I have said in the past that attention is currency. Those who work for you will pay attention to the things that you think are important. I don’t think this concept is in dispute. I do, however, think that this is easier said than done. Just because you say something is important once or in isolation does not mean it will be treated with the same urgency as other things will be. Like so many things in patient experience, HOW matters much more than WHAT. Like so many essays, I was started out intending to explore a number of the important elements of HOW, but 2000 words in, I realized that this is the work for multiple essays. In this essay, I will explore the biggest issue that will underscore all other concepts.
The biggest determinant on the effectiveness of attention to motivate staff is the nature of it. All attention has both positive and negative forms. While both are necessary, it seems like one side of this equation gets utilized more than the other, as negative feedback far outweighs positive feedback. This one-sidedness will not deliver the positive benefits one might imagine.
Some leaders think that by always focusing on the need for constant improvement, they are creating a staff that is always trying harder. This might be true in the short run, but in the long run, it is not. In any relationship, be it romantic, friendly or professional, there will be places where you excel and places where you fall short. But if the other person only focuses on your negative qualities, regardless of how hard you work to address them, you will quickly conclude that nothing is good enough for them and you will stop trying. If this person cannot recognize your effort let alone your progress, what sort of relationship can you really have with this person? In the personal space, you will distance yourself from them, less likely to initiate contact and more likely to look for reasons to avoid conversations with them. In a professional space, you will tune them out and if you cannot tune them out, you will look for other opportunities. A leader who focuses only on the hole and not the donut will lose their staff, either figuratively or literally.
Perhaps you are a leader who is appalled at the gap between where your team is and where your expectations are. If a person really does irredeemably stink and has no worthwhile qualities, well, your solution probably does not include any more coaching and requires a meeting with HR. But most of your staff are probably middle-performers, those in the meaty part of the bell curve. These folks want to do a good job but may need guidance. But if you cannot point out the improvement they have made, even as you chart a course for more improvement, why should they keep trying to curry your favor?
Now the opposite is also true. If I only shower you with praise and do not provide any constructive criticism, you are not likely to try and improve precisely because you think that there is nothing to improve. When I was in graduate school, I was a teaching assistant to a professor’s undergraduate class. I managed student questions, graded papers and exams. The class itself was not an introductory class or a senior-level class. It was a simple midlevel class dominated by sophomores and juniors who were mostly majors. The professor expressed how he hated teaching classes like this, since they were not populated by the curious (freshmen looking to explore) or the committed (seniors committed to the subject matter.) Instead these classes were full of people who were obsessed about their GPA and would argue every little issue to squeeze an extra point out of everything. He told me (but not the class) that he was committed to giving everyone in the class this semester an A or a B. Period. No C’s and certainly no failing grades. He thought that this would prevent the whining and whingeing1 so he could focus on teaching the material.
Instead, though, the class generated far more grade complaints and fighting than any other class I had taught or been an assistant to before. I was the target for most of this, since I was the point-person for class performance. In this, I learned three lessons.
- Failing was as much a state of mind as anything else. If there are only two grades, then B becomes failing.
- Class performance is often not just about doing well but also doing better than someone else. A grading system that puts an above-average student in the same bucket as an idiot who forgets a pen to an exam helps no one.
- Some people will never care about the material and only the grade. A professor who is passionate about the material can only succeed if the class also feels that passion.
This is just the inverted logic of those professors who never gave out an A, because that was evidence of perfection. The real world is full of success and failure, often in the same unit by the same people. If you cannot honor success, then no one will listen when you berate failure. Communication must be about reality before it can be about motivation.
Why do people struggle in making positive attention part of their repertoire? There are two reasons that I see most often that explain why organizations tend to focus exclusively on the negative.
No Time
In a hierarchy the level of specificity increases the further down the hierarchy you go. So, a CEO may know nothing about what is happening inside a specific hospital’s unit while a nurse may know nothing about what is happening outside of a hospital’s unit. Every step up the ladder means being responsible for more things, which in turn means having less time for each individual element on that list. Further, as one goes up that ladder, and is responsible for more things, they must prioritize that list of responsibilities. It is, then, not surprising that fire alarms are one of the most useful things in that prioritization. If that person has five responsibilities and four are performing adequately and one is on fire, that is where their attention will go. This makes perfect sense at some level, since fire=bad is engrained in us from an early age.
