Effective communication needs to be a top priority for both new and tenured executives. This article describes four essential leadership practices, along with corresponding communication tools, to drive alignment across a healthcare organization’s balanced scorecard:
- Establish expectations
- Hold leaders accountable for results
- Engage employees through rounding and recognition
- Cascade information strategically
The first step is to establish what you expect from your team in terms of monitoring communication of departmental and organizational goals. It is reasonable to expect all employees who have a work e-mail account and access to a computer to check their work e-mail at least once a day when they are working. That is not difficult for leaders and those in administrative positions, but other staff (e.g., employees in dietary and environmental services) might not have that same ready access. To share news with all intended audiences, it is important to consider using multiple communication channels. Thus, both e-mail and text messaging may be necessary to reach employees who do not read e-mail on their phones. A departmental bulletin board for posting monthly “stoplight reports” (discussed later) also can help communicate key result areas (or pillar) results. A simple text or e-mail message could point staff to the bulletin board, stating, “This month’s stoplight report has been posted. Please review before Friday.”
Hold Leaders Accountable for Results
The next step centers on accountability and measuring results. This step occurs after organizational goals are set and then cascaded to all leaders and other stakeholders. The aim is to measure results regularly and hold leaders accountable for achieving the prescribed goals.
Monthly Meeting Model for Leaders
Monthly meetings between leaders and their supervisors using a structured agenda can help the organization be more successful in achieving its goals. Each meeting should last about an hour, and at least 50 percent of it should cover results. Holding these monthly conversations with leaders will preclude any surprises at the end of the quarter or year.
Questions to answer in the monthly meetings include the following:
- Is the leader achieving results?
- Does the leader need support or further training to achieve results?
- Are there external factors that require a goal to be changed?
By implementing a model developed by the Studer Group, leaders can bring important items and results to monthly meetings with their immediate supervisor. This model does not necessarily cascade to every employee in the department; it is meant for leaders who are accountable for achieving specific, measurable goals. Leaders who are not on target must come to their monthly meeting with an action plan to achieve the goals.
The model, summarized in the following outline, works best when leaders ask specific, behavior-based questions to understand the actions that their direct reports have taken:
- Results from rounding
- Whom have you rewarded and recognized?
- What process improvements have you implemented?
- What thank-you notes have you written?
- What percentage of your employees did you round on in the past month?
- Monthly report card
- What progress are you making toward achieving your goals?
- What action plans are you putting in place?
- Linkage assignments from leadership development institutes (LDIs, described later)
- Items for discussion
- Stoplight report
- Rounding logs
- Thank-you notes log
- Any people trends or issues that need to be discussed
This agenda has some interesting nuances. For example, the supervisor does not start out by asking, “What percentage of your direct reports have you rounded on in the last month?” The typical response will be “All of them,” and the supervisor will learn nothing. Instead, the supervisor asks specific behavioral questions, such as “Whom have you rewarded and recognized based on your rounding?” and “What process improvements have you implemented as a result of your rounding?” These questions help the supervisor learn which actions the direct report has taken.
The supervisor should also use these monthly meetings to help employees track their progress in applying the tactics they are assigned at quarterly one- or two-day LDIs. By linking assignments from one LDI to the next, the supervisor can ensure that the tactics are being put into practice.
Engage Employees Through Rounding and Recognition
There are many ways to communicate and engage with employees. However, few can provide greater dividends for leaders than the process of rounding on and recognizing direct reports.
To physicians and nurses, rounding means checking on their patients to assess their status, adjust the plan of care as needed, and generally find out how things are going. For leaders, rounding on direct reports helps to identify areas for improvement and supports better decision-making.
The specific questions a leader should ask during rounding can come from the Gallup Q12 employee engagement survey (Gallup 2019). Gallup’s survey results have shown that the top reason employees stay or leave their job is their relationship with their leader. The second reason is their relationships with coworkers. Rounding can help leaders build relationships throughout the organization through monthly, five- to seven-minute structured conversations with their direct reports.
Leadership rounding follows this basic structure:
- The leader creates a personal connection by expressing interest in the employee’s family, activities, and the like.
- To guide the conversation toward the many positive aspects of a job, the leader then asks what in the workplace is working well.
- The leader then asks if there are coworkers the employee would like to recognize for their support and teamwork.
- Finally, the leader moves to process improvement questions and asks if the employee has the necessary tools to do the job.
This simple tactic has demonstrated improvements in employee engagement and a reduction in employee turnover. Turnover can have a significant impact on a healthcare organization; one study found a direct relationship between turnover and both mortality and length of stay (Kosel and Olivo 2002). In addition, employee turnover is expensive. Human resources (HR) professionals estimate that turnover can cost a business up to 200 percent of an employee’s annual salary when recruitment, selection, and training costs are considered (Conerly 2018). Excessive turnover also complicates employee engagement because team members must constantly train new colleagues on tools and processes. This learning curve can affect patient satisfaction, which ultimately affects the organization’s image and growth. Turnover will never be zero, but excessive turnover should cause concern and be managed by focusing on relationships and trust building between leaders and employees.
