Performance Improvement Tip of the Day: The Power of the Feedback Loop

This article from WIRED magazine about the power of feedback loops nicely helps illustrate how this simple biological mechanism works to improve personal performance, and can be harnessed to improve the performance of teams and systems.



Dr. Joseph Kvedar, Director for the Center for Connected Health at Partners, talks about the feedback loop in this wonderful YouTube video. He talks about using the key feedback elements below to help patients change their behavior. However, the same feedback loop and elements can also be used in motivating behavior change for practitioners. When implemented wisely and within the construct of a well designed management system, this loop is a powerful contributor to improvement.

(1) Active Reflection: This occurs through the appropriate use of data, presented in a meaningful way, at the right time in order to make the intended recipient/ audience actively "sit up and take notice".

• This is the concept behind the TrendWatch presented earlier. 
• Critical information is displayed on one page - an important concept that ensures adequate visualization of the overall initiative. 
• This allows individuals and a team to understand how their performance is linked to outcomes and where their collective performance sits in the context of initiatives undertaken to improve performance. 

(2) Sentinel Effect: The idea that someone may be watching you can change your actions.

• Monitoring data regularly, providing feedback, and generating reports all create the signal to individuals and teams that their behavior is being monitored. 
• In my experience, this is sufficient to drive most individuals to change "undesirable" behaviors. 

(3) Social Norm Bias:

• This is the mechanism that drive the power of the SMART Profile system presented earlier. 
• Producing a Profile and sharing it regularly with team members provides the impetus for team members to gravitate their behaviors towards the "social norm" or "team average" or "benchmark". 
• When combined with the monitoring of data, provision of feedback, and generating of reports, profiling helps to keep desired behaviors in place. 

(4) Ability to Take Action: The individual must be able to take action to change the behavior that the feedback is intended for. Many improvement efforts fail because the feedback loop that they generate is on "irrelevant" items, or behaviors that any particular individual is unable to change, i.e., they may need to be changed at the group/ team/ systems level.

(5) Consequence: Consequence is ultimately what makes all of the above strategies successful when implemented within a "system". In most cases, consequence is a theoretical possibility and no consequential action is actually undertaken. However, the possibility must exist of consequence, which in the context of healthcare performance improvement may include the following:

• Coaching 
• Supervision 
• One-to-one meeting
• Letter on file 
• Censure 
• Peer review 
• Suspension

Performance Improvement Tip of the Day: Providing "SMART Feedback"

One of the most essential aspects of behavior modification is feedback - its critical to auto-regulation in all systems: biologic, social, and behavioral. If a practitioner does not find out that an action is undesirable, then she cannot correct it.

Most organizations are not familiar or comfortable with providing feedback. They find that it takes too much time, or the culture of the organization is not "ready for feedback", or they are not sure of how to go about setting up a feedback system, or they are worried about how the recipients will react. The purpose of feedback is not to chastise or blame, but to re-orient, teach, guide, and engage.

Feedback isn't about occasional meetings with the department head, or annual performance reviews. Those are too far removed from individual actions to be meaningful. Feedback is about providing critique about a specific action, in a time-sensitive manner so that the memory is still relatively fresh in the recipient's mind, and can be acted upon soon enough to change outcomes.

PPII has designed a SMART Feedback Tool to help performance improvement specialists structure their feedback in order to gain the greatest engagement and responsiveness from their practitioners:

PPII SMART Feedback Tool

Other "COOL" elements to add to the SMART Feedback structure:

• C - Consistent - to establish a "culture of feedback" and fairness.
• O - Ongoing - to ensure that the performance of a behavior is reinforced and hardwired.
• O - Opportunity - for the recipient to provide further input into the issue or request clarification.
• L - Learning-oriented - the best feedback provides a framework and opportunity for learning. 

This SMART Feedback Tool was provided courtesy of 

Physician Performance Improvement Institute.

Performance Improvement Tip of the Day: Lesson about Motivation from Jim Collins, Author of "Good to Great"

Performance Improvement is ultimately about changing outcomes - which is about either changing behavior or stimulating people to change systems - both of which can be daunting tasks in an organization already burdened with its numerous day-to-day challenges.

Jim Collins - best selling author of Good to Great - delivers a powerful lesson that can help to drive motivation for change in this short video about "letting the people see and feel the clicks on the flywheel".

These are the small victories on the path to the bigger goal. Try to capture them, measure them, and make them visible; they will in turn generate more buy-in, enthusiasm, and support from your staff.

