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Appreciative Inquiry PrinciplesAsk “What Went Well” to Foster Positive Organizational Culture

Learning Objectives
1. Evaluate current strengths, assets and values of the practice, department or organization
2. Construct a “discovery team” to elicit positive stories and themes from the organization
3. Incorporate appreciative inquiry into daily work and existing performance improvement initiatives
0.5 Credit CME
How Will This Module Help Me?

  1. Describes 5 STEPS for building and maintaining a positive organizational culture.

  2. Answers frequently asked questions about appreciative inquiry.

  3. Provides tools and resources to help your team effectively use appreciative inquiry.

Introduction

Quiz Ref IDAppreciative inquiry is an approach to management that identifies and builds on what already works well in an organization to foster positive change. Developed at Case Western University in the 1980s, appreciative inquiry uses “unconditional positive” questions to identify what is best in an organization.1 Asking questions such as, “What was a recent successful team project,” or “What made the team so successful,” or “Have you noticed a colleague go beyond the call of duty recently? What happened?” orients team members to build on the positive and create a shared vision going forward.

Focusing on what's wrong in an organization, such as a clinical practice or department, can lead to exclusive attention to problems and create a negative atmosphere, whereas taking the time to focus on the positives can help individuals recognize what gives life, vitality, and joy to the practice. Fostering the best in one another begins with noticing what is being done well. For example, providing recognition for a job well done has been shown to significantly lower physician burnout scores and result in other positive organizational results.2

Five STEPS to Improve Your Organizational Culture Using Appreciative Inquiry

  1. Build a Guiding Coalition.

  2. Form a “Discovery Team.”

  3. Share Positive Stories.

  4. Incorporate Appreciative Inquiry Into Daily Work.

  5. Link Appreciative Inquiry to Existing Performance Improvement Initiatives.

Step 1 Build a Guiding Coalition.

Sustainable culture change requires leadership. It can be very challenging to “unfreeze” staff from the status quo. The shift to a more positive, productive work experience demands the engagement of leaders who are skilled in non-traditional competencies, such as emotional intelligence, team building, and appreciative inquiry.

To build a coalition of leaders to guide culture change, it is helpful to identify individuals who are dissatisfied with the current workplace atmosphere and who are ready to participate in disruptive innovation.3 These individuals can be physicians or other health care professionals who are curious and ready to embrace change.

The benefits of appreciative inquire include:

  • Quiz Ref IDAppreciative inquiry fosters a sense of optimism, and people tend to work best when they are feeling optimistic.1

  • It encourages collaboration, which engages and helps teams focus on the meaning of their work and inspiring members to do their best.

  • This technique also facilitates storytelling, which engages emotions and inspires collaboration and confidence.

Step 2 Form a “Discovery Team.”

Quiz Ref IDIt is important to begin appreciative inquiry by gaining a sense of the strengths, assets, and values of the practice, department, or organization. Appreciative interviewing, a discovery process that builds on appreciative inquiry principles, can be used to uncover themes and values from across the organization. This process can help team members understand how they interact and connect with one another and what they can accomplish when they are at their best.4

One way to begin the discovery process is to form a discovery team, a small representative group within your larger organization or practice that can use appreciative interviews to inform change within the organization.

Box Section Ref ID

Q&A

  • Who should be on the discovery team?

    Consider including representatives from all aspects of your practice or department: medical assistants (MAs), nurses, physicians, administrative and frontline staff, and maintenance staff.

  • How many people should serve on the discovery team?

    A practice or department with 25 employees might want 5 people on the discovery team. For larger organizations, consider creating a discovery team for each pod or department.

  • What can the discovery team do?

    The team can use an interview script and capture responses with any recording or note-taking method. Leaders need to communicate the guidelines regarding anonymity to both the members of the discovery team and potential interviewees. While the primary goal of an appreciative interview is to identify the positive aspects of a practice or organization, it is important that the interviewee feels safe enough to speak with anonymity about any challenging aspects of his or her work.

Step 3 Share Positive Stories.

Introduce appreciative inquiry on a small scale by including an appreciative check-in or debrief in your staff meetings. Using these tools in meetings will familiarize your team with the concept of appreciative inquiry through experiential learning.

To use appreciative check-in, before beginning your meeting's stated agenda, pose a positively focused question to the team and allow each team member to respond. Possible questions include:

  • “What is something that went well for you today?”

  • “What is a recent positive experience in your work or personal life?”

  • “How would you fill in the blanks? I am feeling _____ today, because ____.”

To use appreciative debrief, reserve a few minutes at the end of the meeting to identify positive aspects of the meeting and opportunities for improvement. Ask the team to answer questions such as:

  • “What was a positive experience you had in the meeting today?”

  • “What did we do well in the meeting?”

  • “What was the most productive part of this meeting that we can continue in future meetings?”

You might also consider hosting a “town hall” meeting to share positive stories. Spreading positive stories within your team or unit is an important component in improving its culture. Hosting a town hall meeting on a regular basis can bring your team together to focus on recent successful experiences. At a town hall meeting, the interviewer or interviewees from an appreciative inquiry exercise can share their positive stories (de-identified, if desired) with the entire team. Include “open mic” time in the meeting, when participants can speak or be interviewed in front of their team.