Rounding on employees yields improvements in engagement and a positive effect on employee turnover, as demonstrated by one South Carolina hospital that saw an improvement in its employee engagement score from 78 percent to 96 percent (Exhibit 1).
Rounding also has a positive impact on food and environmental services departments, where turnover is usually higher than elsewhere in the healthcare organization. One New York hospital saw a decrease in turnover among environmental services staff from 26.7 percent to 10.4 percent and among food services staff from 28.9 percent to 20.2 percent, indicating a potential return on investment exceeding $500,000 in recruitment and training cost savings in one year.
Exhibit 2 documents the positive impact of adding questions about attendance during rounding at an integrated health system in Oregon. No disciplinary action was involved in this approach to the problem of unscheduled absenteeism, only the clear communication of expectations from leader to employee, followed up with informational updates from the leader each month during rounding as to whether the employee’s attendance record was improving. This organization saw a 28.5 percent decrease in unscheduled absenteeism within six months, which resulted in a savings of $750,000.
Exhibit 3 shows the impact of rounding on employees’ and physicians’ willingness to recommend the hospital as a great place to work, rising from 50.2 percent before leader rounding was implemented to 87.4 percent one year later. As mentioned earlier, the average cost of recruiting, hiring, and training a healthcare employee is substantial, so leaders should consider rounding as a five- to seven-minute investment in a crucial resource.
While rounding on their employees, leaders will learn about opportunities for improvement and are then able to make changes. To keep all employees informed about what leaders are hearing during rounding (as well as the organization’s responses), it is a good idea to collect the recurring themes in a stoplight report. This tool will keep all employees in the department up-to-date on changes and help leaders answer frequently asked questions. In the stoplight report, completed improvements are color-coded green, improvements in progress are color-coded yellow, and those that cannot be completed at present are color-coded red (with a note explaining why). Leaders can print stoplight reports on paper or send them electronically to their team, and then share them with senior leaders at monthly meetings. (A sample stoplight report is provided as Appendix A to this article, published online as Supplemental Digital Content at http://links.lww.com/FRONTIERS/A2.)
After they master the basic questions of rounding, leaders can tailor them to meet the needs of their organization or department. Rounding questions can be organized by buckets, such as the relationship bucket, the what’s-working-well bucket (including rewards and recognitions), and the process improvement bucket. To avoid surprises, leaders should notify employees before modifying any of the questions.
Organizational initiatives that everyone is preparing for, such as site visits by The Joint Commission or Malcolm Baldrige National Quality Award examiners, present another appropriate opportunity to change the basic rounding questions. Rounding leaders can look for what preparations are going well, ask if additional assistance is necessary, and encourage any additional questions.
Another communications tactic related to rounding involves writing thank-you notes to employees who have done a great job or who are identified by colleagues during rounding as contributing to the team’s success. Leaders can use workplace thank-you notes to recognize a specific behavior that they want to see repeated. In conjunction with rounding, thank-you notes can help reduce turnover and improve attendance.
Although a thank-you note can be sent by e-mail or text or dropped off at the employee’s desk or workplace mailbox, a handwritten note sent to the employee’s home yields the biggest impact. That mode not only surprises the employee when there is something positive in the daily mail (i.e., something other than bills) but also engages the employee’s family and lets them know the family member is appreciated at work. Thanks also can be delivered verbally, and then followed by a note. In healthcare, we tend to move from project to project, from accomplishment to accomplishment, without stopping to say thanks and celebrate successes. Of course, providing recognition is not only a responsibility of leaders; it is also important that coworkers celebrate and thank each other.
A thank-you from the executive suite can be particularly effective. The note can say something like this: “Your supervisor tells me you are making a significant impact on patient satisfaction through your consistent practice of asking patients if there’s anything else you can do for them after you clean their room. Thanks for making the extra effort!”
Asking employees to recognize their colleagues who demonstrate a specific organizational standard or value is also a good tactic for encouraging a positive practice. Recognizing employees at a huddle or staff meeting is an excellent follow-up to a thank-you note.
The Value of Rounding
A common complaint of leaders about rounding is that they do not have time for it. If they have, say, 40 direct reports and allow five to seven minutes for each, they need to round, on average, on two employees each workday. However, that investment in relationship building and better understanding of employees can lead to a great return for the organization in increased employee engagement.
