The Southwestern Free Clinic: Coaching and Change Essay

Sitting back in her chair, Leeza Smithton, Executive Director (ED) of the Southwestern Free Clinic (SWFC), had just concluded another board-mandated coaching session. Reflecting on the past few months, Smithton felt angry and frustrated that the board had questioned her leadership in the first place and even more frustrated that she had been directed to meet with a consultant to “discuss issues.” A tall Anglo in her early 40’s, Smithton was an attractive, East-coast native. She portrayed a picture of perfection, including a preference for designer dresses, well-coiffed hair, and manicured fingernails. She wondered if now was the right time to move on.

Smithton’s angst was matched by the board’s anguish and the staff’s frustration. Over the past several quarters, interactions between Smithton and SWFC’s board of directors had become strained. Just weeks before the ordered coaching sessions began, a ranking board member had invited his friend, a university faculty member and OD practitioner, to join SWFC’s monthly board meeting. The invitation was extended to “provide input on several issues of concern.” After the business meeting concluded, the board excused Smithton and her senior leadership from the meeting, an uncharacteristic event.

Turning to the consultant, the board member asked several questions: “What is your opinion on Ms. Smithton’s attitude?” “What is your assessment of the executive leaders’ one-hour presentation on the current state-of-the-clinic?” and “What are your thoughts on her dismissal of critical data points—it seems that should have been a loud bell?” For him, Smithton’s disavowal of low employee morale, as evidenced by a high turnover, was striking.

The board member’s questions startled the consultant. She had agreed to attend the meeting as a favor to her friend and the possibility that there might be some OD work for PhD students wanting some “hands on” experience in an organizational change and development initiative. She responded, “I’m afraid answers to those questions will have to wait until I get a clearer understanding of your organization. If you think turnover is high, then that might be a good place to begin our work together. Any other answer would be horribly unethical, not to mention, probably inaccurate, at this point.”

The Southwestern Free Clinic

The SFWC free clinic provided free- to low-cost medical/health-care to low income and uninsured community residents (e.g., the indigent, homeless, and those falling into very low socio-economic categories). Financial support came through minimal patient fees offered on a sliding scale, ability to pay system and some grant funds. The bulk of the monies were from in-kind donations and wealthy residents. Most patients were Latino/Hispanic immigrants from Mexico and Central America, and a small percentage of African Americans. Although the medical staff’s ethnic/race profiles reflected the patient population, the executives were primarily non-Hispanic and white and mimicked both the board of directors and the donor populations.

The clinic’s organization design was highly mechanistic. As part of the healthcare system, its services and processes were tightly controlled. Clinic personnel, including nurses and support staff, had detailed job descriptions and task responsibilities, and leadership and direction were exercised in a top-down, chain-of-command and control fashion. The executive team referred to subordinates as “they” and believed that “their” productivity and effectiveness was best achieved through consistency and uniformity.

On the other hand, there were also several organic features. Communication among staff members was informal and effective, decision-making in clinic operations was local, and the organization’s internal environment, as“lived” by the non-executive staff, was collegial and friendly. The staff saw the clinic as a family, existing for the sole purpose of providing services to the local community or, in many cases, the staff’s neighbors. The highly committed staff enjoyed chatting, “hanging out,” lunching together, and working as a collaborative team to get the job done.

Similarly, the support staff, including clerks and non-medical personnel, mirrored that of community residents, including ethnicity, national origin, and socioeconomic status. Hispanic/Latino employees spoke Spanish as a first language with their English capabilities falling into the very good to adequate range. Considered semi-skilled, they earned just a little above minimum wage (approximately $9/hour).

The trained medical staff, including nursing aids, LPNs, and RNs, were compensated at a higher rate, comparatively speaking, but made significantly less than current market rate for private practice and hospital personnel. In comparison, both of these primarily female groups made significantly less than Smithton’s annual salary of $175,000, a little above market rate for other non-profit EDs. In addition to the paid personnel, most of the physicians were volunteers, committing one day each week to the clinic, donating their time and expertise. Several physicians had been with the clinic 20 years while a handful of doctors had been with the clinic less than 5 years. Some nurses and specialists were also volunteers.

