Wither the Woodshed

One tangent I excised from my essay on trying to make people ‘be nice’ is the reliance of negative reinforcement in behavior modification.  It seems that the arsenal of tools that many organizations have are heavily skewed to the sticks with few carrots anywhere in sight.  I remember having a conversation with a CEO, discussing the things the organization did to drive patient experience initiatives.  As we talked, it seemed that there were a lot of things to address deficiencies but very little to celebrate accomplishments.  When I pointed out that the strategy seemed heavy on the sticks and light on the carrots, he said, “Well accountability goes both ways.”  To which I responded, “Exactly, accountability goes both ways.”  The challenge is that organizations have plenty of ways to be punitive, but not necessarily many ways to be supportive.  This negative focus does not generally lead organizations to broad runs of successful performance. 

This is not an essay about how we shouldn’t hold people accountable.  We absolutely do need to hold people accountable.  Sometimes, when you cannot manage-up, it becomes necessary to move people out.  It is important, though, to remember that behavior modification has two variants.  There is the supportive variety that focuses on rewarding successes as well as the punitive variety that focuses on punishing failures.  Certainly, both are required to break old habits and form new ones.      

When it comes to clinical best practices or financial efficiencies, it may be useful to stress the costs of failure rather than the benefits of success.  I am not an expert in those pillars, so I am not going to talk about motivation in those areas.  I have said repeatedly that for patient experience work to be effective it must focus more on the HOW and not the WHAT.  PX is about being helpful, smiling, patient, calming.  It is about giving patients the space to truly feel their anxiety and help manage it.  It is about giving an extra second of silence to allow someone to respond or ask questions.  In this space, an emphasis on negative reinforcement makes people less likely to dedicate attention to doing these softer things.

This isn’t saying that people cannot be engaged even when they are having a bad day, or when they are being told to.  This isn’t about oppositional defiance disorder where people lash out at authority figures just because they are authority figures.  It is saying, though, that when stimuli on a topic are overwhelmingly negative it creates a visceral, usually defensive, response.  This response, then, will kick in whenever confronted with those stimuli.  I am not a psychiatrist, and I probably know just enough about BF Skinner to be dangerous.  But I don’t think it takes advanced degrees to determine that, if your boss only visits you when you did something wrong, and they appear at your office door, your anxiety rises.  If the only time a leader talks to you about your performance on service initiatives is because you are failing at the metrics, any time that leader appears, your defense mechanisms will kick in.  So why do organizations seem to find it difficult to balance the carrots with the sticks?

Organizations fail to realize that frequency counts

When I was talking to that CEO about accountability going both ways, we were discussing the organization’s strategy for discussing service performance.  In essence, the model was that they would set a fiscal year goal and if they reached it, celebration and if they did not, punishment.  But as the year went along, though, every month that the unit failed to meet their goal, the leaders would be called on the carpet for failing to meet the goal and asked to fix it.  But if an area met the goal, there would be no comment from leadership.  When I asked why this was, I was told that leadership did not have the time to address every area, so they focused on the failing areas.  I pointed out that this essentially meant that punishments happened more frequently than celebrations.  One celebration against twelve punishments (thirteen if you count the fact that if a unit fails 12 times, they are also failing in the fiscal year goal). 

Now understand that if things are not headed in the right direction, we need to address the problems and not just wait until the end of the year.  My suggestion to him was that at the very least, he needed to figure out how to celebrate those who succeeded in their month’s scores.  Otherwise, any time a leader got a phone call from him, they were already going to be assuming the worst and were likely preloading their excuses or defensiveness.  This was especially the case when a unit might have succeeded for five straight months, had a down month, and now they are being called to account for their failure.  Nothing indicates being out-of-touch like delivering the same fire-and-brimstone message to the unit that failed once in six months as to the unit that has failed six times in six months.

My recommendation is to count the touchpoints, not the initiatives.  If a unit gets kicked four times and celebrated once, is the unit getting the right message?  On the other hand, if the unit gets kicked four times and celebrated nine times (again including the fiscal year celebration), then the feedback aligns with performance. 

