Crucial Skills®

A Blog by Crucial Learning

Crucial Influence

Q&A: Influencing an Entire Department

David Maxfield

David Maxfield is coauthor of three New York Times bestsellers, Crucial Accountability, Influencer, and Change Anything.


Crucial Conversations

Q Dear Crucial Skills,

I am the manager of a small intensive care unit. I struggle to get staff to commit to using a tool that would make our patient care rounds more efficient and ensure that we cover all aspects of care. How do I hold sixty-seven crucial accountability discussions?


The Messenger

A Dear Messenger,

Good question! Most managers, whether they work in healthcare or not, face this challenge. How do you implement process improvements that require new and reliable behaviors? Holding sixty-seven crucial accountability discussions sounds too time consuming and inefficient. I’ll suggest some strategies.

Work through a team. You’ll need the support of two groups: formal leaders and informal leaders. The formal leaders include all of the supervisors and managers in the affected area. The informal leaders include the opinion leaders throughout the affected area. Focus a disproportionate amount of your efforts on these two groups of people. Once you’ve gotten their whole-hearted support, ask them to help you bring everyone else on board.

Share your path. Don’t just share your final conclusions. Take the formal and informal leaders along the path you took as you learned about the process improvement. Tell the story of your initial doubts, your data collection, your evaluation, and what it was that eventually convinced you.

Identify obstacles and objections. Ask the formal and informal leaders to help you identify all of the obstacles and objections the process improvement could face. For example, Lisa, a brilliant nurse manager at Spectrum Health in Grand Rapids, MI was working to implement bedside reports—a process that involves patients and their families in shift-change handoffs. This influencer actively collected every concern she could find. Some of her findings included:

1. Overly involved families

2. Verbiage to use in front of patients

3. May not know Plan of Care

4. Addressing patient needs in the moment

5. Cognitive status issues

6. Time management

7. Meal prep interfering with rounds

8. Psychosocial issues

9. Sharing information that might be embarrassing to patient/family

10. Drug-seeking behavior

11. Worry about creating two reports

12. Every patient needing something when you are in the room

13. How to have time to review the Kardex?

14. How to find people to get/give report to?

15. Is this going to take more time?

16. Physician rounds interfering with report

17. What information can I share?

18. Use of phones during report

19. Transfer of patients during report

20. Waking up patients

Find solutions. Take people’s concerns seriously. Work with the formal and informal leaders to create convincing answers for each. Lisa asked her team to suggest solutions to real problems. For example, they decided to get phones for technicians so nurses wouldn’t have to leave during bedside reports.

Answer objections. Many concerns people have require answers, rather than solutions. They reflect a lack of understanding, rather than a flaw in the improvement process. Lisa asked her team to create two-minute answers to every concern. These answers were usually three to four bullets long. Here is an example:

Concern #9. Sharing information that might be embarrassing to patient/family

• We will already have permission from the patient. We’ll know what we can share and what we can’t.

• We will be the ones who ask family members to leave.

• Sometimes, the embarrassment is really ours rather than the patient’s.

Make sure all of the formal and informal leaders are confident they can answer these concerns. Ask them to take the lead in answering them.

Bring everyone on board. Hold a meeting—or a couple of meetings—to orient and educate everyone who needs to change or support the process improvement. Make sure the formal and informal leaders play important roles in these meetings. Remember, they are the people who will tip the balance.

Analyze and adjust. Anticipate and prepare for setbacks. Take extra care to find and quickly solve problems during the first few weeks that people use the new tool. Use the formal and informal leaders as your eyes and ears. They will learn about problems before you will. You won’t be able to anticipate every problem in advance but you can mitigate many issues by including this preparation in your plan.

I hope these ideas will help. The basic idea is to involve formal and informal leaders in a systematic way. Use them to first refine the improvement tool, and then to advocate and educate after it has been implemented. This process will be far more effective and efficient than sixty-seven separate conversations.

Good Luck,


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1 thought

  1. Lora Schafer (@loraschafer)

    Thank you for these points. It too has been my experience that if these steps aren’t followed, managers just end up banging their head against a very hard wall or point the finger. Change is difficult, but can be successful.

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