I recall the first time I did night rounds. I was the hospital’s new vice president of communications, and the system’s new CEO expected all members of the management team to do rounds. Everything went well until I came to the locked psychiatric unit at about two o’clock on a Saturday morning. A patient turned violent and attacked the two staff members on the floor. They pushed me into the nurses’ station, locked the door, and told me to call for help. Fortunately, the incident ended quickly and without injuries. The next morning, I was again doing rounds (our commitment included rounds on all three shifts in all departments at both of the system’s hospitals). I quickly learned that everyone in the hospital had heard of the incident during the night, and now bets were being taken on whether “the new VP” would even show up again. When I did, I set a standard for the importance of communication with employees that provided a solid foundation during my tenure with that system.
The practice of rounding also calls to mind management guru Tom Peters’s (2010) recommendation of managing by wandering around (MBWA), a communications tactic that predates formal rounding. Based on my experience, the executive doing the wandering must be memorable. I once followed a hospital CEO who was doing his usual MBWA rounds. About 15 minutes after he had visited each department or nurses’ station, I returned to ask, “When was the last time the CEO came to your unit?” Most said they hadn’t seen the CEO in months! This CEO just was not memorable. I worked with the CEO to develop short surveys and messages to use during MBWA, and employees started to remember his visits.
Cascade Information Strategically
Communications tactics can be great. However, tactics by themselves will not create a communications-rich environment. There is always a need for an overall strategy—a plan. In some healthcare communications departments, the goal is to win awards for great publications or to position the organization for placement on “best of” lists (e.g., most mother-friendly or best workplace, hospital, or clinical service line).
Instead, the goal of a communications program should be to align employees with the organization’s goals so that they can see themselves in its achievements. To realize this goal, a messaging strategy must be put in place. The organization’s priorities must be identified and then strengthened through communication. The strategy will be modified over time, but education about and reinforcement of the priorities has to be consistent. Data to support accomplishments must also be shared with employees so that they can feel proud of their organization and deliver messages—internally and externally—about the great work the organization is doing.
The Importance of Internal Communication
An example from the hospitality industry illustrates the value of internal marketing efforts. A new manager at the Plaza Hotel in New York wanted all employees to market the features and attributes of the hotel to each guest and visitor. In the Plaza’s fancy restaurant, the wait staff put fresh strawberries on the dessert cart because they knew that even diners on diets would enjoy fresh strawberries for dessert. If their guests ordered dessert, the bill would be higher and the tip would be bigger—and so the concept of “thinking strawberries” took hold.
The moral of this story is that internal audiences are an organization’s most important marketing resource. In healthcare, if employees, medical staff, and volunteers are not familiar with the communication goals and strategy, it will be difficult (if not impossible) for a consistent message to reach patients, health plan members, customers, and the community. A fortune spent on external advertising and billboards is wasted when internal audiences are not in the communications loop.
A review of internal communications best practices at top global companies reveals a significant emerging trend that can be applied to healthcare organizations. These companies’ leaders believe that internal communications need to be treated as a strategic function if they are to make an impact. These leaders have prioritized internal communications ahead of communications with customers and investors. They are not saying that external communications are not important; rather, they are saying that keeping employees informed is important, too.
In companies with the best internal communications programs, senior executives connect personally with employees throughout the world. They use a variety of vehicles, but the common thread is the significance they assign to reaching employees. Even when the communications are virtual, the CEO always delivers the message. Healthcare executives can learn from this example, because nowhere are internal communications more important than in healthcare organizations that are merging and growing.
In these benchmark companies with the best programs, the communications department is responsible for getting messages to leaders so that they, in turn, can communicate with their employees. Most leaders and employees are inundated with information, so internal communicators must sort and filter data and package information to assist in the communications efforts. Internal communicators work with senior executives to develop and update key messages each year. They use plain English so that everyone can understand, and they see that the messages are concise. These communicators then ensure consistency throughout all communications vehicles.
In some of these companies, the internal communications start with a “meeting in a box” for managers. Tools may include a script, PowerPoint slides, and potential questions and answers to ensure consistent messaging at town hall meetings or breakfasts with the CEO, on leadership conference calls, and through other channels such as employee publications.
As even high-tech companies understand, there is value in striking a balance between print and electronic communications. The web, for example, is not the appropriate channel for an organization’s only newsletter. Print publications, although used less frequently now, still provide a unifying voice for all employees. They are the typical channel for feature stories, HR information, and policy changes. Electronic newsletters are appropriate for breaking news, reminders, and short articles.
Unfortunately, in the rush to adopt electronic communications technology, many healthcare communicators merely scan their printed employee or community newsletter for posting on the hospital’s website. This practice is not ideal. Electronic publications have to be written and designed to fit each medium or audience to produce the most engagement. In my early healthcare days, my facility had regular meetings facilitated by the CEO or executive team for all staff to come and hear the organization’s quarterly update. This type of forum has become increasingly difficult. Some organizations do not have a meeting space large enough to gather 200 employees; others have multiple campuses or many employees who work remotely. Also, when a healthcare system stretches across multiple time zones, it can be impractical for the CEO to lead such meetings. However, it is still important for employees to hear periodically from the CEO.
