Study Guide for Joe Tye's book The Florence Prescription

2. By taking The Florence Challenge our organization is telling the world that we: 2

3. Aspire to a culture of ownership where people are committed to the values of the organization, are engaged in their work and with their coworkers, and take pride in their work and in their professions. 3

4. Encourage people to hold themselves responsible and accountable for their attitudes and actions, and to empower themselves to do the right thing for patients. 4

5. Expect a workplace environment that is free from finger- pointing, cynicism, gossip, compl aining, and other forms of toxic emotional negativity. 5

6. The Florence Challenge for a culture that is… Emotionally Positive Self Empowered Fully Engaged

7. As a participant in The Florence Challenge we are asking you to: 7

8. Read The Florence Prescription and think about how the 8 essential characteristics of a culture of ownership apply to your own work and life, and… 8

9. Take the seven simple promises of The Self-Empowerment Pledge to help you in your own life – personally, professionally, finan cially, and spiritually, and… 9

10. Refuse to participate in chronic complaining, gossiping, and other forms of toxic emotional negativity, and replace the words “Not my job” with “How can I help?” 10

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13. Are you willing to make the commitment? Are you ready to start? 13

14. Study Questions for Chapter 1 14

15. Is this true? You can‟t be cynical and negative sitting in the cafeteria or break room and then somehow flip an inner switch and become genuinely caring and compassionate when you walk into a patient‟s room. And patients see right through the fraud. The Florence Prescription 15

16. Is it possible to be cynical and negative at work and then flip an inner switch and become a genuinely nurturing and empowering parent and loving spouse at home? 16

17. If Carol Jean Hawtrey spent an hour sitting in the cafeteria of your hospital, what sorts of conversations would she be likely to hear? 17

18. “Who cares for the caregiver?” is an age-old question in healthcare. But if we don‟t care for each other – emotionally and spiritually – who will? 18

19. Is it important for people to know and embrace the values of the hospital they work for? Do you know and embrace the values of the hospital that you work for? 19

21. Do you agree with this? You can hold people accountable for showing up on time and for fulfilling the terms of their job descriptions, but you can‟t hold them accountable for being committed and engaged. You can‟t hold people accountable for caring. It takes a spirit of ownership for those things to happen. The Florence Prescription 21

22. Do you agree with Connie O‟Dell that negative attitudes increase the stress level in a hospital – and is the reverse true, that positive attitudes can reduce the stress level? 22

23. Florence Nightingale is surprised when she hears someone use the words “patient-centered care,” and asks what other kind of care there is. How dedicated is your hospital to putting patients in the center of the care matrix, and what more can be done to put patients first? 23

24. Carol Jean says that the “Invisible Architecture” is the soul of an organization. Can organizations have “a soul” in any meaningful sense? Does yours? How would you describe it? 24

25. Do you agree that accountability alone is not enough to make a great organization, that it takes a spirit of ownership? How would you define “accountability” and “ownership”? 25

26. Carol Jean describes eight essential characteristics of a culture of ownership: Commitment, Engagement, Passion, Initiat ive, Stewardship, Belonging, Fellowship and Pride. Are any of these superfluous, and has anything important been left out? 26

28. Does this make sense to you? Rules are of the left brain, values are of the right brain. When people don‟t share a common set of values you need to have lots of rules. The Florence Prescription 28

29. John Myerson described the “see-smile- greet-help” rule of Memorial Medical Center. How would your hospital be perceived by a new employee or a lost visitor? Is it important that the environment be friendly? 29

30. Carol Jean said, “When people don‟t share a common set of values, you need to have lots of rules.” Of course, as Myerson replied, you need both – but there is a continuum from rules-based to values- based. Where does your hospital fall on that continuum and what can be done to move it further toward the values-based end of the scale? 30

31. Myerson said that you cannot teach people values if they didn‟t learn them at home. Do you agree with him, or do you agree with Carol Jean who said that not only can values be taught, it‟s essential that they be taught if you want to be a great hospital? 31

32. Carol Jean said that core values define what the organization stands for and what it won‟t stand for. How clear are people at your hospital about the behavioral expectations created by your values (both stated and implicit)? 32

33. Little Timmy tells Myerson that he should give nurses a pay raise because he heard them complaining in the hallways. What are patients likely to overhear in your hospital (keeping in mind that they hear a lot more than you think they do)? 33

35. Do you agree? When patients overhear caregivers complaining and gossiping, it violates the integrity of the caregiver and shows a lack of respect for the patient, not to mention the person who‟s being complained or gossiped about. The Florence Prescription 35

