The decision-making styles that evolve in the fast-paced setting in which potentially life-threatening clinical outcomes are at stake have significant value. They let team members assess large amounts of data in a rigorous manner while acting quickly. But when transferred to other settings, such as hospital boards and committees, this particular approach to conversation and decision-making can be problematic.

Given their backgrounds, healthcare professionals generally expect that their roles in meetings of teams, boards, or committees will involve advocating for their constituencies and mandating solutions to problems. While more directive approaches play an important role when decisions must be made or actions taken, in other contexts, they can undermine team learning. In addressing issues of organizational strategy, long-term planning, and creative problem solving, generative dialogue has proven more effective than one-way communication. Failure to shift to dialogue-based forms of communication will ultimately have a negative impact on an organization’s ability to rapidly adapt to changing market trends and to truly explore the questions involved in reducing medical errors and improving outcomes.

One Organization’s Challenges

In addressing issues of organizational strategy, long-term planning, and creative problem solving, generative dialogue has proven more effective than one-way communication.

The governing board of one healthcare organization was typical of many in the industry. Physicians attended meetings with the expectation of advocating for their constituencies. Managers learned to fear these meetings, as interactions often focused on criticism of the existing situation or proposed solution. The group rarely explored the challenges through healthy dialogue.

To help determine the board’s future role, board members and other stakeholders participated in a retreat. The following perceptions surfaced:

• Physicians and managers believed that there was value in meeting together regularly.
• Both groups felt that the organization needed to address certain strategic themes.
• Managers understood that they needed to collaborate with physicians to elicit the full range of possible approaches to these issues.
• Physicians wanted to help create ways to approach these themes, but wondered if they would have the power and control to make policies and decisions.
• Both groups had difficulty seeing beyond the current board structure, envisioning that the same struggles and limitations would continue to arise.
• Others in the organization were passionate about participating in the process, although they had not previously been invited to do so.

The Compass Group

The consensus from the retreat was that merely tweaking the existing board structure would be inadequate; nothing short of a complete destruction of the structure, norms, and paradigms would provide the organization with the freedom to explore new paths to achieve its stated goals. With this understanding in mind, the board dissolved its existing structure in favor of a dialogue-based forum that was organized around the stated organizational imperatives of customer service, employee satisfaction, strong physician relationships, and financial stewardship.

This forum came to be called the “Compass Group,” because the group felt that these strategic themes were analogous to the directions on a compass. The Compass Group was seen as a risky endeavor. Much of this fear was based on the uncertainty of where dialogue around these concepts might lead. The organization, however, was able to understand that any learning involves some degree of risk.

“Uncoupling” Old Norms

Cultural and conversational norms had been a major barrier to true learning within the organization. Many feared that the old ways would carry forward into the current efforts. A number of important steps were needed to ultimately “uncouple” the organization from existing ways of interacting, thus allowing for new ways to emerge and thrive.

Associating Pain with the Status Quo. A critical event during the retreat involved discussing aspects of the meetings that board members disliked. Surfacing these feelings markedly raised the group’s level of discomfort with the status quo. This discomfort created a compelling need to move the initiative forward.

Incorporating New Perspectives. The group felt strongly that the constancy of the board’s membership over the past several years had contributed to some degree of stagnation. Understanding that many others in the medical group had expressed an interest in participating, members agreed to open the group up to others who possessed fresh perspectives.

Eliciting Desired Norms and Expectations. During the retreat, board members mentioned rewarding and fulfilling experiences that they had enjoyed in other meetings and committees. Common among these experiences were being heard, contributing proactively, understanding one another, practicing mutual respect, and building upon collective contributions to generate creative approaches. By listing these desired norms and expectations, the group was eventually able to develop momentum for change.

Generating “Buzz.” Through reports from the retreat, others in the organization became aware that the Compass Group was no ordinary board or committee. The communications were lively, genuine, and informal; they carried with them a feeling of realism, openness, and innovation that was not typical of standard emails and memoranda. This “buzz” was instrumental in generating interest among others who might not have been comfortable in the traditional board setting, and in creating expectations that helped to overturn the norms of the past.

Setting the Stage for Dialogue

Because of the risk inherent in any team process, a great deal of planning went into the initial dialogue session. The goal was for people to relax, engage in collaborative dialogue, and explore creative possibilities for action. The Compass Group followed some of the principles used in developing a World Café (see “Framing Questions and Guidelines”).