With the right planning, creativity, and accountability, communications can reach at least 70 percent of the total workforce. The following are some best practices I have observed at large organizations:
- Hold a single employee forum, record it, and then post it on the intranet for all employees to view on their own time. Livestream the first session across the company and then play the session on a continuous loop in the employee cafeteria or breakrooms. With no one-size-fits-all approach to communicating with employees, creativity is required. An accountability process also must be put in place to ensure that employees watch the session.
- Require leaders to get their employees to the forums, so that the leaders are accountable. There is no sense in holding employee forums if employees do not attend them or their leaders do not give them time to attend. Rather than making the forums mandatory for employees, make it mandatory for leaders to get their employees to attend.
- Make the employee forums fun. Give out prizes such as logo wear and swag that promotes the organization’s services. Give every attendee a token that can be redeemed for a beverage or dessert in the cafeteria.
- Hold multiple forums on all shifts and in all organizational locations. Remember, your employees, providers, and volunteers are your most important marketing resource, so you want to reach as many of them as possible. Holding multiple forums is a cost-effective investment in your organization’s future.
- Consider holding short (e.g., 30-minute) employee forums or even walking forums (where a leader goes from department to department and meets with small groups of night-shift employees). The goal is to do what works best for your organization.
- Finally, measure the effectiveness of each communications channel to determine whether your messages are getting across. This evaluation should not be unique to the communications department but rather part of the organization’s overall employee climate survey. After all, the purpose of your various communications channels is to support the organization’s business strategy. The evaluation should assess whether employees are receiving the messages and whether the messages are resonating. Too often, healthcare communicators do not talk to the HR executives who are responsible for the employee engagement survey, so the effectiveness of internal communications efforts is not measured or evaluated separately from the organization’s other strategic functions.
When cascading information throughout an organization, managers must learn how to manage up to the decision-makers, especially when they disagree with a decision. Managing down creates an environment in which no one wins. Remember, it takes teamwork to create a great patient experience. Saying “I fought for us, but the administration wouldn’t approve our request for another staff member” sets up a “we/they” mentality and diminishes staff confidence in both the manager and the administration. Helping people understand the why behind a decision may not make them happier, but at least they may appreciate the reasoning.
Making the Most of Meetings
Meetings, of course, are a standard way to communicate. However, it is important that employees do not suffer meeting burnout. Effective meetings start with commitments from all participants to begin and end on time, follow a timed agenda, and come prepared to make decisions or recommendations. Agenda items should follow organizational pillars, goals, or key result areas. To drive organizational results, include something under each pillar at every meeting; time allotments do not need to be divided evenly among all of the pillars, but the sole focal point should not always be the finance pillar. Service, quality, people, and growth also should be covered—perhaps simply by reading letters from grateful patients and family members or by recognizing individual staff members. There is a lot of good news in healthcare, and the good news cannot be shared too often.
In terms of organizational communication, meeting synchronization is a key strategy. Consider how long it normally takes for information to be communicated to the entire organization after the executive team meets and decisions are made. In a perfect world, all senior leaders at the executive meeting meet with their direct reports within a day and communicate key information. Directors meet with their managers and supervisors the same day they meet with their senior leader. Finally, managers and supervisors hold their staff meetings or huddles within a few days of meeting with their director. Without this type of synchronization, some staff will have information long before others and communications may become disjointed. At the end of the senior executive team meeting, five questions should be addressed:
- Who is responsible for communicating this information to staff?
- What should the communication include?
- When should it be communicated?
- How will we communicate it?
- What is not ready for prime time and should be kept under wraps until it is?
The executive team meeting agenda should include these five communication questions as the last item. Then, as other executives cascade information to their reports, they may want to take the same approach. This will ensure that everyone knows what the key messages are, who needs the information, and when they should receive it. It also creates an information-rich, trusting environment where everyone can succeed.
In sharing communications, the recommended basic sequence is why, what, and how. If leaders always lead with why a decision has been made or why they are introducing a new tactic, they will engage the hearts and minds of their employees. In contrast, communicating the what without the why can lead to the team questioning the leader’s judgment. Saying “Because I’m the leader” is not a sufficient reason. If a team understands why a decision affecting them was made, they will be more likely to share the message with patients, family, and others in the community.
When setting goals, objectives, and expectations for your organization, remember that communication needs to be a strategic priority. Without effective communication, it can be difficult to cascade messages, effect real change, and see desired results. The communications tactics and themes discussed in this article can help you be a more effective leader, improve employee engagement, and drive results for your organization. Otherwise, as George Bernard Shaw noted, “The single biggest problem in communication is the illusion that it has taken place.”