Crucial Accountability

P t T W t MD Peter T Watson, MD
Northwest Perinatal Center
Womens Healthcare Associates
Portland, OR
Crucial Accountability: Disclosure
I have numerous interesting conflicts and
will talk about almost all of them at any
opportunity. I dont approve of drugs, pp y pp g ,
products, or devices and can guarantee
they wont come up in conversation today
or any day
Peter T Watson, MD
Crucial Accountability
Patterson K et al, Crucial Accountability:
Tools for Resolving Violated Expectations,
B k C it t d B d B h i Broken Commitments and Bad Behavior,
2
nd
Edition, 2013; New York, McGraw-Hill.
Crucial Accountability: Definition
A subset of crucial conversations (i.e.,
when opinions vary, emotions run strong,
and stakes are high.)
Crucial conversations =disagreements Crucial conversations =disagreements
Crucial accountability =disappointments
(i.e., violated expectations, broken
commitments, bad behavior.)
Crucial Accountability
Conversations: The most important
personal characteristic for making
change happen is:
A willingness to enter into crucial A willingness to enter into crucial
accountability conversations and an ability
to make them successful; i.e., to solve
problems and to build relationships.
Patterson, K et al. Crucial Accountability, 2013.
Crucial Conversations
Crucial
High
Stakes
Strong
Emotions
Crucial
Conversation
Differing Opinions
Crucial Accountability
Violated Expectations
Broken Commitments
Bad Behavior
Crucial Accountability: Examples
Daughter on first date agrees to curfew,
comes home two hours late.
Beloved boss agrees to protocols then
breaks themrepeatedly breaks them repeatedly.
Co-pilot sees ice on wings, notifies pilot
who checked them. Pilot ignores him.
Shuttle engineer discovers O-ring failure,
fails to notify responsible superiors.
Crucial Accountability
Conversations: Choices
Avoid them
Face them and perform poorly
Face them and perform well
Crucial Accountability: Fools Choice
Speak up and make an enemy or
Stay silent and continue to suffer
while a problem goes unsolved.
Crucial Accountability: Fundamental
Consequence
If you dont talk it out you will act it out If you dont talk it out, you will act it out.
Patterson, K et al. Crucial Accountability, 2013.
Crucial Accountability:
Fundamental Observations
You are not only responsible for what you
say, but also for what you dont say.
Martin Luther Martin Luther
I always wondered why somebody didnt
do something about that, then I realized I
was somebody.
Lily Tomlin
Crucial Accountability: If and
What
Before you embark on an accountability
discussion:
Decide if you should have the
conversation in the first place.
And if so, what kind of conversation
should you have?
Crucial Accountability Conversations:
When not to have them (without help.)
Personal danger: Leave, call for help, notify HR
Illegality: Call HR, legal counsel, senior partner,
practice manager
Adverse peer pressure: Discuss with HR,
influential peers, mentors.
Significant uncertainty: Discuss with HR,
mentors.
Crucial Accountability: Questions (if youve
decided to have the conversation.)
How can I be effective when Im so
nervous?
Can I be 100% honest and yet 100%
respectful?
Is this skill innate or can it be learned?
What are the steps involved?
Crucial Accountability: Getting Started
You need to hold a Crucial Accountability
Conversation but youre stuck. Whats
the issue and what sort of issue is it?
Unbundle it with CPR
Content
Pattern
Relationship
Crucial Accountability: CPR
Unbundle it with CPR
Content: A specific event or issue
Pattern: A set of ongoing events or issues
Relationship: A set of interactions between
two or more individuals affecting results
Crucial Accountability: Start with
Heart (Most Important Question)
What do you really want:
For you? For you?
For others?
For the relationship?
Crucial Accountability:
Start with Heart (Questions)
What are you acting like you really want?
What do you really want?
How would you behave if you really
t d thi ? wanted this?
What do you not want?
How should you go about getting what you
want and avoiding what you dont want?
Crucial Accountability:
Conversation Goals
Make it clear: Describe the gap between
what was expected and what happened.
Make it dialogue: the free flow of meaning
between two or more people between two or more people.
Make it safe for all parties.
Make it effective: Diagnose sources of
influence.
Make it last: Establish follow-up.
Crucial Accountability: Overview
Before:
During:
Work On Me First
Get Unstuck
Start with Heart
Master My Story
Silence
Safety
Learn to Look
After:
Violence
Safety
POOL OF
SHARED
MEANING
State My Path
Learn to Look
Make it Safe
Explore Others
Path
Move To Action
Who Does What By When; Follow-up
Diagnose Sources of Influence
Crucial Accountability: Key Steps
Start with heart: Focus on goals.
Master your story: Regardless of anger or fear.
