If It Weren’t for the People, Quality Improvement Would Be Easy
I first heard the title's phrase in the 1980’s from a friend and colleague, Peter Scholtes, lead author of The Team Handbook, a best-seller 25 years ago and available in 3rd edition from various vendors; on-line reviews say to avoid the Kindle edition!
A recent on-line article by Neil Baker, MD and colleagues provides up-to-date reflections on improvement in healthcare and indicates that Peter’s joke is still relevant. Neil’s article is here.
The Baker et al. article starts with an observation: “relational rather than technical issues are the most common barriers to improvement.”
To illustrate, the authors summarize responses from several hundred seminar participants admittedly pre-disposed to be reflective about people issues and eager to improve care for patients and enhance work environments.
Baker and colleagues offer two ways to begin to address relationship and behavior challenges in the workplace:
(1) “…respond to any [relationship or behavior] problem by stepping back to reflect and recognizing the normalcy and sources of seemingly counterproductive behaviors. They often serve legitimate needs. This helps us to avoid making sweeping adverse judgments about others (and ourselves) that have harmful relational consequences and add to the dysfunction. It also diminishes our feeling of helplessness, opening the way for specific, concrete constructive actions.”
(2) “set aside the push to move too quickly to solutions and instead create the opportunity for ‘dialogue’ (defined as eliciting many points of view and ensuring that everyone is heard).”
These suggestions connect with a communication-focused method at the heart of AHRQ's Safety Program for Ambulatory Surgery (http://ascsafetyprogram.org/). The program aims to improve patient safety in ambulatory surgical centers in the U.S. In surgeries, poor relationships and incomplete communication behaviors lead to patient harm.
The program’s thoughtful and practical curriculum includes extensive practice to elicit many points of view and ensure that everyone on the team is heard. The point is to have no concerns ignored before, during, and after a surgery. In my part of the project, we’re working to strengthen the ability of staff and supervisors to reflect on and improve their safety communication. In particular, we want teams to adopt a daily huddle to review use of the safety communication methods taught in the program the previous day and to look ahead to the current day. Importantly, the huddles are not for problem-solving but to practice communication awareness and promote dialogue. It looks like these daily huddles are a direct way to weave Baker’s recommendations about relationships into daily work.
Based on a recent visit to an ambulatory surgical center to learn about safety communication, here's a serious revision of Peter’s joke: If it weren’t for the people doing the work, Quality Improvement would not be possible.
While the revised view can particularly challenge people like me who specialize in the technical side of improvement and for folks with an “engineer’s personality”, it really is the heart of the matter.