Appreciative inquiry is an approach to change that identifies and builds on what is already working 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 "Think of a recent successful team project," "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 even create a shared vision going forward.
Focusing only 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
What are the benefits of appreciative inquiry?
- Appreciative inquiry fosters a sense of optimism, and people tend to work best when they are feeling optimistic.1
- It encourages collaboration, which engages and aligns team members, while helping teams focus on the meaning of their work and inspiring members to do their best.
- This technique also facilitates storytelling, which engages the emotions and inspires collaboration and confidence.
Five STEPS for changing your organizational culture using appreciative inquiry
- Build a guiding coalition of leaders to shape your organizational culture and work experience
- Form a “discovery team” to elicit positive stories and themes from your organization
- Share positive stories to catalyze and spread culture change
- Incorporate appreciative inquiry into daily work to maintain positivity in your organization
- Link appreciative inquiry to existing performance improvement initiatives
Build a guiding coalition of leaders to shape your organizational culture and work experience
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 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.
See these STEPS Forward modules on leading change for more information.
Form a "discovery team" to elicit positive stories and themes from your organization
It is important to begin appreciative inquiry by gaining a sense of the strengths, assets and values of the practice, department or organization. A discovery process can use appreciative interviewing to uncover themes and values from across the organization. This process will help the group understand "how we interact and connect with one another" and "what goes on in this organization when we're at our 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.
Who should be on the discovery team?
Consider including representatives from all aspects of your practice or department: medical assistants, nurses, physicians, administrators, front office and clerical staff, and maintenance staff.
How many people should serve on the discovery team?
A practice or department with 25 employees might want five 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 a script for appreciative interviewing and can capture the responses either with an audio recorder and transcription or with paper-based or electronic notes. Leaders need to clearly communicate the guidelines regarding anonymity to both the members of the discovery team and potential interviewees. Although the goal of an appreciative interview is identifying the positive aspects of a practice or organization, a truly informative interview requires that the interviewee feels safe enough to speak about the challenging aspects of these subjects as well; thus, clarity about anonymity is important.
You can also begin the discovery process by using a staff meeting or other large group meeting to do appreciative interviews (pairing up to interview each other during a one-to-two-hour meeting).
How do I pair people up for the interviews?
Using a concept called "improbable pairs," pair people together who don't generally get to know one another and whose jobs are very different. For example, a doctor would be paired to interview a medical assistant or a pharmacist. These pairings can help break down barriers during the interview process.
What happens after the interviews?
After the interviews, put the pairs into groups of six to eight and ask them to share their partners' stories with each other. You can also ask groups to provide a depiction that represents the important positive ideas that came forward during the discussion. Afterward, come together as a large group and share the themes or the depictions. These positive depictions can become important symbols of "who we are when we are at our best" in the practice.
How can I respond when my team resists appreciative inquiry, saying, "We can't afford to focus on what's going well when there are so many problems"?
When initially learning about appreciative inquiry, people often see it as a "Pollyanna" approach that won't help things improve. However, appreciative inquiry is not about denying or ignoring problems, but rather it is a way to build a collaborative culture and to gather the energy and enthusiasm needed to address problems.
Share positive stories to catalyze and spread culture change
Introduce appreciative inquiry on a small scale by including 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 can we improve for our next meeting?"
Using these tools 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.
Catalyze positive organization change by boosting resilience and collaboration #STEPSforward
How can I make sure we get to our agenda items? Won't these practices consume our entire meeting time?
Often teams find that meetings become more productive when using these tools, because appreciative inquiry has shifted the atmosphere within the team or larger organization to be more positive and collaborative. If you are concerned about time, try using appreciative check-in and debrief questions that require a single-word response.
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 changing 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 get up and 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 "positive gossip" in your internal communications; for example, you can post positive vignettes and inspirational quotes from staff or patients in newsletters, in 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.
Incorporate appreciative inquiry into daily work to maintain positivity in your organization
Once the staff 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 can take several forms. The essential element of these activities is looking for and highlighting mutual values and positive experiences.
Appreciative inquiry activities might include:
- Appreciative check-ins at the start of meetings
- Introductions: ask people to respond to an appreciative question
- Shout-outs: ask team members to share something positive that they observed recently about another member's actions or performance
- Appreciative de-briefs: ask an appreciative question relating to the strengths of a meeting
- Clinical interactions: use appreciative questions with patients
- Positive gossip
- Assuming positive intent
- Taking a barrier and turning it into an opportunity
- Finding the value behind a complaint
Events at which appreciative inquiry can be used:
- 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
See Conducting Effective Team Meetings for more information on using appreciative inquiry in team meetings.