36. Timmy Mallory fights cancer by slaying dragons in his imagination, and Myerson suggests a dragon-slaying area on the pediatric unit. How might a culture of ownership encourage people to come up with the sort of “crazy” ideas that can make a hospital special? 36

37. “Just because the doctors have given up hope doesn‟t mean there‟s no longer hope.” Read The Hope Diamond on the next slide, then discuss Florence‟s comment – both in the context of patient care and of navigating a stressful healthcare environment. 37

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39. Most hospitals have a vibrant rumor mill, but Florence states that gossip violates the integrity of the caregiver and shows lack of respect for the patient. How active is the rumor mill at your hospital, and what can individuals do to help eliminate gossip? 39

40. Culture is to the hospital what personality and character are to the individual. How would you define the culture (personality and character) of your hospital? Are you proud to be part of it? What would you change? 40

41. How wide is the gap between what the hospital says it expects of people (e.g. integrity, respect, initiative) and what it tolerates (e.g. gossip, complaining, passive- aggressive learned helplessness)? What can be done to close that gap? 41

42. “People would have a lot more time and energy for compassion if they spent less time and energy complaining and gossiping.” Do you agree with Florence? Or is “venting” and chatting about other people a necessary feature of a healthcare organization? 42

43. Especially in today‟s challenging healthcare environment, hospitals cannot afford to choose between compassion OR productivity – they need both. What ideas can you suggest for moving from what Jim Collins calls “the tyranny of OR” to “the genius of AND”? 43

45. Do you agree with this statement? The cornerstones of Integrity are honesty, reliability, humility and stewardship. If people are not committed to those behaviors, then integrity is just a word on the back of a name badge, not a core value The Florence Prescription 45

46. Think about the core values of your organization. Why do you think those specific ones were chosen? If you were made King or Queen for a day, what values would you have chosen? 46

47. Think about your own personal values. How well do they mesh with the statement of values of your organization? (If you haven‟t thought about your personal values, this would be a good time). 47

48. How can understanding the Values- Behavior-Outcome Continuum influence your personal life? For example, if your desired outcome is better health or financial independence, what are the required behaviors – and what core values would inspire you to take that action? 48

49. Discuss the 6-Es of Employee Engagement: Expect, Educate, Enable, Energize, Evaluate and Elevate How much of a role can management play in encouraging people to engage with their work and with their coworkers, and how much of it must come from within? 49

50. Florence Nightingale attributed her success to the fact that she “never gave or took an excuse.” What are some ways that you can counter finger-pointing, buck-passing, and blame game in your organization? 50

52. Do you find this provocative? Taking care of the sick should be a mission, not just a business. Being a healthcare professional should be a calling, not just a job. Our hospitals are at risk of losing their souls. The Florence Prescription 52

53. Long hours, changing shifts, and hard work are often facts of life in healthcare. No matter how tired or stressed we might be, our patients still deserve our best. How do we make sure that we give it to them? 53

54. In the cafeteria, Carol Jean asked Sarah what she would tell her CEO had he been sitting there with them. What would you tell your CEO if he or she were in the room with you right now? 54

55. If Florence Nightingale showed up right now (like she showed up in the MMC cafeteria when Carol Jean was talking to Sarah) what would you say to her? What do you think she would say to you? 55

56. Nightingale said that caring for the sick should be a mission and not just a business, and that being a healthcare professional should be a calling and not just a job. Still, hospitals and caregivers alike must pay the bills. How do we reconcile that tension? 56

57. Carol Jean tells Sarah that she‟s hiding behind a mask of negativity and cynicism because it hurts too much to care. Was she being fair? Do you ever feel that way? How can we support each other when it hurts too much, or we‟re too tired, to care? 57

58. As Sarah sat crying by Timmy‟s bedside, CEO John Myerson was standing in the doorway, also in tears, though Sarah could not see him. In what ways might this be a metaphor for the big picture of healthcare today? 58

60. Are you just renting a job? Any time someone says „not my job,‟ walks by a patient room where the call light is on, or does not stoop down to pick up a piece of paper on the floor, that person is renting a space on the organization chart, not taking ownership for the work itself. The Florence Prescription 60

61. Carol Jean says that corporate culture is the only sustainable source of competitive advantage for a hospital, and that “cultural blueprinting” is more important than designing buildings. Do you agree? Why or why not? 61

62. The culture of a hospital is really like a patchwork quilt made up of the cultures of individual areas. What is the culture like in the area where you work? What changes would you like to see in that culture? What actions could you and your coworkers take to bring those changes about? 62

