Key-Managing Change in HealthcarePage 1
The following chapter appears in:
Managing Change in Healthcare: Innovative Solutions for
People-Based Organizations, Key, M.K., McGraw-Hill: 1999, pp. 113-128.
DO NOT REPRODUCE WITHOUT PRIOR WRITTEN
PERMISSION FROM THE EDITOR AND AUTHORS
Appreciative Inquiry:
The Path to Positive Change
Amanda Trosten-Bloom
Diana Whitney, Ph.D.
Health Care Trends and Challenges
In early 1996, Group Health Cooperative in the state of Washington found itself in what may seem like a familiar situation. Intense competition and a period of poor financial performance had led to downsizing and restructuring. Even as they were closing one of their hospitals, they were affiliating with another. Professional and geographic groups within the system were becoming increasingly disconnected from one another, as were leaders, employees and patients. Employee morale was low, and service (as measured by a series of internal performance indicators) was beginning to slip.
This picture is all too familiar to today’s health care leaders and professionals. Managed care and other pressures lead more and more health care organizations down paths of cost-cutting and efficiency. The delicate balance between patient care and profits has enhanced the popularity of continuous quality improvement and other recipes for improving productivity and eliminating waste.
But these tools rely heavily on the good intentions and interpersonal relationships among caregivers and administrators who are experiencing unprecedented workloads and pressures. All too often, well intended improvement efforts create stress and tension which in turn builds resentment and shortens “fuses.” It’s hard to work harder, smarter, and more collaboratively when you’re hanging on by a thread.
As Cheryl Scott (now President of Group Health) said of their situation, “We needed to create a reason to stay here - not just for ourselves, but for our entire staff and our patients. There were pockets of greatness around the Co-op, where productivity and morale were high. We fervently believed that Group Health had the capacity to be a rewarding place to work and a more successful organization. We wanted to identify the ways to achieve that vision, and to nurture its development.”
Group Health’s search for possible solutions led them to a new approach to organization change called Appreciative Inquiry. By applying core Appreciative Inquiry methodologies, they enhanced relationships and communication while building enthusiasm, ownership, commitment, and a sense of purpose which was shared both within and outside their organization..
Appreciative Inquiry is a new way of working . . . a new approach for building loyalty, commitment, contentment, and positive change within a health care setting. Health Care providers, like those at Group Health, are faced with unprecedented challenges which call them to consider new approaches to leadership and organization . . . approaches that significantly increase organizational effectiveness, enhance people’s capacities to change, and instill a sense of joy and wonder in the workplace. Appreciative Inquiry is one such approach.
(A) What is “Appreciative Inquiry?”
“AI,” as it has come to be called, is an organization development philosophy and methodology that enhances organizations’ capacities for positive change and ongoing adaptability (Whitney & Schau, 1998). AI was developed in the mid 1980’s by David Cooperrider, PhD and Suresh Srivastva, PhD of the Weatherhead School of Management at CaseWestern ReserveUniversity (Cooperrider & Srivastva, 1984). It provides a philosophy and tools for leaders to understand and build upon the best of what has been and might yet be within their organizations through inquiry into their “positive core” (Whitney & Cooperrider, 1998). An organization’s positive core is described as the collective wisdom, knowledge, and capabilities - often undiscussed - of the organization at its best.
Consider the individual words “appreciate” and “inquire.” Webster’s Dictionary defines the word “appreciate” as follows:
1a:to value or admire highly
b:to judge with heightened understanding
c: to recognize with gratitude
2 :to increase in value
“To inquire” means:
1 :to search into
2 :to seek for information by questioning
Hence, Appreciative Inquiry guides us to ask questions with gratitude and a sense of “valuing” . . . in order to increase understanding and enhance value. AI is the study of what gives life to a human system, when it is at its best.
(A) What’s Different About Appreciative Inquiry?
Appreciative Inquiry is a highly participative process which builds relationships across functions, business units, and levels within and outside an organization - without overt communications training or facilitation. At Group Health, for example, 500 people (including providers, clinical staff, administrative staff, consumers, labor leaders, insurance brokers, and local employers) worked side-by side and collaboratively to enhance the delivery system through such areas as: population-based care, customer service, teams, leadership structure, communication, and development of “great ideas.” Their internal consultants, Scott Caldwell and Diane Robbins, described a time in the intervention where participants worked in small groups to hash out work plans for six priority initiatives:
“At the end of the day, each small group presented to the whole group. Each small group was a microcosm of the whole system, including consumers (some of whom had belonged to the Coop since early in its history), insurance brokers, nurses, doctors, union leaders, janitors, and organizational leaders. Some of these folks had been at war with each other for 50 years or so. And there they all were, presenting their work together. It was awesome. We’re always struck with how important it is to heal the healthcare system, and this was a clearly healing experience.”
