ... when leaders
   are willing to stand in there for that, then
   employees see it's okay not to be perfect.


EXHIBIT 3

Formal Approaches to Communication

Ad hoc focus groups
Compliance hotlines
Cross-functional committees
Department/unit orientation
Departmental meetings
Departmental retreats
Electronic performance scorecards
Electronic idea-submission forums
Employee-leader forums (town hall)
Employee culture surveys
Employee luncheons
Employee opinion surveys
Employee recognition celebrations
HR-led focus groups
Internal newsletters
Intranet website
Knowledge boards
Leadership meetings
Leadership retreats
Leadership education
Learn and lead programs
Management team meetings
Medical staff meetings
Mission, vision, values team
Monthly CEO report
New employee orientation
One-on-one meetings/luncheons
Performance excellence teams
Process improvement teams
Reporting hierarchy
Rounding
"Round up" reviews
Service line meetings
Shared governance structure
Steering committees
Suggestion boxes
Systems operation meetings
Unit-based councils
Volunteer satisfaction surveys


Executives, it can be easy to isolate
   yourself and sometimes it can be easier
   not to be out there on the front line
   hearing the issues and participating in
   finding the solutions and addressing
   issues. I just think you've got to be
   present and you've got to be committed
   and you've got to be concerned about
   all people.


EXHIBIT 1
Demographics of Studied Hospitals

          Number of   Type of                CEO Tenure
          Employees   Organization

Case 1    14,000      Not-for-profit         4 years
                      Regional system

Case 2    4,000       Locally owned, not-    7 years
                      for-profit Regional
                      hub

Case 3    2,080       Governmental, not-     5 1/2 years
                      for-profit Community
                      hospital

Case 4    5,200       Not-for-profit         4 years
                      Regional system

EXHIBIT 2
Participant-Identified Important Information Communicated
Upward to Leaders

                                      Identified in Case #

Information Type                       1     2   3   4

Complaints
Cultural concerns                            X
Employee concerns                                    X
Employee recognition                                 X
Employee satisfaction/morale           X     X
Ideas for change/improvement           X     X
Legal issues                                 X
Medical staff status                             X
Patient-care issues                    X     X   X   X
Patient satisfaction                   X     X
Physician satisfaction                 X         X   X
Quality data/information                         X
Safety issue/events                    X     X   X
Staff achievement/certification        X     X
Staffing issues                                  X
Status with operating plan/goals                     X
Things that are working well                     X   X
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