How can I learn more about incorporating appreciative inquiry into our work?
Consider additional training, consultation or discussion on this approach with a colleague who has used this process.
Contact the Center for Appreciative Inquiry for training or consultation opportunities. You or a staff member could obtain certification in appreciative inquiry. Certification is available through the Center for Appreciative Inquiry.
What do I do if my team is not responding and participation is low?
Timing is an important consideration in initiating culture change using appreciative inquiry. Just as one wouldn't counsel a patient to stop smoking at a time of high stress, so too must the decision to implement appreciative inquiry take any recent events or issues into account when introducing the concept. Consider using Prochaska's stages-of-change model or motivational interviewing techniques to identify sources of resistance to change.5-7
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 PDSA (Plan-Do-Study-Act) cycles, you might start by inviting staff to write brief (one- to two-page) proposals outlining the question or challenge that the PDSA cycle would address, the way(s) in which appreciative inquiry would affect the desired outcome, the appreciative inquiry methods to be used, 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.
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. Building bridges between specialized silos within an organization ultimately supports the organization's overall purpose and mission.
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. Staff 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.
Appreciative inquiry is an approach to change 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 change an organization's culture.
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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.
- 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.
- Dyer JH, Gregersen HB, Christensen CM. The innovator's DNA. Harv Bus Rev. 2009;87(12):60-67, 128.
- Suchman AL, Williamson PR, Litzelman DK, et al. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med. 2004;19(5 Pt 2):501-504.
- Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press; 1991.
- Prochaska JO. Assessing how people change. Cancer. 1991;67(3 Suppl):805-807.
- Prochaska JO, DiClemente, CC. The transtheoretical approach. In: Norcross JC, Goldfried MR, eds. Handbook of Psychotherapy Integration. 2nd ed. New York, NY: Oxford University Press; 2005.
- Cavallo D. Emergent design and learning environments: building on indigenous knowledge. IBM Sys J. 2000; 39(3&4):768-781.
- Cooperrider D, Whitney D. Appreciative Inquiry: A Positive Revolution in Change. San Francisco, CA: Berrett-Koehler Publishers, Inc.; 2005.
- 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.
- 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.
STEPS in practice
How’s it working in Indianapolis?
Jason Everman, DO, a family physician in a group of 11 providers, describes his experience with appreciative inquiry.
"Our primary care practice is undergoing significant change as we transition to becoming a patient-centered medical home (PCMH). The stress and turmoil of this change could have had a negative effect on morale and communication. However, in my role as a physician leader, I've seen just the opposite. Because we used appreciative inquiry as we pursued this strategic improvement aim, the atmosphere in our practice has actually become more positive. We have used appreciative check-ins when we begin our staff meetings, appreciative debriefs when we conclude them, and appreciative interviewing as we conducted our strategic planning for the year.
"The changes in the practice have been noticeable. I've seen more human touches in our clinic over the last few months than previously, including heartfelt laughter among patients and staff while handling disease and life changes, smiles and kindness even during the most tense (sic) of times, side conversations focused on raising the bar for our approach to patient care, questions of why we function in certain ways and if it can be improved and innovation in clinic-patient communication to raise satisfaction for every patient at every visit.
"During one appreciative inquiry exercise, it became apparent that some of the practice staff had the internal drive for improvement. These staff members displayed a readiness to put the patient first, [a readiness] that had been waiting in the shadows. Since that exercise, I have come to really appreciate the power of humanism to change the culture of a health care organization—and to help us effectively implement improvement projects. I've been truly inspired by my co-workers' focus, motivation and personal commitment during this process. Appreciative inquiry gave us the positive atmosphere we needed to move ahead with the changes involved in becoming a PCMH. It helped us grow together and provide even better care to our patients."
How’s it working in Lafayette, IN?
At Indiana University (IU), reflection and appreciative inquiry are woven into the medical school curriculum starting in the first year of study. Medical students at the IU Lafayette campus routinely reflect on their experiences making house calls as part of their Introduction to Clinical Medicine class. During five biweekly home visits, they form a respectful relationship with a family with chronic health concerns. The students practice skills such as caring presence, empathic listening and verbal and nonverbal facilitative communication behaviors, as well as provide useful, non-medical services such as shopping and transportation.
Educators at IU use a strength-based model that empowers the visiting students and families to form a caring partnership with each other. Reflection, both in small group discussions and through written assignments, plays a key role in this service-learning curriculum.