Performance Improvement Tip of the Day: The Importance of Giving Feedback

Three recent articles all underscore the importance of the feedback function in improving performance:

• Isn't feedback great: http://www.businessleaderslearning.com/archives/2011/07/18/tips/isnt-feedback-great/
• How to give negative feedback: http://leaderchat.org/2011/10/17/need-to-deliver-some-negative-feedback-5-things-to-keep-in-mind/
• "Taking a break" and "being slightly behind" motivates improvement: http://www.freakonomics.com/2011/10/17/call-it-a-comeback-why-performance-increases-when-were-losing/

Feedback is an important part of the "regulatory loop" without which we do not have a mechanism to self-correct. Successful change agents, managers, and performance improvement specialists all incorporate feedback actively into their repertoire as they recognize that very often behavior of their staff and colleagues needs to be modulated.

Formal feedback systems can include annual performance reviews and report cards, as well as punishment and censure for egregious behavior. However, there are often "minor" behavioral issues that do not rise to requiring this level of intervention. Some examples in the clinical setting:

• medical records not signed
• use of unapproved ("dangerous") abbreviations
• specific performance measures - such as CHF or Pneumonia - not met
• minor conflicts between staff members

In these cases, it is incumbent upon a department head or performance improvement specialist to provide feedback to the responsible clinician - usually physician or nurse - about an action that should have been carried out. When provided within a "non-blame" environment, and framed in a non-threatening manner, such feedback can "gently" suggest to the recipient that there are alternative behaviors that he/she should have undertaken.

In my experience working in numerous healthcare settings, most providers receive this feedback in a constructive manner, and are generally happy to have the assistance in identifying the "outlier" behavior.

In some cases, the recipient of feedback will engage in a dialog about why the selected episode is considered an "outlier". In most of these cases, the clinician is generally satisfied with the ensuing discussion - provided that the underlying rationale is made clear, the system for review is fair, and that the practitioner doesn't feel singled out.

In very rare cases, the recipient takes the feedback personally, and can become defensive, or offensive. The reaction can certainly be quite intense, and requires a healthy quotient of emotional intelligence in order to allay. However, even in these cases, I have found that the feedback still has its desired impact - the individual is now aware of the discrepancy in behavior, and is generally more likely to be compliant with desired behavior.

Performance Improvement Tip of the Day: Culture Drives Performance

The culture of an organization determines behavior, decision-making, and ultimately outcomes. It is "baked into the design" of every (clinical) process. Therefore, in order to improve outcomes, one must understand and shape culture. This requires intricate analysis, leadership support, and a broad enough span of time to accomplish the changes required.

Within the context of most performance improvement projects, we generally think about operating "within the cultural paradigm" of the institution, otherwise many targeted interventions may get rejected by the organization.

However, in order to achieve "breakthrough performance", the organization's culture has to be changed as it is in large part the culture that is constraining outcomes. Thus, performance improvement specialists have to be adept at gauging what "cultural change" they can successfully advocate for and implement within the course of their projects in order to lead the organization to higher-level performance.

"Culture" makes its presence felt in many subtle ways. Even in the "simple" case of implementing order sets, the following are variants of interventions that can be implemented based upon "what the organization's culture is ready to handle":

• use of order sets 
• mandating use of order sets 
• implementation of "opt out" orders 
• use of nurse or therapist-driven protocols 
• pharmacist or nurse "pulling the chain" to stop the process for any unclear orders

This blog from Ron Ashkenas on HBR Blog Network presents a nice, concise analysis of culture, its impact on performance, and a few tips on how to assess culture:

"Any management team can assess its culture by asking these kinds of simple questions across a range of organizational behaviors. For example: To what extent do we reward individual vs. team results? To what extent do we share information broadly or parcel it out narrowly? To what extent do we encourage or discourage risk?"

Mission: Improvement; a primer to guide healthcare reformers.

In the upcoming weeks, I'll be blogging a series a posts entitled "Mission: Improvement; a primer to guide healthcare reformers".

Lots of books and articles have been written about project management and continuous quality improvement. Why another one? Simple, there is a need for a practical approach to improvement not a theoretical treatise. This will help you understand what to do in the trenches while fighting the battle for improvement.

Over decades of experience in the field, the author has found that most people know what needs to be done. They have read the books, attended numerous lectures and conferences, and even participated in numerous performance improvement projects. The missing link tends to be inadequate application of that knowledge, perhaps not knowing which tools to use at which time, and how all of the pieces fit together.