Establish a Clear Purpose. Unless the group had a clearly defined purpose and objectives, along with concrete outcomes, participants wouldn’t perceive significant value. For the first of the Compass Group sessions, the management team chose to focus on the strategic theme of customer service. With this theme in mind, participants addressed a series of questions that ultimately led to greater insight and collective shared knowledge on the topic (see “First Compass Group Session” on p. 9).

Invite Great Guests. The management team decided to invite all interested physicians, nurse practitioners, and physician assistants. In doing so, they conveyed the sense that the Compass Group was “no ordinary board meeting”; this innovative forum would truly make a difference.

Plan for a Safe and Welcoming Environment. In planning the session, organizers paid close attention to creating a physical space that would be perceived as inviting, hospitable, and intimate. The goal was for participants to feel a high degree of psychological safety. The creation of a welcoming environment began with the invitations themselves. Rather than relying on email, organizers selected stationary and fonts with earth tones to convey the message that this experience would be different.

Form Powerful Questions. Well-structured, open-ended questions hold tremendous value. These questions are the most important determinant of a successful dialogue session. Because the theme of the first Compass Group session centered on customer service, questions related to service and to recent internal efforts in measuring service perceptions were developed in a logical progression of discovery.

Facilitate for Success. The facilitator’s role was (1) to model the process for internal facilitators in the future, (2) to provide a structure for the evening by facilitating between rounds of dialogue, and (3) to provide some training around the skills involved in dialogue, with a heavy emphasis on inquiry. Members of the management team had already received some training in hosting a dialogue session and in facilitating smaller conversations, mainly by encouraging a balance of inquiry and advocacy. To leverage these skills, one management team member served as a facilitator at each table. The other members at each table were carefully distributed to ensure sufficient diversity of conversations.

The session opened with a time for attendees to arrive, get oriented, and enjoy food and beverages while conversing with colleagues. Participants wrote the answer to the question, “What is the location of your most memorable service experience?” on their name tags. They were encouraged to use this memory as a starting point for conversation with others.

The session began with an overview of the evening and a brief session on dialogue. Each round of dialogue was structured around a series of questions. In this particular case, a review of the organization’s patient satisfaction data and video reenactments of actual patient experiences were used as the starting point for forming questions. During the rounds of dialogue, the facilitators at each table helped to encourage effective inquiry and to surface hidden or underlying assumptions. In addition, they recorded the predominant themes that emerged.

Between each round, the tables shared their discoveries and insights with the larger group. In addition, they commented on their success with using dialogue skills. As one of the goals of the Compass Group was to provide an opportunity to share best practices, the group used a separate flip chart to capture these ideas. In addition, items that warranted action, follow-up, or future dialogue were documented on another flip chart.

After the Session

The feedback from post-session surveys was overwhelmingly positive. Participants reported that they had achieved a high level of shared understanding and accomplished a great deal. They also felt passionate about continuing the conversations.

The themes and best practices that emerged from the table dialogues were distributed to all members of the organization, along with a clear plan for future dialogue sessions on the other strategic directions defined by the compass. In addition, efforts to continue the discussion around service were implemented by providing weekly questions for each manager, physician, and department to use with their staff.

As in other industries, healthcare organizations tend to depend heavily on one-way communication, debate, and criticism. Unfortunately, these dynamics present a barrier to learning and to developing organizations that are able to innovate and adapt effectively to tumultuous market conditions, a necessity in today’s marketplace. Dialogue, specifically the skills of understanding mental models and balancing advocacy with inquiry, is essential for building organizations that learn effectively. By challenging the assumption that committees and boards must always be structured in the traditional manner, organizations may be more likely to explore formats that are more conducive to dialogue. Shifting to dialogue-based forums focused on strategic imperatives can be one approach that fosters learning in all kinds of organizations.

Manoj Pawar, MD, MMM, is a managing partner with Nivek Consulting and is the chief medical officer for the Exempla Physician Network. He is committed to developing high-performing teams and organizations in healthcare. He can be reached at pawarm@exempla.org.

Special thanks to Gene Beyt, MD, Richard Hays, DBA, Charles Jacobson, MD, and Bob Myrtle, DBA, for their wisdom, and for their gracious and insightful contributions in the development of this article.

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The Strategic Action Map

A strategic action map is a tool that helps teams think through, articulate, and implement high-leverage action strategies. It could be called a double loop strategy development tool, because it forces teams to go beyond seeking solutions within their current framework to take actions on that framework (for more about double loop learning in teams, see “Working in High-Leverage Zones with the Double-Loop Learning Matrix” in The Systems Thinker, V12N8).

