Beyond Buy-in

Posted by James

Do you ever wonder why certain hospital committees get more done than others, or why a P&T committee in one institution seems to be on top of every important detail while others can’t seem to accomplish anything? Does one of your medication-safety programs seem to be going in reverse gear rather than making the progress you had anticipated? Perhaps help is at hand.

As I continue to learn how to improve my own management skills, I have been reading widely in the literature on leadership. A Harvard Business Review article led me to Robert Kegan’s great book, In Over Our Heads, published in 1994. The author is not a doctor or a pharmacist; he is the William and Miriam Meehan Professor of Adult Learning and Professional Development at the Harvard University Graduate School of Education in Cambridge, Massachusetts. His book has helped me appreciate the complexities of modern life and its effect on employees and hospital leaders alike.
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Last spring, I had the distinct pleasure of attending a workshop, led by Professor Kegan, for medical educators and leaders in the U.S. Allow me to distill what I learned from this moving three-hour session with this nationally prominent educator and organizational consultant.

In a nutshell, his thesis is that although employees “hold the sincere commitment to change, many are unwittingly applying productive energy” toward what he calls a “hidden,” competing commitment. In other words, most people want to do a good job and are committed to progress, but, for many reasons, they are unable to see their projects through to fruition. As leaders, Professor Kegan says, we have to “support our employees in unearthing and challenging their innermost assumptions.”

To diagnose this immunity to change, he explains that we must go through a three-step process. Essentially, managers need to guide employees through a set of questions designed to uncover these competing commitments. Next, employees have to examine these commitments to determine the underlying assumptions at their core. Finally, employees can start the process of changing their behavior. It may sound easy, but this is a daunting task!

How do you get people to first uncover and then overcome their competing commitments? Professor Kegan suggests a series of key questions designed to help address this challenge.

The first question one might ask is, “What would you like to see changed at work, so that you could be more effective or so that work could be more satisfying?” canadian antibiotics

Generally, responses to this question are couched in the form of a complaint. Professor Kegan contends that these complaints can be immensely useful. People complain only about the things they care about, and they complain the loudest about the things they care about the most.

The second question is, “What commitment does your complaint imply?” In other words, if we complain that there is not open communication among P&T committee members, then we might need to commit to furthering better communication. This is more than just semantics.

We are then forced to ask more questions: “What are we doing or not doing that is keeping our commitment from being more fully realized?” “Do we shoot the messenger on a routine basis?” “Do we belittle people who try to communicate?”

P&T committee members must then ask themselves to consider the consequences of forgoing the (unintentionally) bad behavior. Professor Kegan says that we do this by asking another important question: “If you imagine doing the opposite of the undermining behavior, do you detect in yourself any discomfort, worry, or vague fear?” Although this question might sound like pop psychology, it is distinctly possible that P&T committee members are afraid to promote open communication because then they would have to tackle the problems that became apparent from that communication itself—in other words, they have a latent fear of failure.
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The final step is to transform this potential fear into a statement that reflects an active commitment to preventing undesirable outcomes. Surely, revelations like this can be embarrassing, and it might not be easy to get all committee members to open up about their personal beliefs. The author says that this vulnerability and fear might undermine the way in which people are regarded by others and themselves. It is little wonder that people keep these feelings hidden and hasten to cover them up when they appear.

The author addresses the fact that this process of uncovering competing commitments may put a name to very personal feelings that people are reluctant to disclose, such as deep-seated insecurities or highly simplistic views of human nature. In essence, uncovering a competing commitment makes all the sense in the world. Even the best committee members might be working at cross-purposes to the primary stated goals of the strategic plan that has already been approved!

Regrettably, I cannot do justice to Robert Kegan’s work in a short editorial, and I cannot effectively translate his infectious enthusiasm and outstanding presentation skills in this space. What I take away from reading his book and articles and from seeing him in person is that people attribute their major assumptions to early experiences with parents, siblings, and friends.

“Understanding the circumstances that influence the formation of the assumptions can free people to consider whether these beliefs apply to their present self.” Professor Kegan helped me to recognize that these competing commitments and underlying assumptions are deeply personal, and groups, including P&T committees, are just as susceptible as individuals to the dynamics of this “immunity to change.” Perhaps your P&T committee is unwilling to confront certain problems because the members feel that they lack the skills needed to overcome those problems. Maybe you don’t have the right people on your committee. Maybe your committee is being led by people with a deep resistance to change. tadalis sx

I think that Professor Kegan is right on target when he says, “It’s not about coaxing, cajoling, or even giving poor performance reviews. It’s about understanding the complexities of people’s behavior, guiding them through a productive process to bring their competing commitments to the surface, and helping them cope with the inner conflict that is preventing them from achieving their goals.”
Are you ready to uncover the competing commitments of your P&T committee? Perhaps by undergoing such a process, we can go beyond “buy-in” and effectively confront many of the challenges we face in carrying out our duties, such as improving the use of pharmacological agents.