Similarly, in the author's humble opinion - having worked at a number of different healthcare organizations, most healthcare providers are not "knowledge poor" when it comes to implementing evidence-based medicine - rather what's missing is the knowledge of how to redesign systems in order to ensure the right outcome; what's missing is often the motivation or incentive to change. Unfortunately, the attribution of a knowledge-deficit as the critical missing element often leads most improvement teams to focus on education efforts. However, education does not lead to significant, sustainable change. Change results from redesigning systems to lead to the desired outcome; by making the default option the desired option. Secondly, change results from the collective efforts of cross functional teams; these teams produce insight about the organization's working and capacity that any one individual is not privy to. Thirdly, change results from behavior modification. Physicians and clinicians know what needs to be done; they may not make the action enough of a priority; behavior modification techniques expertly implemented within the context of a performance improvement system can lead to desired outcomes.

The lessons that I will share with you have led in real world settings to what I call "high performance outcomes":

• Utilization Management:

• Reduced inpatient length of stay by 25% at two facilities
• Reduced emergency room length of stay by 90 minutes for patients waiting to be admitted

• Diabetes

• Improved patient education from 81% to 100%
• Improved hemoglobin A1C evaluation from 14% to 57%
• Improved lipid profile evaluation from 10% to 24%

• Congestive Heart Failure

• Improved communication of discharge instructions from 88% to 98%
• Improved “perfect care” (patients meeting all measures) from 80% to 95%
• Reduced readmissions from 18% to less than 10%

• Surgical Care Improvement Project

• Improved foley catheter removal within 48 hours from 46% to 72%
• Improved prophylactic antibiotics given within one hour of surgery from 64% to 100%
• Improved discontinuation of prophylactic antibiotics within 24 hours from 75% to 88%

• Stroke

• Improved LDL less than 100 or statin initiated from 50% to 100%

• Pneumonia

• Improved ordering of blood cultures before antibiotics from 84% to 100%

• Ambulatory Care

• Improved selection of prophylactic antibiotics from 55% to 92%
• Improved initiation of prophylactic antibiotics from 69% to 100%

Watch this blog in the coming weeks for more discussion about the items above and expert tips on how to get the results many of us seek.

Motivation 3.0 for Physicians

Just finished reading "Drive" by Daniel H. Pink and was left pondering the ramifications in healthcare of the Motivation 3.0 operating system that the author proposes is more relevant for success and fulfillment in the 21st century. As opposed to the "carrot vs. stick" theories of behavior modification defined by Motivation 2.0, the "upgraded operating system" is built upon the intrinsic motivators of autonomy, mastery, and purpose.

For physicians, we have created numerous financial rewards and penalties, which essentially take the intrinsic enjoyment out of the work of medicine, and convert it into a system to be gamed. Therefore, we should not be surprised that the system is indeed played, and that the numerous incentives and penalties have in great part contributed to the overall dysfunctionality of the system, not to mention the relative dis-satisfaction that many practitioners now feel in their vocation.

Building a new model upon the Motivation 3.0 framework, healthcare leaders, policymakers, and administrators should attempt to cultivate true internal motivation by creating environments wherein practitioners can find autonomy, seek mastery, and develop a re-connection to the purpose that brought them to medicine in the first place.

Autonomy requires that the physician have some control over their task, time, technique, and team. External pressures from the changing healthcare landscape have impinged upon nearly all of these elements. In order to provide/ return autonomy to physicians, administrators need to observe and faciliate, not censure and command.

Physicians have generally been trained for thousands of hours in order to be "masters" in their practice. However, true "mastery" requires unlocking a deep passion for what they do combined with a desire for steady improvement in their skills. The work of healthcare institutions -efficiency and improvement - is potentially interconnected with the individual's needs for mastery. However, management needs to do a better job of ensuring that the institution's objectives are better interlaced with the professional's and that the need to achieve simplistic outcomes doesn't subvert the practitioners drive for true mastery.

Purpose may be the most ephemeral of these elements, however, this is the one that most likely drew practitioners to undertake a long road of education, training, and practice so that - in addition to making a decent living - they could also serve the common good. Many practitioners are still captivated by that drive, but are unable to connect with this purpose on a day-to-day basis, which may be overshadowed at times by financial and time pressures, difficult patients, and complex cases. Management should endeavor to help make this connection, which can in turn invoke a deeper sense of achievement, and thereby help to drive overall greater performance.