63. Carol Jean distinguishes between management (a job description) and leadership (a life decision), and says that today‟s hospitals need leaders in every corner, not just the corner office. How encouraging is your hospital of informal leaders, and how much influence do they have? 63

64. Carol Jean uses the fact that no one changes the oil in a rental car as a metaphor for the “not my job” attitude of people who are just renting a space on the organization chart. What is the difference between “owning the work” and “renting the job”? Not my job! 64

65. Carol Jean tells a skeptical John Myerson that he should help people work on “soft skills” like self-image and self-esteem because a winning team is built around people who know how to think and act like winning players. Do you agree that leaders (formal and informal) should play this role? 65

67. How “real” is your picture? We can make everyone go through customer service training, and we can put billboards up on the highway telling everyone how caring and compassionate we are. But unless people change how they think and act, all we‟ll have is a pretty picture of an organization that exists only in our dreams... To make the picture real, people have to buy-in, to take ownership. That means they need to change their attitudes and their behaviors. They need to change the way they treat each other. The Florence Prescription 67

68. Dr. Charlie Franklin tells Carol Jean that he‟s skeptical about the latest “program of the month”. How does a hospital infuse new and innovative ideas and inspiration without falling into “flavor of the month” syndrome? 68

69. Carol Jean says that most hospitals are very hierarchical and status-conscious. How true is that of your hospital? 69

70. Put yourself in the shoes of Dr. Franklin when he suddenly finds himself as Carlos the housekeeper holding a mop at the main intersection of the hospital. How do you think you would be treated at your hospital? 70

71. Carlos the housekeeper is reprimanded by his supervisor for dancing with his mop in the corridor. Would he have been reprimanded at your hospital, or would the supervisor have joined him in the dance (at least metaphorically)? 71

72. Once he saw that the problem was real, Dr. Franklin embraced the challenge of chairing the hospital‟s new committee to promote simple dignity. If there were such a committee at your hospital, what would you want it to do? 72

73. Florence tells Carol Jean that whether it‟s the best of times or the worst of times depends upon what we choose to see, and that our perspective of today will shape our reality of tomorrow. What are some of the ways that healthcare today is in “the best of times”? best of times or worst of times?73

75. Have you given yourself that power? Empowerment isn‟t something that can be given; it‟s a choice that must be made. No one can empower you but you, and once you‟ve given yourself that power no one can take it away from you. The Florence Prescription 75

76. The nursing leadership retreat that Carol Jean planned with MMC‟s Chief Nursing Officer Linda Martinez was called “Empowering Caregivers.” What are the implications of empowering the caregivers for both patients and for caregivers? 76

77. “Proceed until Apprehended” is another way to saying “better to ask forgiveness than permission.” What are some of the ways that such a philosophy can improve hospital operations and enhance patient service, and what are some of the ways that this philosophy might be inappropriate? 77

78. Carol Jean describes the defining paradox of Florence Nightingale as follows: She was both a compassionate caregiver and a tough manager. How can we be compassionate without being weak and be tough without being hard-hearted? 78

79. “Empowerment is a choice. No one can empower you but you, and once you‟ve given yourself that power no one can take it away from you.” Do you agree or disagree with this statement? Why? 79

80. Florence says that we overrate the accuracy of our memories but underrate the power of our vision. How can collective memory sometimes hold us back, and how can a shared vision propel us forward? 80

82. Is it worth the effort? If we each do our part, we will change our lives for the better. If we all do our parts, we will change our organizations for the better. The Florence Prescription 82

83. How would you rate your organization on the empowerment scale, and how would you rate your own behavior? Do you think you‟d end up with the same “Lake Wobegon Effect” that Carol Jean found with the Memorial Medical Center nursing leadership team? 83

84. When Carol Jean introduced The Self- Empowerment Pledge at the nursing leadership retreat, some were immediately enthusiastic, some were renewed, and some clearly thought it was a waste of time. What would you think? What would be the distribution where you work? 84

85. Read the seven simple promises of The Self-Empowerment Pledge. If you made a good faith effort to live those promises, what would be the impact on your life – personally, professionally, financially, and spiritually? 85

86. If everyone in your work area made a good faith effort to act on those seven promises, would you do a better job of supporting each other and serving your patients and your community? Would it be a better place to work? 86

87. How much easier would it be for you to act upon the seven promises of The Self- Empowerment Pledge if the people in your work area were to take on the challenge as a group and support each other? 87

89. Is this a valid metaphor? Toxic emotional negativity is the spiritual equivalent of cigarette smoke in the air – as harmful to the soul as smoke is to the body. Just as we once eradicated toxic smoke from our hospital environments, it is now our obligation to eradicate toxic emotional negativity. The Florence Prescription 89