Over the past several years, clinic turnover had hovered between 35 and 50 percent per year. Several comments from the staff included:

• Yeah, we’re a revolving door here—management doesn’t get it. We work hard, very hard, but they don’t care.
• All they want is more, more, more. All they do is sit in their ivory tower and pick on us—never a kind word. They never come down to the clinic floors—they just send messages about what we’re not doing.
• They just see us as a bunch of inner city minorities. They just don’t appreciate us. And the pay—well, minimum wage. All we want is a little pat on the back and “thank you.”

Initiating an OD Project

The board member apologized for “putting the consultant on the spot” and asking questions she couldn’t possibly answer. However, given the ED’s presentation and the board’s concerns regarding leadership and the organization’s climate, he believed that additional insights and recommendations on “where to go from here” were badly needed. The other board members quickly nodded their agreement. More specifically, they wanted more “data points” but given they were a free clinic, they had limited funds. The consultant recommended an action research approach under a pro-bono arrangement. She explained the action research process and proposed that a team comprised of the consultant and several organizational psychology PhD students could work with the organization to assess and address its effectiveness and overall health.

The board members asked a few questions and ultimately agreed that it made sense to understand the full extent of the system’s health, but they also asked if the consultant would engage directly with the ED and work with her on issues of leadership style.

Consultant Reflection: At this point, I was thinking that the board would be the primary client and that Smithton might become a coachee. But the energy and emotion behind their request for coaching was worrisome. The board’s mandate of the coaching engagement appeared to be a “get coached or get out” ultimatum. I was pretty sure that an “obligated” client was less likely to buy into the coaching process and be an active participant in making any personal change.

That said, I did have a strong reaction to Ms. Smithton’s behavior during the board meeting. To me, she came across as arrogant and abrasive. I also found it hard to dismiss the turnover data although I knew that the nursing staff had lots of options in terms of alternative places to work. So, at this point, I just didn’t know whether the turnover might be high or low, a response to Smithton’s leadership, or some other factor.

Over the next four weeks, the consultant spoke with several members of the board and with Smithton to frame two different contracts.

1. The first contract covered activities related to an action research project at SWFC. The intent was to explore the organization’s health and develop a more complete picture of the clinic’s actual issues and problems which might merit attention and change. The hope was that additional data points would offer insights into the causes of any problems.
2. A second contract established a coaching relationship between Smithton and the consultant. The primary objective of these coaching sessions would be to become a more successful leader. This would be measured in terms of improved relations with her subordinates and the board and the creation of a healthier culture.

Early Executive Coaching Activities

Following the initial contracting conversations with the board, Smithton ultimately agreed with its demand for a coaching intervention. A phone call from the board member to the consultant followed, and she was informed that Smithton would contact her to formally begin the coaching process.

At the first face-to-face coaching session, the consultant followed the usual process of contracting and discussing the coaching cycle. There was a brief conversation about ethical codes and standards, on the parameters of confidentially, on each party’s commitment, and on the specifics relative to scheduling, assessment, goal setting, and wrapping up the coaching relationship. For example, Smithton needed to know that the consultant had made it clear to the board that they would not receive any feedback about the coaching process and that they should view any behavior-related change in a positive direction to be indicative of coaching progress. Smithton and the consultant also talked about why she thought the board was so insistent on the coaching. What did she think was the problem and what did she think could be done about it? Smithton actively, but reluctantly, participated in the conversation and was clearly irritated with the board’s “improve or we’ll terminate you” implications. The consultant asked Smithton to spend the next two weeks reflecting on the conversation and deciding on the objectives of the process going forward.

In the second session, Smithton and the consultant continued to talk about the board’s mandate for coaching. She seemed to have put thought into the coaching engagement, even identifying two relevant goals: To improve relationships with the board and to be a better leader. She also agreed to complete emotional intelligence and leadership assessments. But Smithton appeared to be “keeping up appearances,” such as starting on time and respectfully answering open-ended questions.

Consultant Reflection: I knew this was going to be a rough meeting. It’s the difference between “I’m going along with this BS coaching thing to keep my job” versus “I’m looking forward to developing and improving myself—and maybe get promoted.” As a professional I do not change my approach based on a client. I follow the ethical guidelines, try to use myself as an instrument of change, and work in an open, honest, and transparent way.

