Monte Roulier, Vice President of Workforce Engage, LLC, has spent a lot of time in the waiting room of Denver Children's Hospital. Roulier's two-year-old son, Gabe, was born without a right pulmonary artery-the artery that connects the heart to the right lung. Gabe began having seizures before his first birthday.
Roulier's voice has a surfer lilt which is at odds with his organizational development lexicon and his encyclopedic knowledge of his field. He is the leader of the team of subject matter experts, researchers, and statisticians who developed the Workforce Engage™ employee engagement questionnaire, a survey tool designed for hospitals and healthcare organizations. Roulier's characteristic cheerful tone turns solemn and almost hesitant when asked if his experience with Gabe changed his perspective on his work.
"It felt like the quality of the relationships between the members of Gabe's medical team-the way information was transmitted--had a critical impact on the quality of his care. It took the doctors a long time to figure out what the problem was. Different disciplines were involved. Not everyone made the extra effort to communicate between disciplines. In the end, it was a neurologist who figured out that the problem was heart-lung related. He was the doctor who took the time to ask questions, the one who really listened to us."
Communication, discretionary effort, quality of relationships, skill at dialogue-these are some of the workplace attributes that Roulier's employee engagement survey, Workforce Engage, strives to measure.
"We knew there were plenty of employee satisfaction surveys out there," Roulier had explained in an earlier conversation, "but they didn't go far enough or deep enough. None of them focused on social capital."
Roulier defines social capital as relationships within a group or organization that are characterized by trust, reciprocity and shared values-all of which promote and sustain collaborative action. High levels of social capital are associated with improved organizational performance.
"Human capital is the measure what employees can do, but social capital is the measure of what they will do. In today's healthcare environment, the difference between average and excellent performance depends on the level of discretionary effort employees are willing to make."
The heart of the Workforce Engage system is a web-based, multi-level employee survey that gathers data about social capital and employee engagement. The survey focuses on seven organizational practices which Workforce Engage's research has shown to be the key drivers of employee engagement. (See sidebar on the Seven Practices of an Engaged Workforce.)
"Our market research showed us that hospital executives weren't satisfied with existing employee surveys," Roulier said. "They cited problems not only with measurement, but with the process of procuring and disseminating information."
Roulier's team redesigned that process, drawing on its experience leading community-building work for hundreds of organizations.
"Before Workforce Engage begins, leaders sign a compact with employees to heed and act on survey results. Results are presented in town-hall-style forums involving employees from all worksites and departments. Managers participate in dialogue training sessions, then lead dialogues in their departments. The employees help interpret the results and identify solutions. They become a force for change."
Workforce Engage spent almost two years developing the Workforce Engage system. Beta testing began in August of 2002. Twenty hospitals and clinics across the United States participated, including large and small facilities, union and non-union settings. 5600 healthcare workers were surveyed.
"Not only are hospitals plagued by high turnover, but executives report they are losing their most experienced workers," Roulier said. "These are the twenty-year veterans everyone counts on to solve problems and give us a sense of the best approaches."
Leaders also expressed concern about staffing shortages forcing them to put inexperienced employees into situations before they're fully prepared.
"One or more executive leaders at every site shared that they have never felt so reactive to the forces inside and outside their walls," Roulier said. "They feel at the mercy of sweeping trends. Many question whether there's anything they can do about turnover, staffing shortages, and stress. In fact, there is much they can do."
Across all twenty sites, the highest-scoring practice was Embrace Personal Strengths. Fully 93% of respondents agreed that the work they do is important to the overall purpose of the organization, 83% liked the challenge of their work, and 80% were satisfied with their level of independence on the job.
"Healthcare workers know that what they do is important," Roulier said. "They enjoy the challenge and independence provided by their jobs. This is significant, because research has shown that autonomy and meaningfulness of work are critical to the work experience. Healthcare organizations can use this as a base on which to build employee engagement."
The lowest-scoring practice was Sense of Community. Only 53% of respondents agreed that that "People feel included here." Only 43% agreed that their organization rewards teamwork, and 39% agreed that employees are recognized for the contributions they make.
One respondent commented, "I wonder how we can be so friendly within in our work units but not feel much of a relationship with co-workers outside those units."
According to Roulier, "When workers feel they are part of a community, not just a workforce, it transforms the way they work together. It encourages cooperation and responsibility."
How can organizations create a sense of community?
"Civility and manners play an important role. They help build an environment of mutual respect. Training supervisors to consistently acknowledge and appreciate a job well done can help fulfill the critical need for affirmation. Creating physical spaces and opportunities for people to interact informally is helpful, too. Management and especially supervisors can also take steps to make employees feel included--part of the group."
More social activities within and between departments was a common suggestion from survey respondents. "We need to get to know each other on a more personal level to work better together in stressful situations."
The survey also uncovered widespread weakness in the practice called Establish an Open Learning Environment, which includes effective communication and involvement of employees in decision-making-both key factors in building employee engagement.