As a participant in the process said, “There were no barriers. We were all really listening, hearing, and being heard.” In an Appreciative Inquiry process, the choicefully affirmative orientation enables relationships to be established, renewed, and healed as diverse groups of people work on organizationally essential tasks.
Appreciative Inquiry changes the internal dialogue of an organization from problem-oriented, deficit discourse to possibility-oriented, appreciative discourse. In so doing, it accelerates learning and stimulates creativity. In the words of Tom White, President of GTE Telephone Operations (White, 1996):
“Appreciative Inquiry can get you much better results than seeking out and solving problems. . . . If we dissect what we do right and apply the lessons to what we do wrong, we can solve our problems and reenergize the organization at the same time. In the long run, what is likely to be more useful? Demoralizing a successful workforce by concentrating on their failures, or helping them over their last few hurdles by building a bridge with their successes?
Don’t get me wrong. I’m not advocating mindless happy talk. Appreciative Inquiry is a complex science designed to make things better. We can’t ignore problems - we just need to approach them from the other side.”
Appreciative Inquiry creates a wide platform for discovery, dream and design on the part of people at all levels of the organization, and in so doing it enlists and engages the organization’s informal leadership. Through mass mobilization of interviews and high participation in large group meetings known as AI Summits (to be discussed later in this chapter), informal leaders are given opportunities to contribute and act on behalf of their colleagues and the organization. For example, a manufacturing company in Broomfield, CO reported that:
“AI has literally inverted the traditionally hierarchical structure of this organization. Line employees are making decisions previously made one or two levels above them. They are coaching their supervisors when the supervisors slip and fall back into the older, more familiar patterns of communication.”
Last but certainly not least, Appreciative Inquiry enhances people’s capacity for change. To change, we must be curious and open to new possibilities - personally and organizationally. Indeed, change requires a dislodgement of certainty. Older models of change focus on “unfreezing” a system in order to open it to the possibilities of change. Most of these approaches activate high levels of resistance, which is one way that participants have of saying ‘this process is not resonant with my truth, with what I believe will help things around here.’ Exclusive attention to problems - even as the target for change - creates a sense of fear and a tendency to blame.
During AI processes participants are inspired by possibilities, rather than resistant to problems. Their curiosity and desire to understand and honor differences increases. They become more appreciative of the ever-changing nature of organizational life. In short, their sense of possibility expands - and with it, their capacity for change.
Appreciative Inquiry offers an alternative way - and affirmative way - to dislodge certainty and promote change. It has been quantitatively demonstrated to increase employee engagement and commitment, and has been recommendedby employees as a powerful way of facilitating large-scale organizational change (Chandler, 1998).
Meg Leach, an organization development consultant with Fairview Health System in Minneapolis, describes how she uses AI to enhance her organization’s capacity for change:
“I use AI to introduce an impending change by asking the group to inquire into its history of positive change. I also use AI to celebrate the successes of change efforts on significant anniversaries or markers, and to support integrating groups in the process of blending. Appreciative Inquiry processes give people a sense of pride in all they have done and how well they have done it. It gives them a sense of their ability to make change, be ahead of change, and be flexible.”
Sandra Janoff, co-developer of the “Future Search” process for large-system social and organizational change, shared her observations about AI as and its influence on the Group Health organization:
“This group entered their ‘Futures’ conference with a different energy than some of the other groups I’ve observed in similar settings. The appreciative interviews which had taken place during the months before the conference had nurtured a sense of community, optimism, and hope that I believe served the group over the course of their three-day conference.
“Large-scale organizational change is a very complex, very sensitive process. In organizations - as in life - there are things that work, and there are things that don’t work . . . things that give life, and things that diminish life. Unless organizations can collectively dream and hold hope for positive, constructive change, it simply won’t happen. To me, the capacity to nurture (and in some cases restore) organizational hope is the beauty of Appreciative Inquiry.” Foundational Principles
Based on research in health care, athletics, and education (Cooperrider, 1990), Appreciative Inquiry theory states that organizations change in the direction of people’s collective images of their future. Positive images of the future yield positive changes; negative images of the future yield the opposite. Over the past decade, David Cooperrider and colleagues at CaseWestern ReserveUniversity, along with members of The Taos Institute, have worked with over 75 organizations around the world using Appreciative Inquiry. Their experience suggests that the more affirmative and life giving an organization’s images, the more positive and enduring the effects of change efforts.
Many of us have experienced or observed a basic human quality: that as people, we all act in ways that are consistent with our images of the future. All of us are profoundly affected by our prophecies, hopes, and aspirations. When we believe the future holds good things for us, we are courageous and more willing to take risks. When we believe the future is dark, we are more conservative, more guarded, more protective of what we have.