State your path: Persuasion without abrasion.
Learn to look: Notice when safety is at risk.
Make it safe: Regardless of content. Clarify intent.
Explore others paths: Despite silence or violence.
Diagnose: Discuss the six sources of influence.
Move to action: Turn dialogue into results.
Crucial Accountability: Master
your Stories (Path to Action)
SEE AND TELL A SEE AND
HEAR
TELL A
STORY
FEEL ACT
Crucial Accountability: Master
your Stories (Path to Action)
See and Hear: A factual event or events.
Tell a Story: How you interpret the event(s). y y p ( )
Feel: How you feel about your interpretation.
Act: How you act on your feelings.
Crucial Accountability: Master
your Stories (Skills)
Retrace your path to action.
Separate fact from story.
Watch for three clever stories:
villain, victim, or helpless stories.
Tell the rest of the story.
Crucial Accountability: Master
your Stories (Three Clever Stories)
Victim stories: Its not my fault. My motives
are pure.
Villain stories: Its his or her fault. Their
motives are indefensible motives are indefensible.
Helpless stories: Theres nothing I can do.
Its his or her fault. I have only the Fools
Choice, stay silent and suffer, or speak out
and ruin the relationship, be punished, etc.
Crucial Accountability: Master
your Stories (Sellouts)
Clever stories lead to sellouts
Sellouts: conscious actions against your
own best interest:
Y b li h ld l i b t d t You believe you should apologize, but dont.
You see a problem and dont speak up.
Tell yourself useful stories instead, theyre
closer to accurate, complete, the rest of
the story.
Crucial Accountability: Useful
Stories
What is my story? Is it a useful story?
What am I pretending not to know about my
role in the problem? role in the problem?
Why would a reasonable, rational, decent
other person do this? (Imagine the best of
others, start with benefit of the doubt.)
What should I do right now to move toward
what I really want?
Crucial Accountability: You have a
Tough Message; To Be Honest and
Maintain Safety: State your Path
Share your facts re the gap
Tell your story Tell your story
Ask for others paths
Talk tentatively
Encourage testing
(Always end with a question)
Crucial Accountability: You have a Tough
Message; To Be Honest and Maintain Safety:
State your Path
Share your facts re the gap
I noticedTwice you
Tell your story
It seems to me; I wonder if
Ask for others paths
How do you see it?; Help me understand
Talk tentatively
Avoid absolutes. Own your story.
Encourage testing (Always end with a question)
Do you see it differently?What am I missing?
Crucial Accountability: State
your Path ( Key Questions)
Am I really open to others views?
Am I talking about the most important issue?
Am I confidently expressing my own views?
Crucial Accountability: Overview
Before:
During:
Work On Me First
Get Unstuck
Start with Heart
Master My Story
Silence
Safety
Learn to Look
After:
Violence
Safety
POOL OF
SHARED
MEANING
State My Path
Learn to Look
Make it Safe
Explore Others
Path
Move To Action
Who Does What By When; Follow-up
Diagnose Sources of Influence
Crucial Accountability: Learn to Look for
Safety (or Lack of It)
Look for when the conversation becomes
critical (i.e., hostile, tense, one-sided.)
Look for safety problems.
Look for signs of stress.
Crucial Accountability: Learn to
Look for Lack of Safety
Am I withdrawing or attacking (silence or
violence?) violence?)
Are others either withdrawing or attacking?
Crucial Accountability: Make it
Safe
People get defensive when they feel unsafe.
People rarely get defensive about what it is
youre saying (Content ) youre saying (Content.)
If people are defensive, its usually about
why they think youre saying it (Intent.)
Crucial Accountability: Make it
Safe
Clarify intent by building mutual purpose
and mutual respect.
Mutual Purpose: You believe I care about Mutual Purpose: You believe I care about
your goals and vice versa.
Mutual Respect: You believe I care about
you as a person and vice versa.
Crucial Accountability: Make it
Safe
Apologize Contrast
Clear Problem Misunderstanding
Mutual
Respect
Create Mutual
Purpose
Contrast
Respect
Mutual
Purpose
Crucial Accountability: Make it
Safe
Apologize when appropriate.
Contrast to fix misunderstandings.
Crucial Accountability: Make it Safe
(Contrasting to Fix Misunderstandings)
Start with what you dont intend or mean.
I dont think/mean/want to
(Try to avoid but in between.)
Then explain what you do intend or mean
What I do think/mean/want to is
Crucial Accountability: When Others are
Silent or Violent, Explore their Paths with
AMPP
Ask: To get things started.
Id like to hear you opinion on this.
Mirror: To confirm feelings.
You say youre OK but you seemupset You say youre OK, but you seem upset.
Paraphrase: To acknowledge their story.
