The Seven Commitments
Democracy and the Power of Agency
Nothing about you without you and you may get your say but not your way.
This might be the briefest way to describe the Sanctuary commitment of Democracy. You can delete this message and get on with your day, but if you want to know more about what Democracy looks like in an organization, read on.
Nothing about you, without you
(as often as possible)
Democracy in Sanctuary reminds us that we should be bringing the informed voice of all the stakeholders into the decision-making process in whatever ways are most appropriate for the group if a decision is going to be made about how a workflow is to be done, a change is to happen, basically anything that impacts more than the person making the decision. This can be challenging in health care where changes in requirements happen without forewarning, or a workflow change may need to be implemented before it can be brought to all stakeholders. However, as often as possible, a Sanctuary organization should make sure there is communication, time for processing and questions, and LOTS of teach-back, ensuring there is a common understanding among stakeholders about the action before them.
Democracy only really works when the members of the democracy are similarly informed. How could we vote for or against something if we do not share an understanding of what we are really talking about? Teach-back works well in patient care to accomplish exactly this, but organizations are terrible at promoting teach-back outside of the examination room. Does it take a few extra minutes? Yes. Does it save time down the road? Absolutely. I won’t speak for you, but I have had multiple experiences in my life where if people in a conversation had checked for understanding a lot of time and headaches could have been avoided. Teach-back is an essential tool to ensure all stakeholders are similarly informed and able to provide valuable input.
Now, does informed voicing of valuable input mean that we have to satisfy everyone, even when those voices conflict?
Get your say, not necessarily your way
It does not. That may feel deflating to some people who have been thinking that Sanctuary will magically remove the things they do not like. (Remember, Sanctuary is not intended to rescue you from your triangles!) Everywhere Sanctuary is implemented, it happens within the existing structure of the organization where it is being implemented. Sanctuary organizations still have a mission, are beholden to externally enforced requirements (HRSA, CMS, ACGME, and so on), and need to ensure financial sustainability to pay their employees and support their continued existence (billing, GME funding, grants). And, in the case of The Wright Center, that will always be driven by a desire for excellence in an industry that decidedly lacks it and sometimes actively fights it, particularly when it comes to many of the patient types served by FQHCs.
You are not totally wrong if you are thinking more democracy may lead to more conflict. More voice means more voices and people think differently about a lot of things. This is where it is key to keep in mind that the commitment of Democracy happens in concert with Nonviolence, Emotional Intelligence, and all the other commitments, as well as with all the other pieces of the model.
Let’s think through an example.
Let’s say I am toiling away during a fairly stressful week on several looming deadlines. My supervisor then tells me there is a big opportunity but it is due tomorrow. I’m stressed already so my first reaction may be less than professional. I may lash out and complain about all the stuff I’m already doing and the conversation could get heated pretty quickly. I may even say, “it isn’t very Sanctuary of you to do this to me,” and my supervisor may shoot back, “I have a lot of work to do, too, so just do it and shut up about it.”
In this one exchange, we have both violated Emotional Intelligence, Nonviolence, and Open Communication. My supervisor in this instance also violated Democracy. And I will have violated Social Responsibility if I then go and complain to my coworkers.
In the same scenario, but this time using the Sanctuary commitments. It is still a fairly stressful week for me and the deadlines still are looming. My supervisor tells me there is a big opportunity but it is due tomorrow. I still get a little heated internally because there is no cure for being human, but instead of lashing out, I breathe deeply and, with as much calm as I can muster, say something like, “How vital is this? Given my other deadlines right now, I’d really rather not take this on.” My supervisor, also a busy person, may feel irritated at this but they, too, check their emotions and say, “It really must get done. I’m sorry this is late notice and a rush.” I may then reach out to a colleague for some help or just work very late that day. My supervisor gives me an impression in the system. We both exercised Emotional Intelligence, Nonviolence, and Open Communication. My supervisor exercised Democracy by not shutting me down, and I exercised Social Responsibility by not complaining to others.
When we choose to work for an organization, we are choosing to abide by the structures of that organization. There is an excellent possibility that the exact perfect fit between what I might want and what an employer has does not really exist. Big tech builds campuses with restaurants and child care on site for staff convenience but also so employees do not really need to leave very often during the day. Some employers are moving to four-day work weeks, but the amount of work is not changing so that means doing more work in less time. The commitment of Democracy holds employer and employee accountable for a mutual understanding that sometimes, but not always, comes with a mutual agreement on change.
Exercising Democracy can be scary for both the supervisee and the supervisor. It is vital to make sure we are also using the other commitments when we do it. If you’re feeling frustrated about a persistent issue, take some time to get curious first and exercise Emotional Intelligence on yourself. Ask yourself what exactly about the issue is frustrating and get as granular as possible. You might discover that your irritation is not really related to the issue itself (after all, the health care industry in general can be very frustrating). You can take the precise nature of the issue to your supervisor and request a discussion if you can get granular about the problem, and ideally even think up some options for a solution. Doing that may reveal a new piece of information about why the thing needs to be the way it is, or it may spawn an even better way to get to the same outcome.
Using Democracy and Emotional Intelligence together will, if nothing else, increase the effectiveness of our organizational communication.
Meaghan P. Ruddy, Ph.D.
Senior Vice President
Academic Affairs, Enterprise Assessment and Advancement,
and Chief Research and Development Officer
The Wright Center for Graduate Medical Education