It is easier to talk, and harder to communicate, than we realize. Here are a few tips in the military medical setting.
The Chairman of the Joint Chiefs of Staff, Army General Martin Dempsey, wrote in his Mission Command White Paper (3 April 12) “In the Joint Force 2020, operations will move at the speed of trust.” Good communication is one of the most important ways that people and organizations build trust. My purpose in this paper is to provide guidelines to help military medicine better communicate and improve trust.
Communication between individuals appears simple, but it is not. The communicator has a thought to express and someone to whom she wants to express it. However, the communicator must first put her thought into words or other symbols, then transmit those words or symbols in a way that the receiver can understand. The receiver must be able to hear and understand those words or symbols and decipher the communicator’s thought. The process is fraught with potential for misunderstanding. For example, if a woman wants to invite a friend to lunch, she must first have the idea, then ask the friend in a language both understand and in a way that will be appealing to her friend. The friend has to be able to hear (or read) and understand the woman’s intent.
If communication can be difficult between individuals, communication is harder between individuals in organizations. In addition to the normal communication obstacles between individuals as noted above, each organization acquires its own personality that must be considered. A salesman at Apple Inc. works in a different environment than a buyer at Caterpillar Inc. and each will come from a different culture. The larger the organization, the more bureaucratic it must become to manage itself. Communication in a five person local restaurant will be very different than that at McDonald’s headquarters. People in older, larger, wealthier organizations sometimes see themselves as better than those in younger, smaller, less wealthy ones. The converse can also be true. Each individual’s position in the organization also affects their ability to communicate. A mail room clerk is unlikely to email or telephone the Chief Executive Officer in most organizations.
Military organizations are some of the oldest, largest, and wealthiest in the world. They are, by nature and by necessity, hierarchical and complicated. Militaries are affected by not only organizational politics but also national politics. The rank structure is very clear and communications between individuals is heavily influenced or even determined by rank. It would be unusual for a seaman to even address his skipper aboard ship; he would be expected to use his chain of command – the hierarchy of sailors and officers above him – to speak his mind.
Service cultures are powerful and color most interactions between services. Historically Army units fought alongside one another and in the presence of their higher headquarters. They could be destroyed by enemy action but generally not by weather. Disease and starvation were usually more manageable threats on land than at sea. Navy ships, on the other hand, were often patrolling alone or in small groups far from any support. The enemy was a threat, but even in peacetime all hands aboard could perish from a sudden storm. Due to the close quarters aboard ship, epidemic disease was common. Some fatal diseases were inevitable if the cruise was long enough; between 1500 and 1800 an estimated two million sailors died of scurvy. Can we wonder why the Army and Navy cultures are different, and affect communication between them?
To overcome these difficulties as much as is possible, the US military has developed processes to assist communication between organizations. They can be divided into two categories; communication between commanders through chains of command, and communication between the staffs of those commands. Commanders regularly communicate to other commands through informal means, but may formally communicate to subordinates through orders such as task orders, operations orders, warning orders, fragmentary orders, and the like. They communicate to subordinates, peers and superiors through requests for assistance, requests for information, requests for forces, and others, depending on the situation.
Staffs communicate informally. Since staffers are not commanders, they have no authority to tell other organizations what to do. However, since they advise commanders and prepare the documents noted above, they have great influence. Knowing this, staff members at subordinate commands often defer to staff members at higher commands. Staffers at higher commands, therefore, must be very careful about how and what they ask subordinate command staffers to do.
The Army, Navy, Air Force, and other uniformed services have hundreds of documents explaining command, chain of command, and the roles and responsibilities of staff. Those will not be summarized here. Command and staff channels of communication are both necessary. It would be impossible to get anything done between organizations if commanders had to do all of the communicating. However, subordinate commands need formal communications in many circumstances to account for their people and maintain order in their organization.
Taskers to military medical units are fast and furious. Dozens of committee meetings, work groups, medical support missions, and educational activities, developed internally and by every level of command, compete for the time of doctors, nurses, and other personnel. Task requests and orders to other organizations are no different. Subordinate headquarters must know what they are being asked to do and be able to coordinate their response, including saying no when they can no longer support a mission.
As a commander and as a senior staff officer I have been asked for guidance on when to use each channel of communication. The following are guidelines which have proven useful:
When to use an informal request (staff level communication)
1.Requests for information when the information should be quick and easy to obtain. Less than one hour is a good rule of thumb.
2.Tasks that require less than one hour to do.
3.Requests for personnel support when the need is for a single local meeting or series of local meetings but the time commitment is low.
4.Requests are generated locally, such as when the local command (military medicine in the National Capitol Region NCR, the JTF Cap Med) needs to bring together subject matter experts (SMEs) to create a working group for a certain area.
