Appreciative Inquiry Guru

If you feel like your work as a healthcare administrator or patient care professional is causing you to rethink everything you have known and counted on as true and reliable, welcome to a new reality. The reform of healthcare in the US is inviting all of us to evaluate and reconsider many of the management principles and strategic goals that have been the norm for the last generation or two. While this is unsettling, it can be understood better if we compare traditional thinking with emerging ideas for engaging in transformation based on AI and complexity. It's called Second Curve.

If you consider small incremental changes to what we already know and do as First Curve, you will see the distinction since they differ in basic assumptions and beliefs about who the players are in healthcare and how to involve them in shaping the future.

FIRST CURVE ASSUMPTIONS

Acute care is the "hub of the system".
The delivery system is designed to meet the needs of healthcare providers.
Lack of alignment and perverse incentives produce chaos in the system.
System is fragmented. Patient fends for her or himself, moving from silo to silo.
Sickness-focused. Episodic/Individual.
The system is designed to provide care and services to individuals (a diabetic, for example).
Designed to facilitate freedom, independence and autonomy of professionals.
Systems, structures and processes are designed to control and regulate the people working in the system.
Hierarchical, command & control systems/structures/processes/culture creates toxic work environments.
"Accountability" means blame. Blame causes cover-up.
Constant cover-ups means we don't address design flaws in our systems, structures and processes.
Information is centralized and hierarchical. Physician is supreme source of knowledge and dictator of therapy.
Medical record is fragmented and idiosyncratic to a particular silo. Individual caregivers work off entirely unconnected, often contradictory scripts.
Performance problems result from lazy, unmotivated and uncaring people that need to be carefully monitored and controlled.
Designed to encourage political behavior/power games.
Behaviors characterized by fear and anxiety. Little trust.
Solutions to problems translates to retraining or censoring people

Making a change to more inclusive and enterprise solutions begs for a new way of thinking and acting that builds from the capabilities of people and core competencies in the healthcare organization as recognized from the narratives of successes that have been experienced.

SECOND CURVE ASSUMPTIONS

Primary health is the "hub of the system".
The delivery system is designed to be customer-driven - while incorporating the needs of all care-givers along the continuum.
Systems, structures and processes are aligned and intentionally designed to achieve the outcomes required.
Organizational alignment produces synergy within organizations and across the delivery system.
System is seamless. Coordinates needs of complex patients, using case managers for those that are especially difficult.
Health status & outcomes-focused. Systemic/ population-based.
The system is designed to meet the needs of defined populations (diabetics for example) while retaining responsiveness to individual needs.
Designed to facilitate the best combination of independent and interdependent professionals.
Structures, systems and processes are designed to facilitate collaboration, co-ordination and teamwork.
Systems, structures and processes are designed to achieve the right balance of empowerment and accountability.
High staff satisfaction rates.
"Accountability for Outcomes" is clear for every manager and medical professional.
"Learning from our best mistakes" means continuous improvement.
Systems, structures and processes are designed to provide the support people need to achieve the outcomes for which they are accountable.
Information is dispersed. All caregivers and patients have direct access. Physician is integrator and facilitator of choices.
Medical record is electronic and instantly updated and available for all relevant caregivers, all caregivers read from precisely the same script.
Assumption that people are competent when accountabilities are clear and the supports required are in place Knowledge that poorly designed systems, structures and processes leave people feeling powerless and uncaring.
Designed to produce collaborative behavior and teamwork.
Behaviors characterized by creativity and innovation.
Lots of trust - and a real sense of purpose.
Leaders are in stewardship ("in service") to those around them.
Solution to problems translates to redesigning systems and providing people with the learning support they need.

That is quite a shift, however, there are hospitals that have made it in real and impactful ways. Among them you can count Newark Beth Israel Medical Center, Hoag Memorial Hospital, and Tufts University Medical Center. By involving their physicians, nurses, technicians, managers and staff, they have found higher levels of patient care quality and satisfaction achievable while positively impacting their financial outcomes. As AI has demonstrated before, the answers and opportunities for success are in everyone in the system.

