Small steps to tackle a big job

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How do you change an entire culture? Especially if it happens to involve 5,000 very busy healthcare employees spread out over multiple hospitals, outpatient facilities and support offices? Adventist Midwest Health did it by starting with simple, concrete actions that could be implemented and talked about by every employee.

Adventist had always been focused on quality clinical care for its patients. But commitment to great clinical care also had its drawbacks. Employees often seemed rushed and focused on their own duties, sometimes rarely even acknowledging one another in the hallways. Patients and their family members noticed this lack of communication and perceived it as a lack of caring and collaboration among the staff. This ultimately made patients question the level of care they were receiving.

To gain the trust of patients and their family members, Adventist realized it needed to be a friendlier place, one that demonstrated respectful communication to all patients, family members and staff.

Once the executives and employees at Adventist identified the culture they wanted — a friendly environment — the next step involved identifying the behaviors that people needed to demonstrate to create this environment. While some organizations may have attempted to change the culture with a vague mandate such as “be friendly,” Adventist realized it needed to break the concept down into simple concrete actions.

With the help of consultants from the Studer Group, Adventist leaders implemented a 10/5 Rule. They trained staff to make eye contact when approaching anyone in the hallway within 10 feet and to say hello at five feet.

The 10/5 Rule applied to approaching anyone — including patients, co-workers, and vendors. Suddenly everyone had a shared norm and a simple name for it. Employees could easily see whether their colleagues were observing the rule and they held each other accountable. For example, if a nurse was to brush by a lab technician in the hall without the eye contact or greeting, the tech might smile and say, “Hey . . . 10/5 rule!” While some employees acknowledge that it can be annoying to be “called on it” when they forget to say hello, the rule has helped to create a friendlier environment.

The 10/5 rule has become deeply embedded in Adventist’s culture. Within a month of implementing the rule, patients began to remark that “something is different around here,” and employees starting saying, “this feels like a better place to work.”

The 10/5 rule illustrates a number of important points about change and influence.

1. Make change concrete. Culture by its very nature is amorphous and abstract. Rather than attempting to change culture, successful leaders focus on changing critical, concrete behaviors. The authors of the book, Influencer found that in successful change efforts, leaders identify vital behaviors. Vital behaviors are the few key actions that lead to other changes. In this example, the vital behavior was looking up and acknowledging one another. While this one action didn’t change the culture, it did create a cascade of other changes.

2. Make messages “sticky.” In their book, Made to Stick, researchers (and brothers) Chip and Dan Heath argue that an idea needs to be “sticky” enough for people to first understand it and then communicate it to others in order for it to spread. Adventist’s 10/5 rule was sticky — it was simple, concrete, catchy, and memorable enough to spread.

3.Encourage shared accountability. Lastly, accountability was a key element in the success of this initiative. At Adventist, employees across the system were encouraged to remind each other of the 10/5 rule. Everyone in the network became mutually accountable for their own behavior and for reinforcing the rule.

Mack is a Woodland Park-based consultant, speaker and author specializing in leading and communicating change. She can be reached at