History of Appreciative Inquiry at UVA
Appreciative Inquiry was originally developed in the 1980s by David Cooperrider as a tool for organizational change. Unlike traditional change methods, AI “is about the co evolutionary search for the best in people, their organizations, and the relevant world around them. In its broadest focus, it involves systematic discovery of what gives ‘life’ to a living system when it is most alive, most effective, and most constructively capable in economic, ecological, and human terms.”[i] Based on the theory that we create the future through our active images of what it can be, AI can stimulate positive change limited only by the collective conversation and imagination of the group.
AI found its genesis at UVa while our residency training program was momentarily on probation with the ACGME. Finding opportunity in adversity, we recognized that there are many very positive attributes of the GME programs at UVa on which to build. Understanding and improving on what we do well helped address the concerns of the ACGME and also provided the framework for assuring that our programs are among the best in the country. We believed Appreciative Inquiry was an ideal technique to help achieve this goal. This process has also generated opportunities to address needs identified in the recent Employee Engagement process at the health center as well as the annual Faculty Survey in the School of Medicine. As such, AI at UVa is a unique partnership between the School of Medicine and the Medical Center, with the potential to benefit the entire University community. It has been 18 months since beginning the AI process at UVa, and in that time, we have made great strides in bringing our collective wisdom to bear on the culture of our residency program, our medical school, and the entire medical center.
The AI process has four stages, the four D’s: Discovery of what gives life to an organization, Dreaming what might be, Designing what should be, and Destiny or sustaining change. The Discovery process at UVA began with the recruitment of a leadership team, lead by Margaret Plews-Ogan, M.D.: Sharon Hostler, M.D., John Schorling, M.D., MPH, Daniel Becker, M.D., Susan Pollart, M.D., and Elizabeth Graham. Julie Haizlip, M.D. joined the leadership team in March, 2007, and the AI project is coordinated by Natalie May, Ph.D. We also identified a consultant, Rich Frankel, Ph.D., of Indiana University. In May, 2006, we held a workshop to introduce the process to institutional leadership. The key question that this group put forth to pursue with AI was, “How do we create an environment of optimism, collective intellect, inspiration, and teamwork to develop leaders and mentors in medicine?”
The Discovery process continued with the recruitment of the AI “Dream Team” – over 20 UVA faculty, residents, and students – who attended a 2-day retreat at Keswick Hall in October and then began collecting appreciative stories from their colleagues. Following the retreat, each Dream Team member received a digital audio recorder and an interview protocol and were asked to conduct 10 interviews. These interviews were to focus on GME and were designed to elicit stories of when an educational experience truly reflected the values that we hold dear as teachers and health care providers.
To date, we have collected 103 AI interviews, stories from a diverse group of individuals ranging from attending faculty to students to residents to nurses to librarians to lab technicians. Everyone had a story to tell. Every story reflected a powerful moment when their work was meaningful, even transformative, to them and often to others. Some stories were very simple – a public thank you from a fellow to his mentor or attendings helping a test-phobic resident with his boards – and others were extremely moving, such as the story of a young boy whose hands had to be amputated.
All interviews were transcribed, and the leadership team coded them to generate a list of themes. The team linked the themes in a logical framework to define our positive core, to answer the question, “When we are at our best, we…”
Work together as community. Many stories were powerful examples of when colleagues, teachers, learners, and health care teams worked together within what we labeled “community.” This community element exemplified teamwork, collaboration, bonding, appreciation, trust, respect, honesty, and support. This sense of community flourished in a nonhierarchical, supportive environment with “win-win” as the overarching goal, whether that goal was saving a life or establishing a new training program. Working in true communities allowed team members to each create and pursue shared goals. Each member was able to do meaningful work. Team members felt like equals, which fostered learning and made it fun.
We found that within a collaborative environment there were no limits on who was teaching whom. Patients, or patients’ family members, taught powerful lessons to physicians and nurses. Students taught residents, and residents taught attendings. In one story, a medical student stepped into the role of patient advocate, requesting a delay in a child’s surgery to reduce the stress on the parents, despite the wishes of the surgical team. In another, a surgical scrub technician came in on her day off to teach residents how to assemble instruments. Teachers were found in all everywhere in the organization.
