How Twitter can help engage staff by increasing transparency & trust

If you're playing Buzz Word Bingo in the healthcare at the moment then you will know that "Engagement" is a hot word. Nothing new there you say, it's been a consistent buzz word for the last 10 years at least.

Well, there's something new on the horizon. It's a bit scary, you may not like it and it seems to be one way to practically engage some staff. More than that it moves from a passive engagement to an interactive process, which through its transparency leads to increased trust.

Let me explain using a very current example. It is 22nd March 2010 and British Airways is on day 3 of a strike, with another series of strike days looming. It's a mess really, for all involved. As with many crises it's interesting to learn from how companies and individuals manage them to best effect.

I've been following @British_Airways on Twitter. The updates are immediate and a complement to the less frequent and more formal announcements on their website. When I start seeing a string of complaints - or compliments - on Twitter I get a sense of what is going on. I have no idea how many people they have handling the Twitter stream (probably only 1 - if so they need a prize for multitasking while keeping their head about them..). More important than the pattern on Twitter is the manner in which cries of despair, shrieks of delight, moans and queries are being handled. All in public and all is transparent for us all to see. When it gets to personal details they request a DM (direct message). As long as the nice BA person at the end of the Twitter Stream keeps calm I will keep calm. And I'm starting to trust they really will get me to my next destination.

Some hints and tips for using Twitter to engage with staff and customers, especially in a crisis
1) Ensure your Twitter stream is managed by a human and not a computer. Endless feeds of your website will not engage me and will most likely reduce my trust in you.

2) The 3 R's of Regret, Reason and Remedy go down very well. A 140 character Regret is enough of an apology. A quick Reason helps me understand the issue and I then know you also understand what I mean. Then a masterful 140 character or less Remedy will make my day. I don't need 3 page letters within which we all lose the point.

3) Be open. Speaking up in front of the crowd means you need to stick with your tone of voice and content of your speeches. If I know most fo the talk is going on where I can hear it then I will be more trusting. An advantage of the Twitter feed is I can scroll back quite a few days ago to see how the conversation has been going.

4) Allow me to discover people like me. Although the official stuff is importnat, I also like to engage with people like myself. I need to be able to do this without you controlling the place, person and pace./ On Twitter I can see who else is having a problem like me and can contact them to see if they, for example, discovered any easy solution.

If products, ideas and results are not spreading and being adopted then maybe you need to do an ethics check

The most frequent issue people contact me about is "my project results or project methods are not spreading to other places / are not being adopted by other people". A key reframing here is to ask the question "Why isn't my xxx being spread and adopted?". This is the first step in figuring out the problem - and solution.

I wrote a book a few years ago that faced this issue and provided some ideas to get round it. One topic not covered in detail in the book though one I have since reflected on is that of ethics.

House (1980) provides a list of ethical mistakes which include:

Clientism; this is when we are so focused, as facilitators, project managers and consultants, that we do what the client wants rather than a deeper investigation into what problem needs to be solved. This is prevalent in healthcare where there are multiple clients or where facilitators are unable to take the difficult discussions and fall back on making their clients happy. Any consultant can make their client happy - can they help their client solve identified problems, even if it means walking away or referring on if they are not the best person to help? Projects which have been implemented to serve one specific client are unlikely to be adopted by others as they instinctively feel the solution does not meet their own need.

Methodologicalism; assuming that following a ethnically correct method is the same as being ethical. This is an interesting issue for the spread and adoption of guidelines. Different professionals may have alternative interpretation of the ethics are different parts of the guidelines. This conflict results in the oft heard "this won't work here" or "this won't work for my patient". On solution is to discuss and be transparent about the ethical paradoxes involved.

Elitism; giving the most powerful the strongest voice. This is a concern for the development of solutions and introduction of change methods. The most powerful and loudest voice may not be the most connected to the context in which they are requiring change. Potential adopters may instinctively push back against what they perceive are "loud voices". Or they may try to make the changes to keep the "loud voices" at bay and only partially gain the benefits. This issue is also linked to the concept of "inventoritis" which was the subject of an earlier post.

To what extent are your spread and adoption issues linked to ethical dilemmas?

Airlines & Healthcare; what can we learn

We consider airlines safe so in healthcare we adopt some (and only some) of the techniques they use to be safe - like checklists used by pilots and engineers. I say @some@ because we often forgot some of the more basic and fundamental safety aspects employed by arilines - the often more complex human resources, financial aspects, organisational learning, training etc.