At our first session, I needed to acknowledge the circumstances of the coaching engagement. Therefore, I thought it best to begin with an inquiry relative to the board mandate and begin with her relationship with the board. I also wanted to watch Smithton’s initial verbal and non-verbal reactions as a baseline for behavior change as well as whether or not I would continue with the coaching engagement. And, if we were to go forward, this might give me ideas for future coaching interventions/possibilities.

I also wanted to think ahead. I like using a 360-feedback tool that allows peers, superiors, and subordinates to provide insights for the client. However, under the circumstances, this might be redundant as the action research agenda included an all-employee survey (discussed below) with questions on executive leadership. But an “off-the-shelf” emotional intelligence (EQ) and leadership assessment might provide tangible and baseline information.

Consultant Reflection: That little voice in my head says there is a lot more going on here than I can see. But at this point, and with the two goals, all I can really do is continue to ask open-ended or leading questions and listen to her verbal and non-verbal responses. I hope some trust is being developed but for now, we’re just going through the motions

Early Action Research Activities

The initial steps of the action research process included qualitative interviews and focus groups. Employees were selected for individual interviews by the board, and they tried to select a sample that represented different levels, functions, and titles. Identified individuals were sent a personal e-mail from the board that included an attached letter describing the project, its rationale, and the plan.

The focus groups emerged from an open invitation extended by the consulting group, on behalf of the board, to all clinic employees. They were invited to participate in “small groups” to better understand SWFC. The meeting times were scheduled in advance so that participants could select the date and time that best fit their individual routines. Dyads from the consulting team met with six focus groups comprised of 8–10 staff during April and May. Sessions were scheduled for 90 minutes, with some lasting more than two hours. One doctoral student asked questions while a second doctoral student functioned as the “scribe,” documenting all responses.

To secure open and honest communication, and because the project was part of a research process, all participants signed confidentiality agreements. Permission was also requested to tape record the sessions.

Eight open-ended questions were developed for the interviews and focus group meetings. All individuals and groups sessions were specifically asked the first three questions and followed up with the subsequent questions unless the content had already been offered in with the initial questions. More specifically:

1. What are the strengths of SWFC?
2. What are the weaknesses of SWFC?
3. What would you like to see changed?
4. Tell me about the leaders and leadership of SWFC?
5. What would make your job easier?
6. What makes your job more challenging/difficult?
7. Tell me about the communication at SWFC?
8. Anything else?

Information collected from the individual interviews was strikingly similar to the focus groups. Once the analysis was complete, 11 categories ultimately emerged related to work conditions, orientation and training, communications, the job itself, rewards and recognition, relationships within my work unit, relationships outside my work unit, supervision, executive management, organization culture, and overall assessments of effectiveness. These eleven categories were used to develop specific questions for an Organizational Health Survey (OHS).

Doctoral Student Reflection: We are glad that we had a faculty advisor who has done this before. Actually, the overall process is pretty straight forward but as they say, “the devil is in the details.” We’re also glad we tape recorded the focus group sessions, used pairs to ask questions and scribe answers, and had well-developed questions. Using bullet points to capture the comments was helpful since there was a lot of information being shared. And the first three questions usually covered the content that would have come from asking questions 4-7. And, the staff loved to talk—they feel that we are listening and will be able to make the changes they so desperately want. This actually feels a little funny. It’s like they think we have some kind of magic powers. Without doubt, the clinic staff are passionate about what they do and they are angry the leadership behaves in ways that are mean and alienating.

Breakthrough in the Coaching Process

The next several coaching sessions, scheduled every two weeks because Smithton “was so busy,” focused on the board’s mandate, Smithton’s relationship with the board, initial impressions from the focus group meetings, and the upcoming survey. For example, using some of the results from the focus group data—that many people were frustrated with leadership behavior—the consultant developed open-ended questions that guided Smithton to see the consequences of her different behaviors.

“You seem convinced that the staff is just complaining. Do you think there is any other explanation?” As the consultant highlighted the conflict between Smithton’s self-selected goal of “being a better leader” with her actions—does a good leader dismiss the feedback from her people?—she began to consider new behaviors. Over the next several meetings, Smithton identified actions that responded to the sentiments of the focus group’s opinions and observations. For example, she acknowledged that not spending time on the clinic floor could be perceived as “not caring” or “being aloof.”