90. After Sarah left the break room where two nurses were passing a rumor about two coworkers having an affair, she felt “like some part of her soul had been spattered with mud.” What should someone do who overhears other people spreading rumors and passing gossip? 90

91. After the new nurse learns about the false and malicious rumors, she bursts into tears and runs out of the cafeteria. Timmy says that the way people are “always complaining about something or talking about someone” is the same as emotional cancer. Do you agree, or is that putting it too strongly? 91

92. When Timmy says hearing people complain and gossip makes him feel even worse than his cancer makes him feel, Florence calls it “iatrogenic toxic emotional negativity.” Since emotions are contagious, do we really make our patients even sicker with our bad attitudes? 92

93. Imagine yourself as Sarah when she had to listen to every negative conversation in the hospital all at once, and then the peace she felt when they all stopped. How much effort would it be worth to consistently achieve the latter state? 93

94. Carol Jean calls toxic emotional negativity “the spiritual equivalent of cigarette smoke”, and calls upon us to eradicate it in the way we once did smoking. People once thought a smoke-free society was not achievable. Can we dare to hope for a world that‟s free of toxic emotional negativity? 94

96. Do you agree that this is a management responsibility? One toxically negative person can drag down the morale and the productivity of an entire work unit. It is a core leadership responsibility to create a workplace environment where toxic emotional negativity is not tolerated. The Florence Prescription 96

97. What was your reaction to reading about members of the MMC Quality Improvement Leadership Team (QILT) reciting their mission statement aloud at the beginning of their meeting with Carol Jean? Did you think it was corny or did it strike you as kind of cool? 97

98. Do you agree with Carol Jean that caffeine is the drug of choice for people of genius? 98

99. Do you agree with Carol Jean‟s comment that “left brain” statistical quality and productivity tools are reaching a point of diminishing returns, and that future quantum leaps will be achieved by “right brain” qualities like enthusiasm, pride, passion and loyalty? 99

100. What has your hospital done, and what more can be done, to move from the fragmented and ultra-specialized system that treats patients as a collection of body parts, toward a more holistic “right brain” system that recognizes the inter- connection between body parts, and between body, mind, emotions, and spirit? 100

101. When the MMC Maintenance Department tried to “empower” people to perform routine chores like changing light bulbs, the project fell on its face. What went wrong and what should have been done differently? 101

102. Carol Jean points out that you can measure left brain qualities but you can‟t see them (what would ROI or the bottom line look like?) while right brain qualities can be seen but not measured. How would you meet her challenge to come up with new ways to assess the things that can be seen but not measured? 102

103. Carol Jean says it is not left-brain OR right-brain, but how to find the right balance or that continuum. Where does your hospital fall on the continuum and in which direction (if any) do you think it should move? 103

105. 638 readers of the Spark Plug newsletter respond to the 12 questions in The Culture Assessment Survey. Two questions particularly pertain to this chapter…

106. 46% agree or strongly agree; 54% unsure or disagree

107. Only 8% of respondents strongly agree that their coworkers reflect positive attitudes, treat others with respect, and refrain from the behaviors of toxic emotional negativity! Even worse >>>>>>>>

108. More than half of respondents either disagree with or are unsure whether their coworkers have positive attitudes, treat others with respect, and refrain from toxic emotional negativity!!!!!!!

109. Would our answer for this organization be better – or worse? Are we okay with that?

110. Responses from the current survey

111. 67% of respondents believe that more than 10% (or more!) of all paid hours where they work are wasted on toxic emotional negativity!!!

112. What is the cost of all that toxic emotional negativity on:  Productivity  Patient experience  Morale  Innovation

113. How much more productive would your organization be, how much more engaged would your people be, and how much better would your customer satisfaction be if…

114. All those many thousands of paid hours now being wasted on toxic emotional negativity could be transformed into a positive contribution?

115. Since culture doesn‟t change until people change (culture being the collective of their behaviors), what can you do to help your people change their attitudes and behaviors?

