The Indispensable "5 C's" of Effective Communication in the Era of Obamacare

How to use the 5 C's to ensure effective communication in a time of turbulent change.

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With the turbulent passage of the Patient Protection and Affordable Care Act (or, Obamacare), the "brave new world" of healthcare officially arrived.

Sure, it took a while to sink in, and the early problems of the online healthcare exchanges temporarily obscured the new law's long-term impact. But as hospital CEOs, trustees, physicians and other caregivers across the nation can attest, the healthcare times they are a-changin' — permanently. To wit:

  • Federal reimbursements to hospitals for Medicare and Medicaid have been pared.
  • Hospitals are being penalized for rapid readmissions and being rewarded for keeping patients out.
  • Insurers are following suit, flexing their muscles and selecting hospitals and networks that favor "value" over "volume."
  • Consumers, meanwhile, are becoming more savvy about costs and choices among healthcare providers.
  • As a consequence, the traditional "fee-for-service" model is becoming a relic of the past, with smart hospitals and physicians shifting toward "outcomes" and "wellness."

The net impact of all this change has ushered in an epoch of hospitals plagued by a present of soft volumes and financial shortfalls, and a future of uncertainty.

No wonder more than half the country, according to the most recent Gallup poll, believes the U.S. healthcare system has "major problems," with 21 percent believing the system is "in crisis."

The indisputable fact is that trust in healthcare and those who deliver it has eroded.

And faced with such a perilous environment, there remains one inviolate need for those who run our nation's hospitals: The need to communicate. Indeed, communicating — with employees, community, government and the general public — has never been more critical for hospital leaders.

The harsh fact is that if you lead a hospital today and don't (or can't) engage your publics with honest and frequent communication, then you, and the institution you represent, are at a clear disadvantage.

Specifically, what we've learned in more than 100 engagements, at hospitals ranging from 90-bed nonprofit community facilities to 3,000-bed systems, is that there are five indispensable C's of effective communication:  

  • Calculated
  • Candid
  • Clear
  • Consistent
  • And when the news is especially bad, one more "C" comes into play: Contained

Every communication should have a calculated purpose for the organization. An all-hands memo is not meant to display your prose styling. The purpose of appearing at an employee forum or a business roundtable is not to showcase your speaking skills.

The operative question is "Why"  Why send out that memo, why appear at that event, why run that advertisement?

Stated another way, every communication — every one — must have a calculated, tactical purpose. Or else, why send it or present it? Calculating the purpose of communication is simply good management — a thoughtful assessment of time and resources.

And that "calculation" must begin inside the institution, communicating with your own employees, keeping them informed of what's going on and why you're doing what you're doing.

"Without credible communication, and a lot of it, employee hearts and minds are never captured," writes famed Harvard professor John Kotter in his book "Leading Change."

We'll go one step further. It's virtually impossible to change how people outside view the hospital, if the people inside don't believe the story.

When we arrived at a small East Coast community hospital that was suffering from soft volumes and hemorrhaging finances, we found a CEO willing to bite the bullet and let the employees know how dire the situation was and how he intended to turn things around. A primary part of that turnaround was monthly signed letter from the CEO, included both online and in monthly pay envelopes; it discussed why belt-tightening, reduced benefits and even layoffs were obligatory for survival.

The employees winced at the prescription, but they appreciated being treated as adults. The impetus for that hospital's turnaround proved to be the calculation that all hands would contribute once they knew the facts.

Too many healthcare managers pay lip service to candor and honesty. Too often they dissemble, obfuscate and pull their punches.

They seem to fear, as Jack Nicholson raged in the movie "A Few Good Men," that folks "can't handle the truth."

Such trepidation is foolish.  You cannot hope to build credibility by dodging the facts or sugar-coating the truth or avoiding that most dreaded of all hospital constituent groups — the media.

When a large West Coast public hospital suffered significant losses, it not only brought in new executive and financial management, it reconsidered its approach toward communicating with the public.

Under its prior management, the hospital rarely volunteered much at its monthly public meetings. Local media — assigned to gauge how the taxpayers' money was being used — regularly objected to the hospital's opaqueness. Relationships between reporters and the CEO were non-existent. As a consequence, when the hospital suffered financial shortfalls, the media weren't particularly sympathetic.

Successor management devised an ingenious new media strategy — candor.

The new CEO arranged periodic meeting with local reporters to discuss the hospital's plans and goals. Over time, news coverage became more understanding, and editorial coverage more supportive.

Elected supervisors, in charge of the hospital, learned that their constituents were far better served by a candid and straightforward hospital management than one reluctant to share its challenges with the taxpayers who subsidized it.

"We utilized a concert of cross-functional expertise in planning the new Surgi-Center."  (In other words, people from different departments talked to each other.) "Your job, for the time being, has been designated as retained." (In other words, you're not fired, yet.)

