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.

C-Section Rate Variability at MA Hospitals: A Tale of Culture & Performance Improvement Systems

This story in the Boston Globe Magazine is ostensibly about c-sections:

However, the underlying factors leading to high rates at some MA hospitals are all related to culture and/or implementation of performance improvement systems:

(1) Hospital Culture

(2) Physician Culture

(3) Monitoring of Outcomes

(4) Sharing of Outcomes

(5) Use of Report Cards

(6) Design of Systems to Facilitate Outcomes

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.