A Trap When Using Common Key Phrases: A Case of an Organization with Multiple Professions

It has been reported that the use of key phrases that all staff share a common understanding of is effective for integration inside an organization. At the Rakuwakai Otowa Hospital, however, integration failed due to the long-standing use of the terms “for the patient” and “patient first.” The staff had assigned different meanings depending on their profession to these terms based on which they had built successful track records for their profession. That experience acted as an inertia preventing changes in attitudes and behaviors and ended up accelerating individually optimal activities for each profession. It is not merely a matter of staff across units simply using the same key phrases; it is important to reduce the ambiguity of the key phrases through behavior.


Introduction
Approaches to integrate attitudes and behaviors across units in an organization include setting up inter-unit communication channels, such as coordinators and task forces (Galbraith, 1973); standardizing work procedures (Mintzberg, 1980); and rotating staff across units (Edström & Galbraith, 1977), and the approach that we focus on in this paper, which is to use key phrases that can be used by all staff, such as "everyday low prices" (Beer & Nohria, 2000) or "to create a place that inspires human potential" (Edmonson & Zuzul, 2016).
The literature on organizational learning, organizational change, and routine has established the efficacy of using key phrases that make sense to all staff as a way to change staff attitudes and behaviors. 1 Key phrases that can be shared across units are especially helpful in aligning staff attitudes and behaviors in cases where there are gaps in understanding among the people involved (Beer & Nohria, 2000), or staff autonomy makes it difficult for management to exert power (Edmondson & Zuzul, 2016;Matsuo, 2009). In such cases, it has been reported that including key phrases in mission statements (Matsuo, 2009), in vision statements (Edmondson & Zuzul, 2016), or in supplemental explanations of organizational objects (Kotter, 1996) can build a group consensus about new approaches for the organization and encourage behavioral transformation.
It is worth asking, however, if merely using key phrases present across units can promote integration. The reason is that is it not necessarily the case that all staff interpret certain phrases in the 1 Previous research did not explicitly use the expression "key phrases." We use the expression "key phrases" in this paper because of the prevalence of studies claiming that using not words or sentences but expressions combining several vocabulary items can help in integrating staff attitudes and behaviors. same way. Professional organizations involving multiple professions are especially prone to this problem. For example, Ferlie, Fitzgerald, Wood, and Hawkins (2005) demonstrate that new initiatives in professional organizations may fail to develop due to different professions interpreting the explanation differently. Even in the same organization and location, different professions may understand the same key phrases in different ways due to differences in how the profession is practiced, its role within the organization, or their specialty's foundation or culture (Ferlie at al., 2005).
In the case of the Rakuwakai Otowa Hospital (hereinafter,"Otowa Hospital"), this case study examines the management required to integrate attitudes and behaviors across the organization through key phrases that the staff across various units had long used. They believed that staff were aware of the importance of those key phrases and should behave accordingly. This ended up, however, accelerating division within the organization, since the differences in the understanding of the key phrases meant that each profession continued behaving in individually optimal ways, leading to isolation from and conflict with other professions. One underlying factor was the past success in raising professional skill levels through individually optimal initiatives in each profession.

Method
Case studies are an effective research methodology for presenting new theories (Eisenhardt, 1989 However, the behavior each profession engaged in "for the patient" was different. For example, behavior "for the patient" for (a) doctors was offering the expertise and techniques resulting in the best possible treatment; for (b) nurses was working closely with the patient to support the recovery process; for (c) pharmacists was dispensing the prescribed medications accurately to the patient and other professions; for (d) medical technicians was conducting tests promptly and accurately for smooth diagnoses; and for (e) medical clerks was to act between patients and other medical staff to provide accurate and responsive administrative services. These differing behaviors related to "for the patient" in each profession were also what the staff had consistently been taught since their school days.
This meant that even the staff working in the same department (outpatient, ward, and operating room) and providing medical care to the same patient would strive for different outcomes and apply their efforts differently depending on their profession. At the time each profession was territorial, resisted incursions by other professions, and thought trying to intrude on the purview of other professions was rude. The flow of information between professions was limited to the bare minimum required, and most internal hospital meetings were held separately for each profession.
This did not prevent the rise in the levels of professional expertise, technique, and skill, thereby allowing more difficult cases to be treated and expanding the scope of fields they could diagnose. For more than a decade after its founding, the hospital built a successful track record of treatments, saw a steady increase in the number of patients it could handle, and expanded the number of specialties. These successes led all the staff to believe that building their expertise and refining their techniques in their area of specialization was itself the activity that reflected working for the patient and putting the patient first; in other words, making the patient the top priority. The hospital set up forums for the staff to present the results of their daily studies; the staff began to study ever more in the belief that enhancing their expertise and technique in their chosen field was the correct direction.
The hospital administrator and others involved with its overall management began to be concerned, however, that the staff might be giving priority to the interests of the caregivers rather than the patient's treatment experience. Patients' families started to complain that (i) the staff seemed to be focused on other medical professionals rather than on the patient; (ii) they had to explain the same thing over and over to the staff from different professions; (iii) the waiting times were too long; and (iv) the lines of communication were inconvenient. Staff did not have a good grasp of the patient's experience receiving care outside their own area of expertise and did not understand what different professions did even in the same department. (

