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Mary Grassinger was in the midst of a career-defining struggle.

She was less than a year into her job as clinical nutrition manager for St. Mary's/Duluth Clinic Health System in Duluth, Minnesota. She didn't have enough people, and her staff was asking her to help make up the difference. They felt ignored by the larger organization -- not considered as professionals, but treated more like people "slinging hash down in the kitchen." Their workspace was "dismal." A few dietitians were quietly threatening to resign.

"I understood their frustrations," Grassinger says, "but I also needed them to understand that I couldn't change their work environment unless they gave me the opportunity to implement those changes."

Grassinger's struggles coincided with the first time her organization took the 黑料网 Q¹² survey. The first set of scores confirmed her concerns. "As I sat in that 黑料网 session viewing my first scorecard, I thought to myself, 'Well, it looks like the only direction I can go from here is up.'" She decided to give it her all. "The program had exactly one year to make me a believer."

By taking her team's ideas seriously, by encouraging them and getting them the resources to do their jobs better, and by making herself an expert on the group's productivity, she raised employee engagement among the dietitians from average to extraordinary in that one year. Many managers can raise their team's level of engagement; few achieve the increase orchestrated by Mary Grassinger.

No place for a pessimist

St. Mary's/Duluth Clinic Health System (SMDC) serves a region as picturesque as it is challenging. Duluth runs 24 miles along a steep hill on the westernmost end of Lake Superior's north shore. The health system's main campus commands a stunning view of the lake, the aerial lift bridge over the Duluth Ship Canal, and Superior, Wisconsin, across the point of the lake. Despite winter temperatures that average -2潞 Fahrenheit and that can reach -41潞 without the wind chill, enough lumber, iron, and grain have passed through Duluth by road, rail, and boat to sustain the city's economy for a century and a half.

The nature of the region determined the nature of its patients. Early in the 20^th century, St. Mary's Hospital offered a "lumberjack ticket," an early form of workers' compensation and medical insurance that cost $1 to $5 per year. Through 115 years of construction and mergers, today, SMDC runs four hospitals and 20 clinics throughout northern Minnesota and Wisconsin. But it remains a demanding place to do business. The aging local population and the decline of the region's manufacturing industries mean nearly half of SMDC's patients rely on U.S.-government-funded Medicare and Medicaid insurance to pay their medical bills.

Growing up near the Mayo Clinic in Rochester, Minnesota, and as the third generation of her family involved in the nutrition field, Grassinger was a natural fit for her job. While attending college in Duluth, she worked odd days and weekends for St. Mary's and met several of her current colleagues. Marriage and career took her through a whirlwind tour of the southern United States. Tired of all the moving, she and her family packed their bags and headed to Duluth. "Something about the lake always draws you back," says Grassinger.

Word of Grassinger's return soon reached Ellie Dryer, director of nutrition services, who jumped at the chance to hire the seasoned and confident version of the hardworking college student she had known 20 years before.

Grassinger's return to SMDC was no cakewalk. She assumed responsibility for 13 people -- inpatient dietitians, outpatient dietitians, dietetic technicians, and clerks -- all quite different and "very accustomed to doing things the way they were accustomed to doing them," says Dryer. "I don't think they were particularly interested in changing. They rather liked the status quo."

It quickly became apparent there was too much work for too few people. Previous managers had handled the problem by jumping in and becoming an extra dietitian. Grassinger decided she needed to work on the larger problem of workload and staff size if she was going to succeed.

Morale "was at an all-time low because I was handling things totally differently," Grassinger says. "But I thought, 'How am I going to make a change if I don't manage? I can't just jump in there and put a Band-Aid on it; it's not going to fix the problem." She put her faith in the dedication of her team members, hoping their professionalism would help get them through the transition.

Although Grassinger initially took some direct dietitian work to get a feel for the demands on her team, she began pulling back from seeing patients so she could design a long-term strategy. To do so, she needed statistics -- reliable information about what the staff was doing -- to prove her case that they needed more help. She asked her staff to begin keeping track of their work in 15-minute increments. With Grassinger pitching in less and tracking the staff more, some of them felt abandoned and insulted. "From their point of view, I actually made things worse before I made things better, but that was the only way I could do it," she says.

"She was initially not very well-received because her management style was so very different than her predecessor's," says Dryer, Grassinger's supervisor. "As a matter of fact, I had people in my office expressing some very strong concerns. I had to explain to them, 'I did not hire Mary to be a relief dietitian. I hired her to be a manager.'"

"She was not afraid to say, 'In order for us to move ahead, I can't be doing staff relief,'" says Roxanne Bijold, an outpatient dietitian on Grassinger's team.

To make matters worse, the team had no real desks where they could do paperwork or leave their belongings before they went on rounds. "One of the big things was workspace," says Heather Roy, an inpatient dietitian. "When I first started here, there were two or three desks and people shared them. [Workspace] seems like a basic need, but we didn't have it."

