Trust Must Come First

A few years ago, an employee stopped me in the hallway of the facility I was leading to request a process change to patient care. As a VA medical center director, I appreciate discussions with my staff. However, changes to the way we care for our nation’s heroes affect not only our Veterans and their families, but also the entire health care team. I listened intently to her suggestion and then told her we would meet once I came to a decision.

As a proponent of high reliability, I defer to the expertise of my team daily. I also know that as a leader, my most important resource is my staff. However, after careful consideration, I realized that I did not agree with my employee and set a time to discuss my decision with her. During our meeting, I explained my position, how I came to my conclusion and then paused for her response. She said, “Mr. Isaacks, I don’t agree with your decision, but I trust you.”

Although that meeting took place more than three years ago, this employee’s words have resonated with me since that day. They also proved to be more impactful than I realized at the time.

Within all successful organizations, positive employee and customer experiences are factors that should be discussed and improved upon continuously. Without question, both are critically important to an organization’s success and sustainment. However, to achieve a high level of employee and customer satisfaction, an organization’s leadership must develop conditions that eventually lead to organic change. From my experience, the main ingredient necessary to affect this level of success is trust.

Without trust, initiatives to improve employee and customer experiences are unsustainable and always fall short. Trust also enables organizations to meet the uncertainty and complexity of the future through continuous improvement.

James Carse, an author and professor emeritus of history and literature at New York University, wrote about the concept of continual improvement as “finite and infinite games.”

“Finite games are the familiar contests of everyday life,” Carse wrote. “They are played in order to be won, which is when they end. But infinite games are more mysterious. Their object is not winning but ensuring the continuation of play. The rules may change, the boundaries may change, even the participants may change as long as the game is never allowed to come to an end.”

Using this analogy, I would argue that health care could be viewed in a similar way ― a culture where we continuously work to improve without stopping at a certain level of achievement.

Like other industries dependent upon safety and innovation, health care is an infinite quest for excellence. It’s a never-ending, constantly changing and extremely complex field. Those of us who work in health care never should view the experience of our employees and customers as finite. We must look at improvement as a long-term process built on trust.

I feel that trust also is the most import form of currency in any organization. It empowers, enables, and permits innovation and organizational equity. It breaks down barriers that prevent diversity and creates a “just purpose,” or collective culture which is easily shared and accessible at any organizational level.

For the past four years I have led two VA medical centers with the goal of developing each into a high reliability organization (HRO). The staff at both medical centers also is committed to high reliability and the practice of a “Just Culture” built on shared accountability.

Although becoming an HRO and practicing Just Culture sounds great on paper, a key ingredient for sustaining both usually is left out of the mix. In fact, it’s often not even discussed because as difficult as Just Culture and high reliability processes can be to incorporate in any organization, trust is much harder to develop and sustain.

The following are the top five concepts that I have found to be most impactful for developing trust in organizational cultures:

·       Go first. If you want others to trust you, trust them first. Believe that your employees are doing their very best and that your leaders have you in mind when making decisions. Believe in your community before asking them to trust in you. You lead by example.

·       Humility. Don’t be afraid to be vulnerable. Learning about each other and sharing personal struggles helps us connect and find better ways to work together. Humility shows everyone that you depend on them just as much as they depend on you.

·       Be authentic. As humans, we are highly socialized creatures. We know when someone is not being authentic. Others ― especially employees ― already know that leaders don’t have all the answers. Admit that you don’t and watch how creatively and passionately employees respond. Employees want to be part of or provide a solution. They cannot do that with a know-it-all leader.

·       Ensure value alignment. Apply organizational values to every decision, whether in service of safety, timeliness, effectiveness, efficiency, equity, or customer-centeredness. Alignment reinforces trust because employees and others see that decisions are made in the best interest of the organization and not in the best interest of a leader.

·       Guard the learning system. Be fully engaged in work and practice self-reflection that leads to comfortable, nonpunitive transparency. Also, understand and apply improvement science, reliability science and continuous learning. Inspire this kind of work throughout your organization. A leader that allows failure from innovation and process improvement will multiply an organization’s trust equation.

Earlier, I shared the story of my meeting with an employee as an example of the power of trust. Although she may have disagreed with me, she did not disengage as an active participant of our team. Instead, she knew the next time she had an improvement idea it would create a similar discussion ― and she would be an important part of that development process.

What that and other experiences have taught me is that a person can achieve some measure of success in a finite process, such as maintaining the status quo. However, I believe that improvement should be an infinite process. And if you want to be a leader of sustained success, continuous improvement is required ― and trust is where it all begins.

David Isaacks, FACHE, is a U.S. Marine Corps Veteran and the Medical Center Director of the Kansas City VA Medical Center, Kansas City, Missouri.