5.When the request can be expected to be readily accepted by its recipients.
6.Urgent requests that have a very short suspense should be informal at the beginning and be written into an order ASAP.
How to use an informal request (staff level communication)
1.Email and verbal request to appropriate staff level communication point of contact (POC). Email is important to document request and clarify the suspense.
2.Ensure that the request does not come across as an order and that it is done in the most collegial manner.
3.Track request to ensure that the request is addressed on time.
4.If request is not honored by the suspense, refer to higher level and re-request or commence an order.
When to use an order (command level communication)
1.Requests for information when the information will be difficult and time consuming. More than several hours is a good rule of thumb.
2.Tasks that require more than several hours to do.
3.Requests for personnel support when the need is for many meetings and the time commitment is high.
4.Requests are generated from other entities, such as when higher headquarters (in the NCR, TRICARE Management Agency or the Department of Defense) needs to bring together SMEs to create a working group for a certain area.
5.When the request can be expected to incite resistance in its recipients (These should be informally staffed beforehand to evaluate the resistance and identify the cause – they probably have good reasons for not wanting to do it).
6.Urgent requests that have a very short suspense should be informal at the beginning and be written into an order ASAP.
How to use an order (command level communication)
1.The SME must write the substance of the order.
2.Work with operations (JTF Cap Med – J3A) for formatting.
3.Let the Joint Staff (J-code, such as J4, J5, etc) director know what is going on so he can brief the commander, the deputy commander, or the chief of staff.
4.Review the final order.
5.Ensure that it makes it through J-code and upper level reviews.
6.Track when it is signed by the CDR.
7.Contact your POCs at the subordinate MTF to ensure receipt.
8.Help ensure that it is done on time. Subordinate commands sometimes view higher commands as work generators and information parasites. Higher commands need to work hard to be value added.
Readers will notice that these guidelines do not cover many of the situations which arise. They are not intended to, since each situation is unique and must be handled as such. Here are two guidelines for things that “fall in the middle”:
1.Send a courtesy copy of the request to whoever in the leadership wants it at the receiving command. For example, sometimes chiefs of staff of subordinate commands want to be copied on all significant informal requests.
2.Send a courtesy copy to the proper level at the J-code so that no one at the higher command is blindsided if the request generates anxiety at the receiving command.
Guideline two mentions sending courtesy copies “at the proper level”. While we as Americans are taught that “all men are created equal”, we as humans have a tendency to believe that we are a little more equal than everyone else. Thus the senior staffer in the subordinate headquarters might take offense if he or she is asked to do something by a junior staffer in a higher command. Even if they do not take offense, everyone has limited time, energy, focus and talent, and the senior staffer is often a lot busier than the junior one. Therefore it is generally good for staff level communication to occur between roughly equivalent levels. Rough equivalents US Federal service:
|Military Officer Grade||General Schedule (GS) and Senior Executive (SES)||DoD Civilian Military Equivalency Rate (DoD Financial Management Regulation 2/98)||These tables are primarily used for comparing pay between military and federal service. They do not reflect the importance of the positions. In terms of communication and authority the senior enlisted ranks (E7-E9) align better with the senior military officer grades (O5-O6) and senior civilian grades (GS 13-15). The middle enlisted ranks (E5-E6) align better with the middle military officer grades (O3-O4) and middle civilian grades (GS 10-12).|
|E1-E3||GS 1-3||GS 1-3|
Rough equivalents by position in a military compared to a civilian medical organization:
|Military Medical Equivalent||Civilian Medical Equivalent|
|Commander, Med Group Commander (AF)||Chief Executive Officer or President|
|Deputy Commander, Chief of Staff, Staff Directors, Squadron Commander (AF)||Chief Medical (Nursing, Operations, Financial, etc) Officer|
|Department Chief, Flight Commander (AF)||Department Chief|
|Service Chief, Element Chief (AF)||Service Chief|
|Clinic Chief||Clinic Chief|
Generally, in hierarchical organizations such as the military, routine communication should occur between people at the same level, one level up or one level down. Therefore department chiefs routinely communicate with department chiefs, service chiefs and staff directors, while chiefs of staff typically interact with commanders, deputy commanders, and department chiefs. Some communication occurs between levels but in non-emergency situations, routine communication usually follows this rule. Nothing written here is intended to stifle positive communication, but rather to enhance it.
These guidelines have been useful in the past and hopefully will be useful in the future. Our success or failure as a nation has much to do with the success or failure of organizations within it. Our success or failure as a military has much to do with the success or failure of military medicine. Our success or failure in military medicine has much to do with how well we communicate with each other and with the most important members of our team; our patients.