Putting safety aside I read the report by the USA Bureau of Transportation on the statistics for 2009. In 2009 of the 19 airlines who reported they had an average on-time arrival performance of 79.5%. Hmmm. What I like about this figure is it represents the complexity of different airlines, operating in different ways, to different airports - and all affected in some way by the things out of their control, like the weather. This sounds to me like the healthcare system - in public sector systems anyway. So the airline travel system in 2009 was designed for 1 late arrival in every 5 flights. This makes me feel a lot better about the flow of patients around the National Health Service in England. A way higher percentage experiences experiences on time care. I also feel that the NHS is able to work well in a crisis like bad weather.

Ever lost your baggage? Well in the USA in 2009 3.91 bags were mishandled (isn't that a lovely term!) in every 1000 handled. This was an improvement from the 5.26 in 2008 - well done. As rates go these mishandlings are very few. Of course, if it is your bag lost, then the amount of year on year improvement and the overall rate is of no interest. A failure is a failure. This reminds me of the way most healthcare projects adopt goals that are less than perfect. For instance, 95% of patients to be treated xxx. What this tells me is that the improvement project team and the organisation are opting to design for a certain amount of failure. And I am not sure I am happy with this. Mistakes I can forgive. Designed in failure rate, often large ones, are to me a sign of lack of confidence in the people and processes. And as a patient I am less confident being treated there.

We have a great deal to learn about and adopt from other sectors as part of improving healthcare. What have you adopted from another industry and how has it worked for you?

To share or not to share?

I've spotted a proliferation of new initiatives within the NHS in England attempting to encourage staff to share their knowledge online. While this sounds like a useful and pragmatic action to take I wonder what the implications might be.

The main exhortation is about encouraging staff to share what has worked well for them. I expect there will be many who would like to share, though inputting your information into a fairly anonymous database is at the higher end of the perceived risk continuum. Without knowing who (as in a person) will be editing or reading the information, many people will be hesitant to "share" in this way.

The proliferation of different places to share is also confusing. In their own way, each organisation requesting sharing is doing so for the right reasons. However, how do you choose - NHS Networks, NHS Institute, NICE, own organisation's database... random sharing with colleagues using other online networks, professional groups?? Each organisation requesting sharing is doing so for it's own reasons and these reasons may not be easily identifiable by those who are targetted.

For some healthcare staff and their organisations the incentive to share may feel like a perverse one. In a competitive market there may be a disincentive to provide information about how well or how innovative you have been. In my experience the best results are seldom shared because of this restriction. So what we do get shared is often the less innovative and more obvious results of projects and changes.

I think the issue is not "to share or not to share". Sharing is only part of the story. Sharing is only of value if there is someone listening and looking. If the main group looking at what is shared is the group who owns the database then the value of what is shared is quite limited. The real issue is in encouraging staff to look and listen, to be curious and to accept that in just about everything thing they do and every problem they have, someone, somewhere has already addressed it - and this information is already available.

So if you're developing databases to captured shared information then a few pointers to consider:
a) how much of your time, budget and strategy is devoted to encouraging the look and listen?
b) how unique is your database? How will it be found and why should those who are searching use your database?
c) In what way can you build on or link to existing databases so you build a wider knowledge base rather than divide up a crowed space?
d) How can you move from the transactional share and disseminate approach to one which is based on the concept of interaction, dialogue and learning?

Large Scale what? Change, outcome, implementation or impact?

I prefer the phrase "large scale outcome" or "Large scale implementation" to the more generic "large scale change". Why? When the words outcome and implementation are included it feels more active, more directive, more specific.

For example, it is possible to have a large scale change that is not resulting in the outcomes you set out to achieve. A huge amount of change can happen and yet only a small scale impact is achieved.

Equally it is possible to have a large scale impact from a a small change that might affect only a small scale (numbers and geography). Using Pareto analysis can provide organisations with hints on where to leverage the smaller changes for the bigger impacts.

By focusing on impacts, by elevating the results we want, we can design organisation and system interventions to deliver targeted outcomes. In my experience, many groups who talk of large scale change are ending up creating busy-work that is not specifically directed at delivering a large scale outcome. For me change does not equal outcome or impact.

I'm reminded of a quote from Thoreau which runs along the lines of "It is not enough to be industrious; what are you industrious about?"