This is not communication. It's gibberish. It's mumbo jumbo. And mumbo jumbo can be hazardous to your organization's health.

Plain, simple language can even save lives. A survey at two public hospitals found that more than four in 10 respondents were unable to understand directions for taking medicine on an empty stomach. Six in 10 could not understand a document that gives informed consent.

An estimated one-quarter of U.S. adults are functionally illiterate, according to one government study. And yet we churn out enrollment forms and patient literature and medicine instructions of astounding complexity.  

We once visited a Southwest hospital that claimed to have streamlined and simplified all its patient forms. So we asked to see the new and improved informed consent form. Here is just one paragraph, verbatim:

"Item #3. I consent to the performance of operations and procedures in addition to or different from those now contemplated whether or not arising from presently unforeseen conditions, which the above-named practitioner or his associates or assistants may consider necessary or advisable in the course of the procedure."

Imagine for a moment, that you are the one being asked to sign the form. It's a stressful situation. Do you understand what you are reading? Is your consent informed?

In a letter to a young friend, Mark Twain wrote: "I notice that you use plain, simple language, short words, and brief sentences  That is the way to write English. It is the modern way and the best way. Stick to it."

Good writing — and good speaking, for that matter — cannot be confusing. It should be clear and understandable, and the shorter the better.

Equally important, once you dictate direction, stick to it. Don't switch signals in midstream.

A new CEO began his new job facing multiple issues: widespread staff discontent over a large salary increase for senior management, slumping ratings on an independent medical staff satisfaction survey, and rumblings of union organizing. He immediately began an all-hands weekly newsletter that promised straight talk about the health system's situation, its challenges, its plans and its successes.

That was 2007. Six years and more than 375 issues later, his newsletter is still going strong, and its electronic distribution has spread to hundreds of opinion-leaders throughout the community.

Newsletter topics have ranged from improving access to improving the patient experience, from IT advances to national awards, from pay and benefit adjustments to new service lines. Since the arrival of the PPACA, topics have included population health, reductions in reimbursement, new means of measuring quality, and promoting and rewarding accountability.

The point is that once you've begun to communicate, keep it up. An offer to the local media for a "state of the hospital" review should be an annual offer. Once you begin posting your Form 990s on the hospital website, you're committed to doing so forever.  

On again/off again communications undercut management's commitment to keeping people informed. Programs that start out with promises of candor, then quickly pull their punches, paint you as shallow and opportunistic.

Bad things do happen to good hospitals.  

  • A flash drive with personal data on 20,000 patients goes missing.
  • The medical staff issues a unanimous vote of "no confidence" in the CEO — the second time in an 18-month period.
  • A thriving hospital in an affluent suburb is rocked by a suspicious death after surgery. An emergency internal audit reveals that post-op nurses might have misread physician instructions for an IV drip.
  • A once-respected surgeon is dismissed after surfing X-rated websites on hospital computers, in plain view of co-workers. He also admits to intentionally miscoding billing codes for patient services, and is soon after arrested (along with his teenaged daughter) for shoplifting.

We've seen 'em all.

A negative event is bad enough. Don’t make matters worse by ignoring or denying the problem, or by dribbling out the bad news. The best way to contain a negative story: Tell it all, and tell it fast. It's better to be the source of bad news rather than the victim of it.

This is perhaps the toughest advice for hospital CEOs to accept. Nobody — especially CEOs — like to admit failures or mistakes. But confession is not only good for the soul; it makes great sense when you’re trying to contain bad news.

When a multi-hospital healthcare network in the Southeast confronted a reduction-in-force of more than 300 individuals, management at first balked at the idea of delivering all the facts to the media. "Why not stress the positives in terms of improved service through increased efficiencies and downplaying the layoffs?" the CEO asked.  

The answer, of course, is that to the media, layoffs are "news." And any attempt to bury the fact that local employees would lose jobs would only serve to infuriate the reporter assigned the story.

Instead, management provided the numbers in the context of percentage of systemwide employees let go — less than 2 percent. And the CEO, after expressing sadness at the layoffs, emphasized their necessity in terms of increased efficiency and better patient service.

In the end, the local media appreciated the candor, and the healthcare network successfully conveyed the rationale for the reductions.

The goal of "containing" is to try to make it a one-day story, not a multi-day battering.  You do that by quickly marshalling the facts, getting out ahead of the story and telling your side in plain English.

Again, it all comes down to communication that is calculated, candid, clear, consistent and, when necessary, contained.

In the Age of Obamacare, there is simply no other alternative.

Steve Rivkin and Fraser Seitel are partners in Rivkin & Associates LLC, a management and communications consulting firm that specializes in crisis counseling for healthcare institutions. They have handled assignments for more than 100 hospitals and healthcare systems.

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