2) Actions taken by the management
With the arrival of the 1990s, the management decided to enhance the patient care experience by sharing the directions for the behavior staff should take and having each work location think and behave accordingly. The specific approach was to repeat explanations using the phrases "for the patient" and "patient first." The staff had in fact been frequently using "for the patient" and "patient first" in discussions and documents and so the management believed staff had a common understanding of these phrases. The management also believed that initiatives using the phrases "for the patient" and "patient first" would lead the staff to put themselves in the shoes of the patients receiving care and rethink their words and actions.
The management emphasized the notion of thinking "for the patient" and putting the "patient first" at formal occasions such as morning staff meetings and conferences held for each role and at informal gatherings such as dinners and voluntary study groups. They repeated the mantra of "cooperate across professions" and "act for the patient" again and again. Other explanations were to think about how you would like to be treated if you were a patient and work in such a way that you would like to bring your family to see. They would also sometimes cite words of appreciation from patients as examples of desirable behavior.
The staff was also convinced of the importance of this message from the management. All staff, no matter what their profession, put the patient first and made it their first priority to act for the patient. They reconsidered their behavior, thinking it was natural to act in ways the patient would appreciate and choosing to act for the patient even more in the future.

(3) After using the new approach of the management
However, the behavior of the staff after these management initiatives did not match what the management intended. As explained in the "(1) Previous Situation" section above, for each profession, the behavior "for the patient" and putting the "patient first" had meant leveraging their own expertise and techniques to the maximum extent. That type of medical care behavior had continued for more than a decade leading up to that point, thanks to which each profession raised its skill level and the hospital extended its track record of medical care. For that reason, staff believed that continuing their past behavior constituted what the management was calling "for the patient" and as described below, each profession retreated further into its shell, thereby refining its expertise and techniques.

Discussion and Conclusion
Previous research has emphasized on the importance of using key phrases that are understood in the same way across units as an approach to integrate members' attitudes and behaviors. In the case of the Otowa Hospital, however, the use of key phrases had the opposite effect of exaggerating gaps on the attitudes and behaviors among professions and, in some cases, engaging in behavior each thought was good for the other, but ending up harming relationships and leaving integration further away than ever.
At the Otowa Hospital, the key phrases "for the patient" and "patient first" had different meanings for each profession, with the staff being trained specifically to those ends. Conducting tasks under these circumstances allowed skill levels in each profession to be improved, thereby building the hospital's reputation for medical treatment. Given that the organizations tend to follow past experiences that have been successful (Leonard-Barton, 1992), the emphasis at the Otowa Hospital on the staff's past experience could be considered natural. Although previous research has not addressed the gaps in the understanding between professions, if those involved have already assigned strong meanings to specific key phrases and believe those meanings are correct, as is the case with the Otowa Hospital, then repeated interventions designed to increase awareness of the same words merely reinforces their meaning, thereby making it harder to align attitudes and behaviors due to the gaps in the understanding among the different staff.
The crucial thing, therefore, is not to simply make use of key phrases that the staff can share and that the management believes to be effective in bringing about a certain state of affairs. Instead, the point is to reduce the ambiguity of key phrases by taking into account the particularities of a professional organization. Effective ways to reduce ambiguity (Jehn, Northcraft, & Neale, 1999) include presenting more concrete interpretations for key phrases; using staff who can mediate between the staff possessing different attitudes to add concrete information that both sides can understand (Galbraith, 1973); and combining activities to raise awareness of the necessity for change, rather than merely communicating with words (Abe, 2019).