Only 47% of respondents agreed that management listens seriously to employees' ideas, and only 50% agreed that it is safe to express different opinions.
One voluble respondent, making a comment about this topic which was typical in terms of content but memorable in terms of style, said, "We are all a part of this picture, and the employees are told but not listened to, and I feel management could learn a lot if they listened, and we could problem solve together to make this place a better place for everyone."
Ironically, many senior leaders felt an obligation to figure out solutions on their own, often with limited or inadequate data.
Across all beta sites, there was a sharp dichotomy in the level of information sharing within departments (72% of respondents agreed that it was adequate), and between departments (only 36% agreed that it was adequate).
"This in itself is not a surprise," Roulier said. "The question is why so little is being done about it. Dialogues with employees suggested some answers, ranging from poor relationships to outdated communication systems to differing policies and protocols between departments."
When asked if they perceived opportunities for advancement and growth, only 53% of respondents agreed. There were numerous requests in the comment boxes for a career path (in the form of laddered pay and prestige) for those who wish to stay in their jobs and not become supervisors.
Accountability
Many respondents felt their supervisors were unable or unwilling to hold employees accountable for inferior performance or behavior.
"It was clear from our dialogues with employees that this lack of accountability is taking a toll on everyone's performance," Roulier said. "There were widespread requests for merit pay and the discharge of underperforming workers."
"Some individuals put forth the bare minimum in their performance and get rewarded the same as everyone else," one commented. Another said, "Get rid of the dead wood!"
The majority of employees voiced strong positive feelings about their supervisors, but this did not translate or transfer to upper management. Only 43% of respondents agreed that their organization practices what it preaches, and only 53% consider management of their hospital to be trustworthy.
"This issue came up in our dialogues," Roulier said. "In many cases, supervisors contributed to this problem by expressing to staff their own frustration with management policies or decisions."
Respondents also expressed a desire for top management to make itself more visible. "They need to come to the employees in more informal settings, just visiting units or department."
While employees in other industries are complaining about having too many meetings, Roulier found that many non-administrative hospital employees wanted more meetings to ask questions, solve problems and get on the same page with their co-workers.
"In dialogues, we learned that meetings were not always providing the space or climate for problem solving. Several managers and supervisors shared that running team meetings was not their strength. Clinical competence doesn't magically translate into leadership and management skills. These skills need to be taught."
Across all beta sites, only 56% of respondents agreed that their organization has a good process for helping new hires gain competence.
One respondent wrote, "New hires are barely given any time and training before they are thrown unsupervised into the fray."
When asked for one thing a hospital could do to increase the level of commitment of its employees, the most frequent response was more appreciation and recognition for good work.
"One particularly moving quote came from an orderly," Roulier said. "It was obvious from the spelling that reading and writing and were not easy for him. But he cared enough to struggle through the survey. When his opportunity came to type a suggestion in a comment box, he wrote, "Have sugery rooms thanx or compement orderlys on how they do on stuff for them."
A demographic analysis revealed that nearly 40% of survey respondents had worked for three or more health systems prior to their current hospital--indicative of the high turnover in the industry--and almost 20% had worked for five or more. On the other hand, over 50% of respondents had been with their current hospital for at least five years, and 38% had been there for ten years or more. This suggests that the workforce of the beta hospitals is divided into two groups, one stable and one not.
Lessons about the ProcessTwo steps in the Workforce Engage process turned out to have a critical impact on outcomes:
- creating a strong leadership compact--a formal commitment on the part of the executive team to follow through on the changes indicated by the survey process, in order to counteract the cynicism that typically accompanies change initiatives; and
- engaging the employees in playing a central role in the interpretation of survey results and creation and implementation of solutions.
A final discovery arising from statistical analysis was that questions contributing to Sense of Community co-varied with questions that measured Learning Environment.
"It makes perfect sense," Roulier said. "Communities 'contract'--lose their vibrancy and energy--when they don't learn together. And authentic, sustained learning requires behaviors, attitudes and skills associated with healthy communities: relationships based on trust, shared values, reciprocity and checked egos. Both factors impact the quality of patient care."
During 2002, Roulier's son Gabe, then one year old, underwent two open-heart surgeries at Denver Children's Hospital. In the first procedure, Gabe's right pulmonary artery was connected to his aorta. The purpose of the procedure was to force blood through the artery in order to expand it. Several months later, in the second operation, Gabe's right pulmonary artery was connected to his right lung, as it should have been at birth. Both procedures were successful. Gabe, now two, is still on oxygen.
"He's connected to the tank by a seventy-foot hose," Roulier said. "He gets twisted up in it a lot, but he's learning how to unravel himself."
How does the two-year-old spend his time?
"He loves playing with balls of all kinds-tennis balls, playground balls. He also likes to imitate his older brother, Grant, whom he idolizes. Lately, the two of them have gotten into wrestling with each other. Gabe's favorite game, though, is hide-and-seek. Grant pretends not to notice, but finding Gabe is pretty easy. You just follow the plastic tube that leads into the closet or under the bed."