This focus skews our attention. We define our priorities by what is currently burning, what is smoking, and what seems to be giving off warning signs. We are focused exclusively on what is going wrong and will dedicate all time to that. This means that we have no time to focus on what is going right. An organization will say “We don’t fix what is not broken,” and this sentiment tells you exactly what they see as a manager’s job. So, the senior leaders’ attention is to fix problems, so the manager’s attention is to fix problems.
I had a boss once that said, “You will know when I have a problem with you because I will tell you.” This can be satisfying because you don’t have to worry about how to interpret silence but also illustrates that person’s managerial shortcomings. He didn’t say, “You will know when I think you are doing a great job because I will tell you.” You make call this silly or being a snowflake, but by not identifying this side of the spectrum, staff may wonder if
- They are doing a great job, a good job, or an adequate job
- The work they are doing to strive for greatness is really working
- The leader can even tell the difference between a great performance and a good performance
So, a leader will beat staff when the dashboard shows RED. The leader will beat the staff when the dashboard shows YELLOW. But the leader will not show interest in a GREEN. While they may care that it is GREEN, by not showing interest in that, they demonstrate to their staff that there is no value in learning why the number is green, or how we can learn from this or spread this message to other areas where the numbers are red and yellow. So, the great irony is that by not dedicating time to explore why things are working well means it will be less likely that you will need time to explore why things are working well.
Not obvious
The other reason why leaders don’t focus on positive messaging is because they don’t know what success looks like. They may know what success looks like using broad metrics at the end of the quarter or the fiscal year, but they don’t know what it looks like in day-to-day behaviors. Or perhaps it doesn’t look like what they think it should look like.
Back when I was a road warrior, I remember visiting a hospital system that had made the journey from the middle-of-the-pack to the Top 10% in our database. I thought this trip would be a victory lap and it was, mostly. I talked with a lot of staff who saw positive changes in process. I talked with a lot of leaders who talked about the hard work to get from there to here. But the only exception was when I met with the CEO of the system. He complained that he didn’t trust the numbers. Usually, people don’t trust the numbers when the numbers say that you are not as awesome as you think you are. In this case, though, he thought that the organization was not as awesome as the numbers said they were. I was startled, but we ended up having a long conversation that he said was helpful. It also ended up changing how he talked about success with the organization.
The core of his confusion was that he expected being in the top 10% of patient experience would feel different. He commented that the hospital still had medical errors. The hospital still had budget problems. He stated that staff turnover was still present. None of this looked “Top Ten Percent.” I pointed out that being in the top 10% still meant that you were a hospital and it wasn’t a Disney movie. People would not suddenly be whistling while they worked. PPE would not be donned and tied with the help of bluebirds. The bad employees would not turn into donkeys. The only Disney thing present was that Bambi’s mom was still gonna die from time to time.2
Being awesome was not the absence of bad things. In fact, there are two truths to great patient experience scores.
- Pillars still stand alone. Just because you WIN at service doesn’t mean that all your staffing or budget issues will magically disappear, any more than solving your budget issues will all of a sudden make patients love your hospital. While there are broad correlations, and you should see a reduction in the count and severity of negative events when you have happy patients and staff, you should not expect a paradise.
- Some patterns will continue, but the quality of those patterns should change. For example, your turnover may not change dramatically, but if your patient and staff experience scores rise, you should see a change in who is leaving. It will likely transition from your high performing staff looking for a place that values awesomeness and towards your low-performers looking for a place where they will be more comfortable being, well, low-performers.
Most people don’t know what awesomeness looks like, since it is not simply the absence of problems. Frankly, you should see the reduction in problems as you climb from bad to average. The paradox is that the absence of problems is easier to spot, but hard to celebrate, while the absence of average (in becoming the top 25% or 10%) is easier to celebrate, but harder to spot. I will discuss the concept of celebration in another essay.
It doesn’t take an above-average marketing department to know that posting a banner that said, “WE SUCK LESS!” in the lobby is a bad idea. But it does take an above-average leader to know that the time for celebration is really when the organization does start sucking less to reaffirm the improvement. If you wait to celebrate when you achieve perfection, you will never celebrate.
1He was a Brit ex-pat who used language like that.
2Sorry, if I needed a spoiler alert for a movie that is older than I am.
PX Matters with Joseph Snipp 
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