Are Self-Aware and Reflective. At our best, we are reflective and self-aware. Stories within this theme demonstrated examples of remaining centered in the moment, taking time to enjoy the process, recognizing the needs of the patient and the learner, and being nonjudgmental and forgiving not only others but also ourselves. This cluster encompasses idealism, humility, compassion, as well as high standards and personal responsibility.
In one story, an attending realized that his resident, who was frustrated dealing with a patient with many complaints, was in every bit as much need of empathy as the patient. He listened quietly to the resident’s concerns, and then by “staying centered and not feeling overwhelmed myself” modeled that same compassion to the patient. The patient felt better having someone listen to her story, and the resident learned that it was okay to accept the limitations of medicine: that sometimes we cannot fix everything. A surgeon told of how he constantly reminded himself that his patients are important to others, just as “my brothers, sister, mother, father, wife, daughters are all so important to me.”
Exhibit human connection and empathy. We called this the “goose bump” category with its stories of extraordinary moments of connection, either between a student and teacher or a healer and patient. Powerful learning occurred in these moments. A resident “stepped into his role as healer” after apologizing to a patient for a difficult interaction between them. His attending observed, “it’s not always a pill, or an IV fluid…sometimes it is just a matter of how we interact with people. It can change a very negative experience into a positive one, and the resident has mentioned that [incident] many times since then. He is very good with patients because he has come to understand his role and his power.” Human connection requires vulnerability, faith, a sense of family, loyalty, a sense of investment in what we are creating, seeing patients and learners in their entirety, and loving and honoring others.
Experience excitement, joy, and innovation. This category exemplifies what gets us out of bed in the morning, that joy and excitement of going to work each day. When the other elements-community, reflection and self-awareness, human connection and empathy-are in place, then excitement, joy, and ultimately innovation flourish. Professionals desire to be good at what they do. They want to be able to fulfill their personal and professional goals, sharing the excitement of what we do with others. This theme reflects delight, enthusiasm, courage, optimism, humor, awe, and wonder. One story told of a surgeon who trusted his fellow enough to say, “You learn how to do this procedure that’s never been done here before, and we’ll do it together.” Other stories captured the excitement of helping a resident “get it” or performing a difficult procedure or successfully interacting with a difficult patient, the thrill of a job well done.
In October 2007, we held a second Keswick Retreat, inviting not only the Dream Team but also key individuals from nursing, the health sciences library, the Center for Human Development at the health center, the PICU, and neurology – all areas in the medical center that had expressed an interest in pursing appreciative inquiry themselves. This second retreat generated a lengthy list of ways we could spread AI and apply what we had already learned from the GME project. Thirteen projects were identified as “next steps” and are currently underway. These are in addition to other efforts, including the collection of medical student stories in the booklet, I Even Heald His Heart in My Hands: Notes from Our Medical Education; each UVA medical student finds one of these collections of narratives in their white coat pocket during the white coat ceremony.
Our AI infrastructure is growing now as well. With the development of our AI web site, Appreciative Approach Awards, Appreciative Inquiry workshops, and AI Quarterly Luncheons, we hope to keep AI firmly rooted at UVA for years to come.
We have also submitted an article to the ACGME Bulletin, “Feeding the Good Wolf: Appreciative Inquiry and Graduate Medical Education.” We have submitted abstracts or proposals to the ACGME 2008 Education Conference, the annual meeting of the Society for General Internal Medicine, and the 2008 meeting of the European Association of Communication in Healthcare. Dream Team member, Charlie Friel, presented AI at a workshop for the American College of Surgeons. Leadership team members have presented Grand Rounds and provided faculty development training in a variety of venues.
[1] Cooperrider DL & Whitney D. A positive revolution in change: appreciative inquiry. In Appreciative inquiry: Rethinking human organization toward a positive theory of change, Cooperrider DL, Sorensen PF, Jr., Whitney D, Yaeger TF. (eds.). Champaign, IL, Stipes Publishing, 2000.