Lets see if Ive got this right
Prime: If youre getting nowhere.
Let me guess, you thinking (feeling)
(Now youre ready for a discussion about
motivation and ability)
Crucial Accountability: Overview
Before:
During:
Work On Me First
Get Unstuck
Start with Heart
Master My Story
Silence
Safety
Learn to Look
After:
Violence
Safety
POOL OF
SHARED
MEANING
State My Path
Learn to Look
Make it Safe
Explore Others
Path
Move To Action
Who Does What By When; Follow-up
Diagnose Sources of Influence
Crucial Accountability
People change their behavior when
theyre both motivated and able to do theyre both motivated and able to do
so.
J oseph Grenny, in Crucial Accountability, 2013.
Crucial Accountability: Six Sources of
Influence
Motivation Ability
Personal
1 2
Social
Structural
1
3
5
2
4
6
Make it
Motivating
Make it
Easy
Patterson, K et al. Crucial Accountability, 2013.
Crucial Accountability: Personal Motivation
Left by yourself, would you want to?
Do you hate or enjoy it ?
Do you find meaning in it ?
Does it fit with who you want to be ? Does it fit with who you want to be ?
Sounds like
I dont like
Thats not fun for me
Thats just who I am
Crucial Accountability: Personal Ability
Left by yourself, do you have the knowledge,
skills, and physical ability to ?
Sounds like
I t h i ll I cant physically
I dont know how
I keep trying, but I cant figure it out
Crucial Accountability: Social Motivation
Are other people (including me)
encouraging the right behavior or
discouraging the wrong behavior ?
Sounds like...
The boss told me to do this
Shes been praising this for months
Everyone is doing this
Crucial Accountability: Social Ability
Do others (including me) provide or
withhold the help, information, or
resources required at critical times ?
Sounds like
He didnt get me the material I needed
She didnt teach me the new system
I needed her approval, but she said no
Crucial Accountability: Structural Motivation
Are the non-human motivators (pay,
performance reviews, promotions, perks,
costs, etc.) encouraging the right behaviors or
discouraging the wrong behaviors? discouraging the wrong behaviors?
Sounds like
That wont affect my yearly review
Thats not what I get paid to do
Crucial Accountability: Structural Ability
Does the environment (equipment,
facilities, information, policies, proximity to
others, etc.) enable good behavior or bad?
Sounds like Sounds like
This ultrasound machine cant give me the
images I need
This policy gets in the way of good care
I struggle counseling patients with all this
noise
Crucial Accountability: Six Sources of
Influence
Limitations of Diagnosis
Causes can be complicated
M ti ti d bilit b li k d Motivation and ability can be linked
Responses may be ambiguous
Responses may be masked
Diagnosing can sound like excusing
Crucial Accountability: Six Sources of Influence
Removing Ability Barriers, Making it Easy
Start here; ability often fixes motivation
Clarify boundaries, constraints
Ask for ideas; empowers, motivates, likely to produce
the best suggestions
Dont
Play read my mind
Leap in with a suggestion
Discourage others suggestions
Worry about having to know everything
Feel the need to solve everything
Crucial Accountability: Six Sources of
Influence
Make it Motivating
Look for self-motivation
Avoidtrying to motivate with power (i.e.,
leading with imposed consequences) leading with imposed consequences)
Clarify natural consequences instead (i.e.;
make the invisible visible)
Consider all three motivational sources
(personal, social, structural)
Return to ability barriers as a final step
Crucial Accountability: Six Sources of
Influence
Motivation Ability
Personal
1 2
Social
Structural
1
3
5
2
4
6
Make it
Motivating
Make it
Easy
Patterson, K et al. Crucial Accountability, 2013.
Crucial Accountability: Moving to Action
The way you complete an accountability conversation is
as important as how you start it; if you swap your
backbone for a wishbone, you set yourself up for a whole
new set of problems.
J oseph Grenny p y
Those people blessed with the most talent dont
necessarily outperform everyone else. Its the people
with follow-through who excel.
Mary Kay Ash
Action is the foundational key to all success.
Pablo Picasso
Crucial Accountability: Move to
Action (Questions)
Who will do what by when?
How will we follow up? p
Check-up or check-back?
Do others need to be involved?
Lead
Manager (e.g., Practice Manager,
Managing Partner)
HR
Crucial Accountability
Conversations: The most important
personal characteristic for making
change happen is:
A illi t t i t i l A willingness to enter into crucial
accountability conversations and
an ability to make them
successful; i.e., to solve problems
and to build relationships
Crucial Accountability
Conversations: Start with the heart
Focus on what you really want.
For you, others, relationship
Refuse the Fools Choice
Speak up and make an enemy
or stay silent to preserve the
relationship.