AI theory also states that people and organizations collectively create their images of the future, their realities, and their social order through language, communication, and relationships. The stories that they tell about themselves, their organizations, and the relationships among people in their organizations constitute the organizational images, and inform day-to-day actions - both today and in the future.
For this reason, organizational discourse (conversations, dialogues and stories) which is imbalanced in a positive direction contributes to the development of positive action and high performance. Discourse that is skewed in the direction of the negative has the opposite effect. In fact, the more positive the stories told in and about an organization, the more likely its success. Appreciative Inquiry positively influences an organization’s anticipatory images - the images of the future believed and repeatedly told by organization members and stakeholders.
(A) From “Discovery” to “Delivery”: The 4-D Model of Organization Development
Unlike with some organizational change models, every AI intervention is unique. Interventions will vary significantly based upon the organization’s goals and size, the length of time it devotes to the effort, and participation in the process. Some organizations will choose to use AI systematically, over a period of months or years, while others will move immediately to a two- to four-day “Summit” (involving groups as small as 50 and as many as several thousand people).
However the intervention has been structure, the “4-D model” (see Figure 1) is the primary process by which AI realizes positive change. Based on the assumption that change occurs through thoughtful inquiry into and dialogue about affirmative life-giving forces, the four phases of the process are: Discovery, Dream, Design, and Delivery.
(B) Discovery: Appreciating What Gives Life
The Discovery phase is a quest to identify positive stories and spread them throughout the organization. It brings into focus those things which give life and energy to people, their work, and their organization. It assumes that the life-giving forces are indeed present in every situation, but that our habits of organizing and talking often overlook the positive in favor of analyzing obstacles, resistance, and deficits. The Discovery phase shifts the balance of organizational attention from what isn’t working to what is, and to what may possibly work in the future.
Discovery begins with the introduction of AI theory and practice to the organization (see Figure 2). The purpose of the effort is clarified, and a “core team” is selected to both guide the effort and select topics for the inquiry. Topics are affirmative, and are stated in affirmative language.
For example, an organization wishing to reduce turnover might study “employee retention.” Another wishing to reduce conflict might study “collaboration.” In the selection of affirmative topics, organization members are asked to focus on the things they want more of in their organization - the things they want to grow. (“What would make this organization more the place you want to work?”)
“Appreciative interviews,” the core technology of Appreciative Inquiry, are at the heart of the Discovery phase, and are often woven into later phases of the process as well. Generally conducted as a mutual interview among diverse stakeholder groups, they may also be conducted as a focus group process. Interview questions are crafted around the affirmative topics, and an interview guide is created, exploring: a) people’s beginnings with the organization; b) what they value most about themselves, their work and the organization; c) their appreciative stories related to the topics being studied; and d) their hopes and dreams for the organization and its future. Discovery involves interviewing many - if not all - members of an organization, and often includes interviews with external stakeholders (i.e., patients, suppliers, and community members).
(B) Dream: Imagining What Might Be
The Dream phase is a time for groups of people to engage in thinking big, thinking out of the box, and thinking out of the boundaries of what has been in the past. It is a time for people to describe their wishes and dreams for their work, their working relationships, and their organization.
The activities of this phase, which can take place in a large group meeting of 50 to over 1000 people, encourage participants to consider what their organization (department, business unit, or entire company) is being “called” to do. This connects the work of all members of the organization to a greater purpose and vision.
Working together in small groups of eight, participants share and discuss the data and stories collected in the Discovery phase. Even as these discussions ground them in the most positive aspects of their organization’s past, they inspire them to imagine possibilities - what “might be” for themselves and their organization in relation to the world.
Small group conversations have been preceded by one-on-one appreciative interviews, and small groups have been given guidelines for self-management. Participants have been encouraged to “check their titles at the door,” and listen for the “lone small voice” - the one with a different idea or a different way of looking at things. This focus on relationship and dialogue builds safety and trust, which in turn inspires lively, enlivening, participative, and highly creative conversations. In fairly short order, divergent groups of people begin to converge towards and focus on the things that bind them together, as opposed the things that pull them apart.
Often, small group conversations are followed by high-energy, creative presentations to the larger group - which in turn inspire even greater ease and creativity. Skits, murals, songs, poems, and commercials are all possible modes of expression for dramatizing the positive possibilities envisioned for the organization and its future.
(B) Design: Determining What Will Be
In the Design phase, organization members and stakeholders (including customers and suppliers) recreate the “social and technical architecture” of the organization, so that everything about organizing reflects and is responsive to the organization’s most positive past and highest potential.
Whereas the Discovery and Dream phases generate and expand the organization’s images of itself, the Design and Delivery phases ask members to make choices for the organization. Stakeholders draw on interviews and dreams to select high-impact design elements, and then craft “Provocative Propositions” (or Design Statements) which incorporate the positive core into high-impact processes, systems, and programs.