116. Sarah Rutledge challenged her colleagues to take The Pickle Pledge – should we? 116

117. How would we answer Sarah‟s questions:  How much better off would we be in our own lives if we were to take to heart The Pickle Pledge?  Would this be a better place to work and would we do a better job of caring for our patients if we all took to heart The Pickle Pledge? 117

118. What creative ideas can we come up with to promote The Pickle Challenge here? 118

120. Are you being treated like an owner and a partner, and if not what‟s missing? To foster a culture of ownership, you must treat people like owners and not just employees, like they are partners in the enterprise and not just hired hands doing the work. The Florence Prescription 120

121. Did you have any “first day on the job” experiences like the one Carol Jean had where her patient coded and died, the doctor called her a candy-striper, and the head nurse told her (calling her by the wrong name) to get over it? How can such experiences be prevented from being inflicted upon junior employees at your hospital? 121

122. Florence reminds Carol Jean that she has two ears and one mouth, and that this should guide her proportion of listening and talking. What is the listening culture at your hospital? 122

123. Standing outside of the room for her meeting with the union reps, Carol Jean was subconsciously imagining a gang of finger-popping Teamsters looking for an excuse to rough her up. How do the assumptions we make and the stereotypes we draw distort the reality of how we experience other people? 123

124. Shari Levenger complemented the CNO Linda Martinez for not putting up with slackers and for requiring people to do their work “and cut out all the pettiness.” Would Levenger make similar comments about operations at your hospital, and what recommendations would you anticipate that a consulting team might make in response? 124

125. If you were a consultant, what advice would you give to John Myerson for reducing we-they, management-staff differences and remind everyone that, as Bill Bristow put it: “We‟re all in this together.” 125

127. Do you agree with Sarah Rutledge? We need to see opportunities where others see barriers. We need to be cheerleaders when others are moaning doom-and-gloom. We need to face problems with contrarian toughness because it‟s in how we solve those problems that we differentiate ourselves from everyone else. The Florence Prescription 127

128. Sarah Rutledge did not let Timmy get by with using the word “try” (“do or do not – there is not try” she said, quoting Yoda). What are some of the words, phrases, similes and metaphors commonly used in your hospital that can create a disempowering environment? 128

129. Healthcare professionals are rarely lectured on their lack of mental toughness by 10-year old cancer patients. Did Sarah, speaking for Timmy, have it right when she said that we need to see opportunities where others see barriers and to face our problems with contrarian toughness? 129

130. Carol Jean told the story of how Tom Sawyer – who was accountable for white- washing the fence, coaxed friends who were not accountable to take ownership of the work – and actually have fun doing it. What is the lesson for us? 130

131. People with strongly negative and cynical attitudes often find themselves, metaphorically speaking, standing outside throwing rocks when they‟d be much more effective, and much happier, coming in from the cold to help with solutions. What barriers prevent this from happening and how can we bring those barriers down? 131

132. Other than Sarah, no one noticed our heroine Carol Jean crying on the patio; she was expected to put on a happy face and continue leading the retreat. We all carry hidden hurts. What are some of the ways that your hospital could help people cope with them? 132

134. Tough-loving leadership? Some people aren‟t going to buy in to a culture of ownership and a few will actively seek to sabotage the effort. Are you willing to raise your expectations, lower your tolerance level for deviation from those expectations, and perhaps lose some people who have good technical skills but a bad attitude? 134

135. What do you think of the suggestion made by CNO Linda Martinez that there be an organization-wide training initiative on values that would cover both the I-CARE values of MMC and help people crystallize and act upon their own person values? 135

136. Carol Jean asked why the hospital workplace can‟t be more like a support group environment, where at the end of the day people leave physically tired but emotionally uplifted. Would Dale Prokopchuk‟s suggestion of hospital-sponsored support groups help this happen? 136

137. What are some of the ways that we can encourage employees to share their strengths and talents at work, even if it‟s not part of their job description, like the nurse Carol Jean mentioned who loved poetry and wrote poems for her patients? 137

138. How would you answer the universal icebreaker question “What do you do?” in a way that conveys: I love what I do I‟m good at what I do I‟m proud of what I do What I do is important 138

139. Sarah Rutledge said that after she‟d started bringing a more positive attitude to work, some of her coworkers did not like the “new me.” How do we create an environment that neutralizes peer pressure to be negative and mediocre? 139

141. What do you take away as the ultimate meaning of The Florence Prescription? That was the ultimate meaning of the Florence Prescription… to foster a culture of ownership that honors victory of the spirit as much as it celebrates healing of the body. The Florence Prescription 141

142. Sarah Rutledge described the recovery of Timmy Mallory as a miracle. Do miracles really happen in hospitals? 142

143. Let‟s do a quick review: The 8 Essential Characteristics of a culture of ownership 143

144. 144

145. The Florence Commitment: Refuse to participate in toxic emotional negativity. Replace the words “Not my job” with “How can I help?” 145

146. 146

Study Guide for Joe Tye's book The Florence Prescription

Study Guide for Joe Tye's book The Florence Prescription

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Study Guide for Joe Tye's book The Florence Prescription