- Kahneman, Daniel Thinking Fast and Slow Farrar, Straus, and Giroux 2012.
- Baker, Neil J. et al Hidden in Plain View: Barriers to Quality Improvement Physician Leadership Journal (2) Mar-Apr 2016, 54- 57
- Lencioni, Patrick The Advantage Jossey-Bass 2012
(text of video)
Tool for Ongoing Review Meetings for Improvement Initiatives
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Here are two brief stories of improvement initiatives told at conferences in which critical success factors emerged only when I later talked individually with the presenters.
An executive in charge of quality improvement used 30 slides to present a workshop on his organization’s successful integration of Lean thinking. All of the questions and discussion focused on Lean methodology. When I later talked to him, I told him, “I noticed one slide on physician engagement. What was the importance and sequencing of that relative to the work on Lean?”
He said, “We spent 10 months in meetings with all the physicians to talk about our plans before we ever touched the work on Lean. We worked through some tough conversations. Now that you bring this up, I have to say this first step with physicians was crucial to our overall success.” As he talked, I was startled at how such a big issue had remained barely mentioned and in the background throughout the workshop.
Story #2: It all looked so easy…after the fact
A director of a primary care clinic led their first ever involvement of two patients on one of their quality improvement work teams. She told what seemed to be a great, straightforward story of success with how-to tools for helping patients feel comfortable working with clinical staff.
Later, meeting individually with the director, after about 20 minutes, I discovered their first team meeting with the patients had been “disastrous.” One patient revealed with anger that a relative of his had significant health problems several years prior due to clinic error. Unfortunately, the clinic staff got defensive and the meeting ended badly. The director said, “I can’t believe that I have forgotten how bad that was. I even considered giving up.”
With this director, I elicited further details about how she had helped her team recover remarkably well from a “disaster.” Anticipating and managing such inevitable, unexpected hurdles that occur in human affairs was a crucial learning left out of the presentation.
Why secrets on the relational side of change get missed
Both of these stories are examples of flaws in remembering that can occur once we know the outcome of a situation which is called “hindsight bias.” (1) Once a tough relational issue resolves, we tend to forget the level of stress and unpredictability in the original situation so, outside of full awareness, those events may not be considered important enough to report. Also, we may even miss our own level of skill and courage that was necessary for success leading to under-reporting about key actions.
There are additional reasons why improvement stories all too frequently miss secrets to success on the relational side of change.
- Our professional and social culture values science and technology over relational issues. Telling relational stories requires a higher level of self-exposure and vulnerability.
- Getting at sufficient detail about relational issues requires a higher degree of safety in conversation. It is not unusual to need 1:1 interview time.
- Relational stories require asking for behaviorally specific information which is not a commonly practiced skill.
Why this is important and what you can do right now
That important details about relational challenges so often remain hidden is not a small problem. Evidence points to relational issues as a major cause of lack of expected success of innovations within and across organizations despite using the same quality methods and technical designs for change.(2)
Telling relational stories we can learn from requires no less than a change in professional culture. But, there is at least one important step you can take now—in meetings to review progress of improvement initiatives, always integrate at least one or two questions about relational issues. Below the video, there are instructions on how to access a tool for guidance.
The illusion of simple and commonplace methods
Having been a quality consultant for many years, I know that methods to address relational issues can seem quite simple and commonplace—such as listening and asking questions. But, as noted by Patrick Lencioni, to be consistent and wise relationally requires “uncommon levels of discipline, courage, determination, and persistence.”(3) To help sustain these qualities, we need the best possible stories about relational challenges to learn from.