Driving a culture of quality
Colleen Hughes Driscoll is an assistant professor in the division of neonatology at the University of Maryland Medical Center, Baltimore, MD. She serves as the director for quality improvement in its neonatal intensive care unit.
Early in my career as a neonatologist, I began to transition into a leader in quality improvement at my institution; a transition that I continue to undergo. I was initiating a quality improvement program within my division, never an easy task in the health care setting for a variety of reasons: often there are no extrinsic fringe benefits available to motivate people, academia rarely honors performance improvement with promotion, and often the resources needed to fund quality improvement projects are non-existent. Moreover, faced with the challenge of asking my colleagues to take on more when time is a precious commodity, I was desperately in search of an instruction manual. In November of 2013, I was introduced to Daniel Pink’s book, Drive: The Surprising Truth About What Motivates Us. Drive is a synopsis of research on human motivation that spans decades, and illustrates how businesses can flourish, or destroy, the motivation of their workers. Pink uses this evidence to demonstrate the intrinsic motivation that lies at our core as humans and how this can be channeled to maximize innovation and creativity.
Whilst not an instruction manual per se, “Drive” provided insight from a body of scientific evidence and provided lessons from industries that I was not familiar with as a physician, such as manufacturing and technology. A central theme of Pink’s book is that humans possess a natural, innate drive to create, to preserve autonomy, and to learn and grow as individuals. Viewed from another angle, this means that people are born to approach their life as a series of Plan-Do-Study-Act cycles by defining what they want to achieve, having the autonomy to make strides toward that goal, learning from their actions as they move toward that goal, and altering their course to achieve mastery.
Unfortunately, in our day-to-day responsibilities we aren’t often given the autonomy we need to focus on what really motivates us. We are saddled with task lists, deadlines, and other responsibilities that are rarely make us excited to get up in the morning. However, Pink demonstrates that many successful companies, like Google, have been able to harness their employees’ “drive” by giving them the autonomy to innovate. He describes how one Australian software company encourages innovation by allowing employees to work on any idea or project that they desire within one 24 hours period per quarter. The caveat is that they must present their work to the group at the end of 24 hours time. This approach has enabled employees to solve problems with existing software and develop a variety of new product ideas.
Upon reading this, I was intrigued by how this approach might affect quality improvement in our division. Certainly, there was an infinite list of quality improvement and patient safety issues that needed to be addressed in our division. My instinct was to prioritize that list and lead the charge to tackle each one over time. But Pink’s book made me re-think how I wanted to encourage the culture of quality improvement in my unit. What if, instead of trying to rally the group’s support and effort around an agenda that was not their own, I provided a forum for them to explore their own quality and safety concerns within the unit? It turns out that the forum already existed, at least partially. The division held a monthly quality assurance meeting to discuss patient morbidities and mortalities, along with a comparison of our outcomes with other institutions. This was a trainee-driven conference that was attended by physician staff from our unit. We decided to re-purpose this meeting to give the trainee (or any other physician) autonomy to explore and highlight any safety/quality issue that they view as a problem.
The first step in achieving this was to re-name the conference as the “quality assurance/quality improvement” meeting. We wanted to signify to our staff that performance improvement is not only encouraged, but valued. Next we re-structured the agenda to include not only a review of morbidities and outcomes but also to provide a monthly progress report of our ongoing quality improvement initiatives. We believe that highlighting the QI work being done in our unit persuades others to undertake their own QI initiatives. Finally, we gave the trainees the opportunity to try to solve a quality or safety problem of their choosing, one that is important to them. They are encouraged to objectively investigate the scope of the problem, elucidate the key contributing factors, and propose potential solutions.
The outputs from these meetings over the last year have been very positive. Sometimes the trainee is able to bring an unrecognized, yet significant, safety concern to the forefront of divisional/departmental leadership. Other times the trainee finds that a safety risk can be reduced with one simple step, such as the re-organization of medical supplies on a stock shelf. Occasionally, the trainee discovers that what they assumed to be a pervasive problem in the unit isn’t prevalent when the data are examined objectively. Frequently, the trainee identifies a problem and a solution that is feasibly translated into an ongoing quality improvement project. Trainees are not required to participate in QI projects that are derived from their learning and innovations, but almost always they do. I believe this is because the projects are generated from the trainees’ instinctual need to excel at what intrigues them.
As leaders in health care quality improvement, I encourage us all to consider how we develop our culture of quality in the workplace. Do we want to work in an environment where we are asked to continually improve for an agenda not our own or one where we are valued for doing what we believe will make us better? Let’s discover the collective passions in our own workplace and promote them.
Reference
Pink, D. H. Drive: The surprising truth about what motivates us. 2009 New York, NY: Riverhead Books.
Colleen recently published her quality improvement report “A daily huddle facilitates patient transport from a neonatal intensive care unit” using BMJ Quality. Read it here.