But during this same time period, the doctoral students reported that Smithton continued to demonstrate questionable behavior. She stayed in her office, yelled at executive staff, and refused phone calls from the board. At one of the coaching sessions she stated, “I don’t want the focus groups and the intervention to continue, but my hands are tied.”

After several sessions and several intense confrontations, the consultant began forming a view of Smithton’s behaviors. Smithton was, in fact, very angry at the world and herself. The mandated coaching sessions brought these feelings to a head. On the one hand, she had a strong commitment to inner city clients desperately in need of medical care. She wanted to keep the control she had so she could do something about this problem, but also began to realize that it had vanished, or worse yet, never really existed in the first place. She began to recognize how she had alienated herself by her actions and verbal “craziness.” On the other hand, she felt powerless, isolated, and somewhat depressed. She was “looking for love”—she talked about having a family—yet put all her time and energy into SWFC.

Consultant Reflection: The revelations about Smithton’s views of helping the indigent and about her disappointments in her personal life caught me by surprise. Despite all the outward appearances, Smithton was in a downward spiral. She believed in the mission of the clinic but also wanted another life. She realized her caring nature wasn’t being enacted in her leadership style and it wasn’t helping herself, the employees, or the clinic. She understood she was up against a wall and at a pivotal point. In other words, she would be fired unless she began to change her behaviors and verbal “expressions.” She felt terrified, especially since neither option—change or termination—seemed appealing.

The coaching intervention and process certainly did “turn on the faucet.” Although it was risky to confront her with the contradictions between her objectives and actions, it was the right intervention because the risk to return ratio was stacked in the right direction.

Survey Data and Feedback

The 80-item OHS survey also included three open-ended questions and a demographic section. The survey was distributed to all employees in May and was returned to the university for analysis. The low response rate of 50 percent (42/84) was attributed to several factors, including difficulties finding the time to complete the survey during work hours, little knowledge of the survey process, not understanding the importance of the survey, or not understanding how the information would be used or communicated back to the staff. It was also possible that the low response rate was an indication of the low levels of engagement in the clinic.

The results of the OHS survey were presented to the board in June, followed by the executive staff several weeks later. The sequence of survey feedback was a point of contention. Smithton and her staff believed that since the data was about her and her team, they should have received the information before the board. Although sympathetic to Smithton’s concern, the consultant noted that the board had asked for the work and as the client, the order of feedback was appropriate.

The data confirmed the “gut level” instincts of the board. The large number of problems indicated a need for fundamental change. For example, there were clearly identified weaknesses in the following areas:

• The Board and ED were far removed from employees; people were dissatisfied with executive management;
• Supervisory behavior and attitudes were inconsistent;
• Communication was inadequate;
• Lack of employee input into decisions negatively impacted jobs and services;
• Recognition, rewards, and respect were inadequate;
• Organizational values and beliefs were inconsistently applied;
• People felt overly stressed by the workload;
• The physical workspace/environment was tired;
• High turnover made it difficult to be efficient.

But there were also some strengths, including

• A strong understanding and belief in the SWFC mission;
• The clinic was well respected in community;
• The clinic was perceived as a caring organization with a strong customer service orientation;
• High degree of cooperation with, and appreciation for co-workers (especially one’s work group);
• Many HR systems were considered flexible and easy to use.

Continued Coaching Progress and Frustrations

Between receiving the feedback and an all-employee offsite retreat scheduled for early fall, Smithton and the consultant continued to focus on goals 1 and 2 and the little successes reflecting her “new” leadership style. Although the data confirmed earlier discussions about the overall dissatisfaction with executive management, they were still hard to hear. As well, Smithton continued to open up about aspects of her personal life, and together they developed a “My Behavior Assessment Tool” that tried to integrate her personal and professional goals as well as specific actions and behaviors that were quantifiable and related to the diagnostic findings identified above.

Consultant Reflection: The good news was that Smithton was figuring out her own behavior. The bad news was the timing of everything. Although the survey results corroborated the off-the-shelf results from the emotional intelligence and leadership tools, the information was still hard for Smithton to hear. I actually took this as a good thing. The “old” Smithton might have just brushed off the results as complaining. The other good news was that as SWFC emerged as Smithton’s metaphorical mistress, she had diligently tried to improve herself both as a leader and potential life-partner. At this point I was wondering if executive coaching might need to taper off and Smithton begin to see a clinical therapist.

