Why It Matters
Unless we take action to protect and nurture civility, none of the other necessary changes we need to make to transform health care will take root.
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Civility Is Everyone’s Responsibility

By IHI Team | Monday, May 9, 2016

In his keynote presentation at the December 2015 IHI National Forum, Don Berwick, IHI President Emeritus and Senior Fellow, identified nine crucial steps that health care needs to take to get to a new, more efficient, more effective, and more person-centered era. Don called for ending excessive measurement, embracing transparency, abandoning complex incentives, and recommitting to improvement science.

He also spoke about civility, quoting Dr. Bob Waller, former CEO of the Mayo Health System and former IHI Board Chair: “Everything starts with civility.” I agree wholeheartedly. Unless we take action to protect and nurture civility, none of the other necessary changes will take root.

Don advocated for a new set of relationships in health care — relationships grounded in civility, with new ways to talk to and listen to each other. We need a new approach that both respects and leverages the advantages of our differences and diversity. We need a new approach that’s rooted in what health care is really about — caring and humanity.

Civility is by no means absent in health care. We see wonderful examples of it every day. But in those instances where we see a lack of civility, I sense a reluctance to talk about and address it. Far too often, uncivil behavior, sometimes shockingly uncivil behavior, is simply accepted as “the way things are around here” or as part of people’s “initiation” into a health care profession. This needs to change.

Some of this behavior is grounded in our traditions in health care — in the way we’ve trained people and what has become acceptable. It’s the job of leaders to stand up and say, “OK, that’s enough. We’ve gone too far with this.”

Start with Language

How we change can start with the language we use. For example, I don’t like the expression “the front line.” To me, this connotes a battle zone. Conflict is surely part of any job, and conflict can lead to new ideas and new solutions. But characterizing the setting for caring interactions between patients and providers — no matter how stressful and chaotic those interactions can be — as if it’s a war zone simply isn’t productive.

Creating and embedding a zero-tolerance policy for harassment and bullying is a good place to start, but ensuring civility is about more than just the absence of unacceptable and toxic behavior. There are subtler ways in which incivility has crept into health care.

I’m reminded of a story I heard at the opening of a person- and family-centered care collaborative in Scotland. A young woman — we’ll call her Mary — gave an account of overhearing her doctor, with whom she had a longstanding and positive relationship, refer to her as “the rheumatoid in the cubicle.” Courageously, she confronted her doctor and said, “My name is Mary. I’m not ‘the rheumatoid.’” Not everyone has Mary’s courage to speak up, nor should they need it.

These small but important changes in how we work and interact with those we serve, and those we serve with, can really make a difference. We won’t ensure civility in health care by chartering new projects; we need to start treating each other differently.

Why Civility Matters

At this point I imagine some of you are thinking, “C’mon Derek… with the scope and severity of the problems we’re facing in health care, isn’t civility a bit of a soft issue to focus on?” I don’t think so.

If you think so, ask a colleague who’s been on the wrong side of incivility whether this felt like a soft issue to them. A lack of civility exacerbates the stress and demands of already stressful and demanding professions. Incivility is contributing to burnout and driving talented and caring people out of the health professions. We certainly cannot achieve the kinds of improvements in care and health that we need if we continue to lose talented people.

There’s at least one person who agrees with me. US Surgeon General Dr. Vivek Murthy, speaking at IHI’s 17th Annual Summit in March, talked about the need to “cultivate the ability to give and receive kindness” to help people live healthier lives. This isn’t abstract rhetoric. There is evidence that kindness and empathy are therapeutic. Just as we need to reliably apply evidence-based medical interventions, we also need to reliably use kindness and empathy as tools for healing.

Ensuring civil and respectful relationships among colleagues is a key driver in IHI’s theory on how to restore and increase the joy of the health care workforce. If health care is characterized by civility, then we’ll have a workforce that’s much easier to engage in improvement. We’ll have people more engaged in the organization’s priorities and activities. And we’ll have more productive relationships with patients and families.

IHI seeks to improve a whole range of things in health and health care that require an environment characterized by civility, kindness, and joy. So, we are using our collective voice to build will for change around these issues, and using our improvement knowledge to test and refine real changes that can improve civility and restore joy.

Don’t Walk By

One change that everyone, everywhere can test and implement right away is what we call the discipline of “not walking by.” During my keynote at the IHI Summit, I shared this video of Australian Army Lieutenant General David Morrison speaking about his experience dealing with sexist and demeaning material circulated among his staff. General Morrison deserves credit for taking a forceful stand and making it clear to everyone in his command that such behavior would be punished.

But his more important message is for all of us. He says in the video, “The standard you walk past is the standard you set.” Deming taught us that “quality is everyone’s responsibility.” So, too, is civility.

If we see our colleagues and peers treating others —or being treated — without civility, it’s our duty to call that out. It’s our responsibility to raise that issue, and to comfort and support those who are on the receiving end.

I know this is difficult, perhaps especially in health care with its long tradition of hierarchy. That’s why it’s a crucial responsibility of leaders to not only deal with uncivil behavior, but also systems and cultures that strongly encourage everyone to “not walk by” when they witness such behavior.

This will take real courage — moral courage. And I’m confident that we have enough moral courage in our health professions. It’s up to us — all of us — to confront the issue of civility in health care. Without it, we’ll all fail.

Derek Feeley (@derekfeeleyIHI) is IHI President and CEO and expert faculty member on the IHI Leadership Alliance.


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Video (07:05) "Let Era 3 Be the Moral Era" - Don Berwick describes crucial steps needed to get to a new era in health care.

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