Dr. Janet Hortin, now at Duke University, was instrumental in developing the model used for the curriculum at the IU Lafayette campus. Small group reflection sessions are held every other week to reinforce ways of mindfully being present for one another. Poetry, short narratives and artwork are used to transport the students to a welcoming space where they can explore how to develop caring, respectful relationships across cultural and generational differences. Robert Coles' A Life in Medicine is used as a resource for guiding provocative reflection and discussion about professionalism and ethics.
Dr. Hortin relates: "Through reflection, we come to understand some of our personal biases and challenges in dealing with people from different backgrounds. We foster a sense of trust and mutual support within the class of 16 students so that we attend to one another as well as to the mentor families. The rigors and stressors of the medical life are discussed along with self-care topics such as coping with failure and mistakes."
Many of the themes in the reflective writing assignments and small group discussion sessions center on the students' house call experiences. Stories abound. Students have a front-row seat from which they can witness how biological, psychological, social, spiritual and economic factors impact the well-being of their mentor family. A few examples of issues encountered during house call experiences that students have chosen to reflect upon in their written work and discussions include combating caregiver burnout, transitioning from home care to an assisted living facility, estrangement from family members, coping with the loss of a spouse and use of herbal or complementary therapies.
Written reflective activities include assignments about the healing power of touch, elements of a healing environment, walking in your neighbor's shoes for a day, assessing your strengths and the mentor families' strengths, assessing networks of support within the community and family and painting a word picture of the mentor family. These assignments are submitted online, allowing for prompt feedback and dialogue with the instructor.
The students select their best written work for an end-of-semester portfolio to demonstrate the trajectory of their personal and professional growth. During individual conferences, the portfolio is presented and discussed with the instructor. This portfolio project, known as "The Good Neighbor Mentoring Project," seeks to reinforce habits of reflection and attentive human engagement within the medical school.
Safe, welcoming spaces for reflection must be available throughout medical training if one is to, as Arthur Frank writes, "renew a sense of generosity in medicine."
Adapted from Hortin J. Engaging reflection in health professional education. RCCI Newsletter, Indiana University School of Medicine. 2009;6(1):4-5.
How’s it working in Charlottesville, VA?
The University of Virginia Health System is a large academic medical center with approximately 7,500 faculty and staff. The system includes a Center for Appreciative Practice, which facilitates and spreads the use of appreciative inquiry (AI) methodology throughout the organization. AI was successfully applied within the health system to improve the transition from inpatient psychiatric care to outpatient mental health services.
Leaders of the inpatient psychiatric unit recognized the need for better communication and collaboration with community services for outpatients. Too often, patients discharged from inpatient care did not successfully transition to care in the outpatient facility or community service site to which they were referred. Frequently, these patients would experience a psychiatric deterioration and require readmission. Leaders believed that better communication and improved relationships among inpatient and outpatient care providers and community service providers would help prevent these transition issues.
Faculty of the Center for Appreciative Practice facilitated a two-day event focused on application of AI towards this goal. A total of 50 attendees gathered for three hours each day; attendees included physicians, nurses, representatives of community services groups, members of a mental health advocacy group, and individuals who had used inpatient services at the health system in the past.
On the first day, the facilitators walked the group through a discovery process in which participants reflected on the positive aspects of the current state of mental health care in the community and the present care transition process. Participants told stories of their experiences that illustrated commitment, collaboration, empowerment, empathy and perseverance. Next, participants described the ideal state of how they hoped care transitions could be. They listed improved access to substance abuse treatment services, additional face-to-face and electronic networks for providers, and the development of a transition clinic staffed jointly by inpatient and outpatient care providers. An especially moving moment occurred when one of the patient participants reflected on his experience of the day: "I can't believe how much you all care about us." On the second day of the event, facilitators helped the group create a revised transition process and begin plans for future implementation. As part of the new process, the group agreed upon a common format for care plans that would travel between sites and a common form for shared documentation.
As a result of the AI event, the connection and communication between inpatient care providers and outpatient community groups has improved. During the event, attendees learned about the services available from the other groups and about the roles of various members of those groups. Colleagues in outpatient settings, many of whom had worked together virtually for years, met in person for the first time, fostering improved professional relationships. After the event, connections continued to grow. An inpatient nurse joined the board of a mental health advocacy group. Clinicians from the inpatient unit began volunteering at a homeless shelter that was frequented by patients. Individuals from community mental health groups hosted three educational sessions for inpatient staff and created a handout listing available community resources. Throughout the two-day event and during the subsequent action steps, AI facilitated improved connections between inpatient, outpatient, and community services and a produced a new transition process. Ultimately, patients benefit from smoother transitions and patient satisfaction scores have improved for psychiatric services.
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