The idea behind Appreciative Inquiry is building from a position of strength. Focusing on what works within a system, the participants in an AI delve into the circumstances and elements that have brought about success in the past. They find the positive core that was previously unseen and base their aspirations for achievement upon it. Energized by confidence that they can bring about more of the excellence they have previously achieved, they design the practices, roles and parameters that insure achievement.

Appreciative Inquiry helps teams and organizations discover and amplify the root causes of their success to build from them in the future. It is a systematic search for what gives "life" to an organization - that which is most effective, most purposeful and which contains the most potential for mobilizing members' energies for positive change.

Instead of asking, *What are the problems; what hasn't worked?* Appreciative Inquiry (AI) asks questions like: Think of a time when this unit has performed superbly: What conditions were present at those moments? What organizational changes would allow more of those conditions to prevail?

This simple shift in perspective constitutes a powerful intervention in its own right that can begin nudging the organization in the direction of those questions - and toward significant innovation.

AI comes out of a belief that what we ask about we get more of, a commitment to the crafting of "unconditionally positive questions" which have the power to enable members to develop visions for their organizations which surprise them in their boldness and which elicit their best energies and creativity as they design and plan ways to bring those visions to life.

The inquiry is often conducted in four phases:
1. Discovery: What is the best of "what is" -- peak moments when the unit has excelled in the past and is doing well in the present? Stories or critical incidents are collected about best practices and the unique conditions, which enable them. "Through this process new insights emerge about what drives the organization, what its capabilities are, and what contribution its members can make to the world."

2. Dream: What are the possibilities, expressed and latent, that provide opportunities for more vital, successful and effective forms of organization? Unlike many visioning exercises, these images of the future are grounded in the organization's proven capabilities and past successes.

3. Design: What kinds of, structure, systems, roles, procedures, work processes, leadership, relationships, measurements, etc. are needed to assure implementation of the dream? Participants identify the high-leverage changes needed to support the vision.

4. Destiny: How will we create the future that we envision and deliver on these new images of the excellent performance? Participants develop specific action plans and commit to who will do what by when.

Appreciative Inquiry is redefining the way companies and individuals experience change, with dramatic implications for management. It mobilizes inspired action and innovation focused on transformation of the business through a deliberately strengths-based approach to strategic planning, culture change, knowledge management, business process improvement, leadership development, customer satisfaction, joint ventures and alliances, and more.

Learn and experience this powerful, new vehicle for energizing change. In my practical courses, you will gain understanding of and skills in:

> The fundamental ideas and practices of AI
> Key phases and roles in the AI process
> AI principles in traditional and non-traditional businesses
> Implementation in corporate, nonprofit, government, healthcare and education settings

Courses include:
Ignite: A 1-Day AI Experience
* Highlights the phases and the impact of AI in various situations for managers and leaders.

Foundations of AI Practice: 3-Day Hands-on Course
* A learning experience for internal and external consultants who are interested in applying AI in their work.

Advanced Applications of AI: 2-Day Workshop
* A collaboratory for experienced practitioners and academics with an integrated look at collaborative learning and social network techniques for consulting and teaching.

Social Media and AI: 1-Day Experience
* This sandbox is a primer on Web2.0 tools and technologies for blended and online AI events

Sometimes it looks like Appreciative Inquiry is a single approach to fostering change. In fact, its principles can be applied in many forms including:

> Short Introductions to AI
The organization wants to prepare many of its leaders to the possibilities of AI prior to a planned engagement; or wants to introduce large number of people to their being involved in its implementation.

> Interactive Practice of the AI Process
The organization wants to assist leaders or members in applying AI processes to increase change capacity and create a culture of shared leadership.

> Focused Action
The organization wants to involve small groups or teams in total AI processes that address specific issues and in formats that are adaptable to the constraints of available time.

> Whole System Transformation
When the organization wants to create its vision or set overall direction for services, products, markets for multiple years.