Action Planning Retreat

In October, eight months after the initial board meeting and almost five months after data collection began, the survey results were presented at a full day off-site “retreat” that included the entire SWFC staff as well as several board members who were available to attend the meeting. The purpose of the meeting was to set up an action plan for change.

The morning session began with a short meet-and-greet activity followed by a description of the clinic’s vision and mission for change. The OHS results were presented as a snapshot of “today” and the group used Weisbord’s Six-Box Model to summarize the diagnosis. Because of the five-month period between data collection and feedback, the morning session needed to be adapted to listen to the angry and frustrated staff. Interestingly, and perhaps rightfully, this lag was noted as “just another indication of the lousy leadership.” Several of the managers and leaders squirmed in their seats during the passionate and honest comments from the staff.

The afternoon shifted to discussions of “tomorrow.” A vision sharing exercise was followed by the formation of a Task Force for Change (TFC) to continue with the day’s discussions and plan change initiatives that had been suggested. They included: workload, management/leadership, communication, and respect and recognition.

Executive Coaching and the TFC

“WHEW—made it through THAT harrowing experience,” Smithton noted after the feedback session. Justifiably worried, she had secretly hoped the staff would recognize she was making changes. In fact, Smithton asked if “these changes were enough to satisfy the board” going as far as to suggest wrapping-up the coaching intervention. The consultant acknowledged her progress, provided encouragement, and reminded Smithton of the unfinished work. Using the “My Behavior Assessment Tool,” she provided specific feedback and identified the specific goals where behaviors and actions could be improved. Stating “I’m sure the board will be happy with your progress, but based on the all-staff retreat, the TFC initiatives might bring on new opportunities for development and revising the goals.”

Consequently, and working with the consultant, she made a list of the positives and negatives of TFC’s presence and activities. Interestingly this piece of paper became the tangible tool for many of the subsequent sessions.

Coaching Reflection: The survey feedback and “Task Force for Change” (TFC) initiative created mixed feelings for Smithton. Initially livid about the TFC, she “needed” to embrace the TFC solution since rejecting or denying the TFC’s presence would not look good.

Although a number of Smithton’s attributes could not be changed, the work continued to be interesting, challenging, and fulfilling. The dilemma was she really did not want to be on the treadmill forever, but rather a wife and mother.

The TFC Goes to Work

Twelve TFC volunteers were identified based on their availability and included nine core and three support team members. Interestingly, the core members were all in leadership positions at SWFC while an SWFC intern and two PhD students composed the support team.

The TFC included a “full committee” and four subcommittees each focused on an area identified at the all-staff retreat (e.g., workload, management/leadership, communication, and respect and recognition). The full committee held their first meeting in late October, three weeks after the off-site retreat and met eight times over the next four months. The sub-committees met on an as needed basis over that same period ultimately involving 36 different staff members from different parts of the clinic. While each subcommittee focused on one of the four key issues, the full committee was tasked with integrating all feedback, refining possible solutions to the perceived weaknesses, and guiding several of the identified change solutions.

The TFC identified a set of interventions and made both short-term (3-6 months) and long-term (6-12 months) recommendations. The interventions included a list of training subjects and possible curriculum ideas related to the four key issues as well as proposing a new performance management system, recognition awards, computer upgrades, and leadership development. One intervention recommendation garnered considerable attention: bike racks. As the clinic was located in a densely populated area, parking was extremely limited (approximately 20 spaces for 80 employees). Consequently, some of the staff used public transportation or walked to the clinic, while a significant number of employees rode their bikes. The executive leadership previously had rejected the request for bike racks on numerous occasions. Other actions included recommendations for “Guiding Principles” with respect to how the implementation would be conducted, and a role for the TFC during the next phase of the change process.

Smithton returned to the question: Was now the right time to leave SWFC or was there more work to be done?

Discussion Questions

1. Evaluate the change process at SWFC, including the coaching and action research processes.
2. What do you think of the TFC’s recommendations for change?
3. How would you manage the year 2 process?