Action out of panic doesn’t usually work

Further, if a leader fails in a month and is asked to defend themselves and fix the problem, they are likely to pick the lowest-hanging fruit.  (Or, perhaps, the closest branch in the raging river is a more apt metaphor.)  Perhaps it says more about me, but decisions I make in the heat of stressful situations are not necessarily the best ones.  In fact, if I don’t pause a moment and take a breath, I tend to pick things that will make things worse.  Maybe this is just me.  But I don’t think so.  If your organization demands action plans to address service gaps every month, you should read them.  My experience is that they are often full of platitudes (We will focus on being nice), broad baseline behaviors (we will discuss in the daily huddle), or strategies that have no purpose (we will put a team together).  None of these things will do anything.  Yes, being nice and reminding staff at the daily huddle about the unit’s service vision is good.  But since we don’t know why the scores dipped, or if it is a blip or a trend, we don’t know if these things, as vague as they are, will even address the core issue. 

The reality is that, especially if a leader’s defenses are raised because people only call when they do something wrong, they are likely giving the first thing that comes to mind.  It either means that they are either going with a basic fix or throwing someone else under the bus.  “If you think my daily reminders in the huddle aren’t working, well, how about I blame the doctors?”  Again, you may say that if the boat is leaking, then bailing water is a good idea.  I agree, but bailing water is not a solution.  It is what you do to buy time as you try to come up with a solution.  You cannot expect people to craft a thoughtful solution as they stand in front of you sweating profusely, as they are bailing water as fast as they can, hoping that the meeting will end.  Perhaps the best example of this is this simple question: has anyone actually seen one of these on-the-fly action plans work?  I have seen dozens and dozens of them and not one has ever been held up as an example of what has turned the tide.

Sometimes neutral things are perceived as negative things

As mentioned, a quick fix to address gaps is to require teams to generate action plans.  An action plan itself is not negative.  In fact, as it represents positive work towards a goal, it is a constructive tool.  But an action plan that is assigned to you because you are failing is a punishment.  This seems completely obvious to me, but if you disagree, please let me know in the comments.  If a manager is meeting their goal, they are not being assigned an action plan to hardwire current performance or even construct ways to build on current success.  No, they only get this homework assignment if they are failing.  So, while organizations might see these action plans as a way to jump-start improvement, a way to help a unit find their way forward, to the person assigned this busywork it is not seen as empowering.  It is a punishment.  This is only made worse because more often than not, the action plan simply checks a box, and no one is reviewing it, making constructive suggestions, or even reading it.  It is the very definition of performative. 

I remember working with a system where the PX team kept a list of boilerplate action plans in a common folder, so any time a leader needed one, they could peruse the list and pick one that they haven’t used recently.  (You know, on the off-chance anyone was comparing it to the previous month’s action plan.)  Since these action plans were not reviewed or validated, the whole process was a game. 

Frankly, even positive things can feel like negative things.  No matter how one constructs fiscal year goals, there will come a time that a unit, clinic, or emergency department will become mathematically eliminated from being able to achieve the goal.  At that moment, the target number becomes an albatross around the unit’s neck.  Every month, the unit is reminded that they failed and they can do nothing about it.  Even if the scores bump up and they are improving, it is already known that it is too little, too late.  Over the course of the final couple of months, this is one thing.  But if your goal is lofty and you are not meeting it, it can get late pretty early.  Clinics, as an example, often have very high goals, since the comparative database for clinics is pretty aggressive.  Often, the 75^th percentile can be at or north of 90% top-box.  If you must finish the year at 90%, or average 90% every month, and you are consistently scoring 85% top-box, you will be mathematically eliminated from meeting goal by the eighth month.  Given that by the fifth or sixth month, you will need to be performing 10% higher than you ever have historically, you are effectively eliminated with half the year remaining.  That means that for six months, no matter what you do to improve, even if you do show improvement, you KNOW you will not meet goal.  That is a punishment.

Now, you may say, “Joe, this is not about participation medals, where everyone gets one, it is about real goals with real consequences.”  I absolutely agree.  I am not saying that goals should be easy or that or that inability to improve should be tolerated.  I am merely asking the question: are people more or less motivated to engage in the work, if they know that it just doesn’t matter?

I don’t think organizations set out to be overly punitive with goals.  It just works out that way.  Part of it is the asymmetrical approach to failure and success.  Failure must be immediately addressed before it is too late.  Success, though, cannot be immediately celebrated because who knows what tomorrow will bring?  It is funny that people will push away success by saying, “there is always room for improvement.”  We all know this.  We also know that, if we are failing, there is always room for additional failure.  This is the motivation for quick action.  If it is never too early to fix a problem, then logically, it should also be never too early to celebrate a win.  How organizations can do this, I will explore in another essay.