A variety of other communication channels can be used to share positive stories and help the practice become a narrative organization. The inclusion of positive stories supports culture change. Identify ways to include storytelling in your internal communications; for example, you can post positive vignettes and inspirational quotations from patients and team members in newsletters, company-wide emails, on your intranet, and on physical message boards in your office or clinic. For example, Indiana University School of Medicine sends an electronic newsletter weekly to the entire medical community that includes reflections of faculty and medical students, poetry, and information about related workshops, conferences, and awards.

Using these methods can shift the focus and atmosphere of meetings and help your team experience the benefits of appreciative inquiry. They can be especially helpful at garnering enthusiasm for required early-morning meetings.

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Q&A

Step 4 Incorporate Appreciative Inquiry Into Daily Work.

Once members of your practice or department have gained some experience with appreciative inquiry, it is important to embed this approach into the daily work of your organization. Embedding appreciative inquiry principles can take several forms. The essential element of these activities is identifying and highlighting mutual values and positive experiences.

Quiz Ref IDAppreciative inquiry activities might include:

  • Appreciative check-ins: asking an appreciative question at the start of a meeting.

  • Introductions: asking people to respond to an appreciative question.

  • Shout-outs: asking team members to share something positive that they observed recently about another team member's actions or performance.

  • Appreciative de-briefs: asking an appreciative question relating to the strengths of a meeting.

  • Clinical interactions: using appreciative questions with patients.

  • Assuming positive intent.

  • Transforming an obstacle into an opportunity.

  • Finding the value behind a complaint.

Events at which appreciative inquiry can be used include:

  • Daily huddles.

  • Staff meetings.

  • Leadership meetings.

  • Performance improvement team meetings.

  • Other team meetings.

  • Performance evaluations.

  • Interactions with patients and family members.

  • Practice or administrative rounds.

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Q&A

Step 5 Link Appreciative Inquiry to Existing Performance Improvement Initiatives.

It is important to look for existing skills and strengths within a group to fuel positive change.8 For example, if your organization already uses Plan-Do-Study-Act (PDSA) cycles, you might start by inviting team members to write brief (1- to 2-page) proposals outlining the question or challenge that the PDSA cycle could address, the way(s) in which appreciative inquiry could affect the desired outcome, the appreciative inquiry methods to use, and plans for using the results within the cycle. Members of the discovery team can act as a selection committee for these proposals. For example, a practice might use appreciative inquiry within the daily team huddle to test ways to optimize the care of each patient to be seen that day and identify time slots for same-day appointments. By using this technique, the practice can build on its strengths and work collaboratively to identify the most effective scheduling process for the group, ultimately improving care coordination, reducing wait times, and increasing access.

Box Section Ref ID

Q&A

  • Our performance improvement projects are managed by a specialized department. How should we link to their projects, and why?

    It is often helpful to meet with the current leaders of improvement projects that are managed by a specialized department (e.g., Quality Improvement). You can explain that appreciative inquiry is a set of practices that support the overarching business goal of improving organizational culture and the quality of work life. Provide some examples of the successful use of this approach in other organizations (see this module's related Case Reports for a few examples). Building bridges between specialized departments within an organization ultimately supports the organization's overall purpose and mission.

Conclusion

Appreciative inquiry is an approach to management that identifies and builds on what is already working well in an organization. This technique fosters optimism and collaboration. It also encourages the sharing of positive stories, which can improve an organization's culture.

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Graphic Jump Location
AMA Pearls

AMA Pearls

Focusing exclusively on the negative about a situation (“what's wrong”) can sap the energy and enthusiasm needed to make positive change. Identifying and noticing the positive (“what's working”) can catalyze positive change in an organization.

Ensure the involvement of leaders when introducing appreciative inquiry. A coalition of leaders can help guide the introduction and continued use of the appreciative inquiry.

Forming a discovery team is an effective way to begin appreciative inquiry in a practice, department, or organization. These representatives of the larger group can conduct appreciative interviews to inform change.

Encourage the sharing of positive stories to catalyze and spread culture change. Team members can share stories at staff meetings, “town hall” events, and other forums.

Using appreciative inquiry activities in daily work can maintain a more positive environment.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn their required annual part II self-assessment credit in the American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC). It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of recognizing participation.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in Lifelong Learning (Part II) of the American Board of Pathology’s (ABPath) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABPath MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Additional Information: About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Renewal Date: August 22, 2019

References
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May,  N., Becker,  D., Frankel,  R.,  et al.  Appreciative Inquiry in Health Care Positive Questions to Bring Out the Best.  Brunswick, OH: Crown Custom Publishing, Inc.; 2011.
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Shanafelt  TD, Gorringe  G, Menaker  R,  et al.  Impact of organizational leadership on physician burnout and satisfaction.  Mayo Clin Proc. 2015;90(4):432–440.Google ScholarCrossref
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Cooperrider  D, Whitney  D.  Appreciative Inquiry: A Positive Revolution in Change.  San Francisco, CA: Berrett-Koehler Publishers, Inc.; 2005.
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Richards  JJ,.  Storytelling in Appreciative Inquiry.  [master's thesis]. East Tennessee State University; 2012. Paper 1494.http://dc.etsu.edu/etd/1494. Accessed May 18, 2016.
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Center for Substance Abuse Treatment.  Enhancing Motivation for Change in Substance Abuse Treatment.  Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999.  (Treatment Improvement Protocol (TIP) Series, No. 35.) Chapter 3—Motivational Interviewing as a Counseling Style. http://www.ncbi.nlm.nih.gov/books/NBK64964/. Accessed May 19, 2016.

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