So, with the cautionary tale of the San Francisco chart-ripper in mind (refresh/rewind? Part 1 is here), here are a few ideas for how to align the use of performance data with the trust, goodwill and momentum required to do the work and fix things.
But first, two key concepts:
For bosses and leaders of change, create trust and safety so that change can happen. People need to hear, understand and feel in their bones that they are supported, encouraged, and required to take risks and try new things. People have to trust that their bosses truly want them to let down their guard and experiment, risk looking silly because they don't know how things will go. A safe environment for quality improvement is one where, in the words of a participant in a workshop I led recently, “You can take risks without being at risk.”
For everybody, key concept: Improvement is learning, together, better ways to do our work, and putting those effective ways into daily practice. And we use numbers to track how it’s going. The work is developmental, iterative, and creative. And the goal is to figure out how to do the better thing every time, as a reliable process. It’s NOT about “Hey, let’s try real hard just this once on this project, and then we can relax again.”
We know from the chart-ripper story, and probably from your own experience, that it’s not sufficient to just tell people once why the numbers are important and move on. Here are some ideas on how to get everyone on the same page about why we need to track the numbers and why that's a good thing.
1) Use a common language that makes sense. Avoid tired clichés. Use your common language to explain the improvement culture you want. Here are some phrases and a metaphor that I like.
a. “Do your work. Improve your work.” When I worked in a hospital, way back, the fact that this second thing was part of my daily work was a real epiphany. It wasn’t exclusively my boss’s job to come up with all the answers. After that realization, everything else about quality improvement made sense.
b. Renters and Owners. Quint Studer is famous for helping hospitals make performance breakthroughs through developing staff. He says that high performers act like owners of their work. Owners want to fix things, where renters just want to get through the day.
c. Elephants, Riders, the Path. The metaphor of an elephant, elephant rider, and the elephant’s path is described in Dan and Chip Heath’s book “Switch.” (They learned it from Jonathan Haidt.) The simple image helps with real-talk conversations: “Oops, that’s my elephant talking” means “Sorry I made an emotional decision to shove your new idea aside because I’m feeling stressed right now.”
2) Ask all managers and supervisors to use your shared language to describe improvement and the use of data to make improvements. If the bosses don’t speak the same language and believe in the process of improvement using data, you are sunk.
3) Measure and improve things the team cares about, that also impact patients or customers. What conditions and quality problems are the most important to them? One people get used to using performance data, they seek it out in other parts of their work.
4) Go first. Walk the walk and improve trust. Two ideas here:
a. Say “I don’t know” a lot. Get over any know-it-all or need-to-know-it-all tendencies. If everyone is working on new solutions to achieve ambitious goals, everyone should say “I don’t know.” Especially the bosses, if you are expecting frontline staff to come up with their own solutions. Say: “I don’t know, what do you think? What can we try?”
b. Post personal metrics. In the 90’s, the book “Quality Is Personal” was a staple of quality improvement, back then called Total Quality Management. The idea is to give yourself an individual scorecard week to week, with measures of things like getting your optimal amount of exercise per week, or being prepared for each meeting you lead, or meeting sales targets. A scorecard on your office door is a brave way to show your imperfection and your commitment to improvement. It sets an example.
5) Recognize productive risk-taking. Productive risks are manageable, well-planned experiments to try something new. Productive risks have potential to lead to better performance. In improvement, good risks are often tests of change. A nurse decides to try to complete her charting away from the main unit desk so she can focus and finish quickly. Or someone who is usually quiet in meetings speaks up to share ideas and insights.
6) Get personal. Make time for 1:1 discussions. Most people need one-on-one education and reassurance with their boss or other leader in order to feel positively about performance data. It’s anxiety-provoking to see numbers on the wall where we can and should do better. We are used to audit findings and other report cards leading to micro-management and judgment. Want to change the culture? Spend time with people individually to make sure they get it and are cool with this new way of seeing their work.
7) Develop individual expertise to increase confidence and capabilities. Understand what people do and do not know already. Eddie is still hiding his lack of computer skills. Susannah needs to practice outreach calls to patients at home, because this is a new expectation and she’s afraid of getting questions she can’t answer. Help people identify and follow up on learning needs. The same goes for the tools and activities of quality improvement. At first, most people need to be trained on the meaning and purpose of run charts.
The clinic with the chart-rippers has gone through management changes since that meeting a few years back, and the new leaders have carried over some of these ideas into their current work. From a chat I had with one of the staff physicians recently, they are well on their way to a culture where everyone make the most of the basic tenets of quality improvement: Keep sharing, keep learning, keep improving.