The first scorecard

SMDC's first administration of 黑料网's Q¹², a 12-item employee survey focused on the most important attributes of an effective workgroup, occurred 10 months into Grassinger's tenure. (See "Feedback for Real" in See Also.) Although she felt she'd made progress, it was still early, and the results were not a surprise. The clinical nutrition group's overall engagement score was mediocre, and scores for individual items relating to "recognition or praise" and having the right "materials and equipment" to do their work received very low ratings.

"At that first 黑料网 meeting, I thought, 'Hey, I am open to anything, and I will give this program a year. I'll really work it. I'll give it my all.' I was in the perfect situation," Grassinger says. "They were beginning to be open-minded. They'd seen some changes they liked, but they weren't quite there yet."

The battle for increased engagement was fought on several fronts. Grassinger and her manager drafted a budget request to get some modular furniture. She began holding regular meetings with her staff to discuss the Q¹² items. The ideas flowed so quickly that not everything could be taken on at once.

"She is very good at getting people to participate," Bijold says. "There was never a sense of, 'Boy, that's a dumb idea.' You never, ever get that feeling from Mary."

From the group's discussions, it became apparent that the dietitians felt recognition from each other, but not from the rest of SMDC. The team's solution: a four-page quarterly newsletter entitled "Chew On This," which is distributed throughout the organization.

Inside the group, they began recognizing each other's accomplishments by passing around a toy pickle with a note of encouragement attached. The pickle became so highly prized that "pickle pages" were printed to be passed from one team member to another when the toy pickle was already being used. And to ensure that part-timers received timely notices of important changes, the team developed a "communications log" that everyone reads to keep up-to-date.

Meanwhile, Grassinger used the productivity statistics to petition for more people. On paper, the number of patients appeared manageable, but the severity of their medical needs -- their "acuity" -- was high. Patients referred to the clinical nutrition team ran the gamut from high-need patients -- such as those in intensive care who received food through a feeding tube -- to patients who just needed a normal-but-healthier diet. A disproportionate number of SMDC's patients were in the high-need category, which put a burden on the nutrition staff.

"It's really unfair to compare our staffing to an average community hospital," Dryer says, because SMDC is generally ranked as "the second or third highest acuity facility in the state."

By the time Grassinger had removed herself from being a relief dietitian, "I had the figures to prove we were largely understaffed and had a plan for how to move forward," she says. "At the same time, we had a rise in patient acuity. There is no way that four dietitians can see 25 patients a day. No wonder the manager had to do some relief work -- because we didn't have enough staff."

To make her case, Grassinger needed some objective assessments of the workload. "Mary did some benchmarking with other high-acuity facilities at Mayo and Abbott Northwestern [a large Minneapolis hospital]," Dryer says. "She really had her facts together."

Grassinger and Dryer took the facts to SMDC's Position Review Committee. The committee approved the hiring of two more dietitians and one more clerk.

"That was the real turning point," Dryer says. The team began to realize that Grassinger was there to advocate for them. "Finally, the light bulb went on: 'This is really going to be a good situation.'"

Even with the added staff, the workload requires team members to cooperate to meet patient needs. Grassinger instituted a brief morning meeting to review each person's schedule and make adjustments. "They can't really escape; they're all in the same room," Dryer says. "Obviously, if one person has a horrific workload, and one person doesn't have as much, it seems only fitting and proper they should help one another out."

To further increase her team's commitment, Grassinger began meeting quarterly with each member of her staff. As difficult as it was, the effort yielded unexpected results. "I give them an opportunity to talk about work, but I also use it as an opportunity to get to know them better as a person. When else do you have a chance to sit down with somebody for a half hour or an hour and talk just about them?" she said. "I've learned so much more about each of them in those meetings. Every time, I think, 'These meetings are really worth it.' It's not easy to do. But who said this job was going to be easy?"

A huge increase

When SMDC administered the 黑料网 Q¹² again last summer, the results Grassinger and her team had achieved were remarkable. Their engagement score jumped from slightly below average to a level above all but 8% of the workgroups in 黑料网's database. Team responses were higher on every one of the 12 key items, including a huge increase in the formerly problematic item about praise and recognition.

Grassinger's manager isn't surprised by the results. "She's worked very hard at working with the team," Dryer says. "She really wanted these scores to improve. She felt it was important to make the workplace more fun . . . and to make sure people wouldn't think this is a 'flavor of the month' that was going to go away."

What does higher employee engagement do for SMDC's patients? 黑料网 analyses show that engaged employees are less likely to resign, more likely to be productive, and more likely to create better patient experiences. "You'd see it in our attention to detail," Roy says. Where a less engaged team might make due with outdated materials for patients, the SMDC team continuously updates them with the latest information. If a patient wants chicken soup that's not specifically allowed, Roy says, "A dietitian who's not engaged would say, 'Chicken soup is not in compliance with your doctor's orders.' But someone who's engaged might say, 'Let's call your doctor and see if we can get that for you.'"

Word of the clinical nutrition team's accomplishments has spread through the SMDC system. Grassinger was asked to help coach some of her fellow managers on improving employee engagement. She's currently mentoring another manager who "realizes she wasn't invested in the program," she says. "She is where I was last year, and she is just going gangbusters with a team that is really struggling. I said, 'Just give it a year. I can guarantee you will be in a better place.'"