In “Example of a Strategic Action Map,” notice that the gray portion in the middle (steps 8, 9, and 10) contains only three elements: phases, activities, and a timeframe. This is where the action is specified and

EXAMPLE OF A STRATEGIC ACTION MAP

A strategic action map is a tool that helps teams think through, articulate, and implement high-leverage action strategies.

progress is tracked. Notice also that this section contains pictures, for a little right-brain reinforcement of each item. Now, look at the surrounding areas of the map (steps 1-7). These sections literally frame the action portion of the map. This is where the framework, or basis, for the action is made explicit. When someone asks, “What are you planning to do?” you can show them the center of the map. When they ask, “Why are you doing that?” you can refer them to the frame around that action.

The map summarizes the following information: “We intend to go from our current condition (2) to our desired condition (3) by operationalizing the strategy (1) listed at the top of the page, and this is why we think this strategy will work (4). We have named the barriers we must overcome (5), we know what ‘success’ will look like (6), and we have considered the perspective of key stakeholders (7). What we will actually do is specified by the phases (8), timeframes (9), and activities (10).” Isn’t this the very stuff that a board of directors or leadership team would expect to know?

The Power of the Map

A strategic action map incorporates several of the organizational learning disciplines. In encompasses systems thinking by taking into account the “big picture” and the interests of key stakeholders throughout the system. It includes shared vision by establishing creative tension between our vision (desired condition) and our current reality (current condition). Additionally, a strategic action map supports team learning. Because teams complete the map together, members must make their assumptions about the change process explicit: Why are we trying this strategy, and what are we trying to create—really?

Because a strategic action map is more of a conversation facilitation tool than a precision planning tool, it is not a substitute for project management tools. However, we have found that, as a result of the high-quality conversation that this tool generates and the visual way in which the information is presented, we have less of a need for a deadline-driven tracking system. The work just seems to get done because of the high levels of synergy and alignment that creating the strategic action map as a group engender.

Completing the Map

As a first step for completing a strategic action map, the project team must analyze the problem situation and discover some new insights for addressing it. Team members then ask themselves specific questions at each of the 10 steps and enter the answers into a blank process map (you can easily create a template using Microsoft Visio or some other business drawing software package). A facilitator is usually helpful in guiding a group through the process.

1. Strategy. What is the goal and how do we intend to achieve it? Naming the “how” is the same as naming your strategy for this change initiative.

2. Current Condition. What is the current condition of the goal? What symptoms are you seeing? What data do you have? A little soul-searching goes a long way here. If a team has not already done so, developing causal loop diagrams at this point is helpful in describing “what is.”

3. Desired Condition. What is the desired condition of the goal? What is your vision for this change initiative? Notice that the team has just established creative tension by juxtaposing the current condition with the desired condition.

4. Strategy Assumptions. What leads you to believe that this change initiative will work? What has been tried in the past and why didn’t it work? Why do you even want this goal? This is where you test the strategy you have named in step 1. You must define clear reasons why you selected this strategy, so you can defend it when others ask you about it. Test the validity of the assumptions by asking questions such as: How often is this assumption true? When would this assumption not be true? What are some examples? Does anyone see it any differently?

5. Barriers/Obstacles. What barriers must we overcome for this change initiative to be successful? What are we up against?

6. Desired Accomplishments. How will we know that we have achieved the desired condition? What measurable outcomes will we see?

7. Key Stakeholders. What groups are affected by this change initiative? Whose view do we need to consider?

8. Phases of the Process. What phases (groups of activities) must we go through to move from the current condition to the desired condition? Add a symbol to represent each separate phase.

9. Timeframe. What are the dates by which each phase must be completed?

10. Activities. What specific actions or events must occur during each of the phases for them to be completed successfully?

Strategic Action Maps in Action

At GMHS, we develop strategic action maps for our organizationwide initiatives, as well as for smaller projects. We create our diagrams over the course of several meetings, refining and changing them as our thoughts percolate. The team that completes the map shares it with other associates to track progress, communicate action strategies, and induce further learning.

As an organization, we have found many of the mainstream business tools to be “too hard,” in that they fail to take into account the insights that emerge when participants compare their mental models. We have also found some of the organizational learning tools to be “too soft,” in that they don’t integrate enough measurement and concrete action steps. So, we have developed this hybrid tool that we think encourages insight for action—a way to operationalize our systems thinking all on one page.

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