There’s a well-known quote attributed to Henry Ford: “Quality means doing it right when no one is looking.” Sometimes that’s a hard sell for organizations that haven’t done the cultural transformation work to make it a reality. Practice administrators sometimes make excuses for this with the old adage, “When the cat’s, away the mice will play” or try to convince me that their team just tends to slack off.
Usually this conversation segues right into the concept that what gets measured gets managed, and that there are ways to motivate people that don’t always involve having a manager looking over their shoulders. Quality is often driven by the goals we set for people – whether they are goals related to compliance with a specific processes or to a desired outcome.
I’m a big fan of setting both individual and organizational goals. I’ve worked with too many organizations that either set one or the other, or try to blend goals but give too much weight to one. When individuals are overly incentivized without the right systems in place, we sometimes see a breakdown in teamwork.
I’ve seen members of consulting teams who jeopardize their clients’ success by scheduling them far into the future when other team members have current capacity — to make sure they hit their billable metrics. Others may create their own collateral and tools and not share with peers because they feel it offers them a competitive edge. They don’t believe that the rising tide floats all boats, but rather seem to be focused on making sure their boat doesn’t take on any water and stays farther ahead than the competition.
When organizations swing too far to the group incentive side, I tend to see formerly hard-charging individuals begin to withdraw. They may feel that the group is pulling them down or that they aren’t empowered to lead the group to higher levels of achievement. If the group incentives aren’t aligned with what individuals can actually impact, we sometimes see outright apathy.
I saw this recently with a group of workers who previously had individual productivity goals that were directly tied to tangible bonuses and were then shifted to a bonus framework that was tied exclusively to the overall financial performance of the hospital. They had done a great job controlling their own costs and utilization metrics under the previous system, but were disheartened at knowing that poorly performing departments would likely cost them their bonuses in the coming year. Since there weren’t any cross-functional initiatives to take the successes from one team and implement them elsewhere and there weren’t any ways for the teams to work together, they saw it as a lose-lose situation and their own performance suffered.
These are always challenging issues to deal with in healthcare, where our ultimate customer is a patient with a health need. It sometimes feels crass to talk about processes and metrics when you’re working with a certain quantity of human suffering in the equation. Of course, there are extremes: organizations that seem to treat the patient like a widget that can be moved from point A to point B and always with the same characteristics. Such organizations are often accused of being heartless or profit-driven, regardless of their not-for-profit status. The other end of the spectrum often fails to understand the business ramifications of their processes and decision-making or refuses to factor in efficiencies due to the perceived uniqueness of each patient’s or worker’s situation.
As with many things, the answer is typically somewhere in the middle and this also applies to how we incentivize our teams. In addition to balancing individual goals, we also need to look at blending both short-term and long-term goals. When the finish line (or the prize) is too far in the future, it’s hard to stay motivated.
This is the particular challenge we are seeing in trying to motivate physicians and their teams to fully engage with quality initiatives. I think many of our friends in government assume that physicians are motivated by money, hence the way regulatory programs have been structured. Although a good number of physicians took advantage of the incentives or finally jumped in to avoid the penalties, others were more motivated by the idea of autonomy and continue to opt out. One could argue that the incentives (or penalties) weren’t large enough to meaningfully hit people in the pocketbook, but that only applies to some.
Autonomy can sometimes be a negative force when we’re looking at clinical transformation, as providers feel that “their way” is better than that of their peers and don’t want to come together to participate in common care paths or clinical protocols. I’ve seen this to the point of irrationality, where one physician was willing to leave the practice because her personal colorectal cancer screening protocol (which incidentally didn’t mesh with current available data) was not built into the EHR’s clinical decision support framework. Providers like this are the same ones who argue with me when I recommend posting signs for diabetic patients to remove their shoes (shown to increase the percentage of diabetic foot exams) because they have any number of reasons they disagree with it.
In order to be successful under new value-based care systems, we have to let go of some of that autonomy and figure out how to align our individual goals with those of both small (practice) and large (ACO) organizations. We also have to design systems to address short term “wins” such as a more efficient workday that will help get people to the right psychological space to play the longer game with quarterly holdbacks and annual payer incentives.
Finding the right way to motivate people is always a challenge. Physicians tend to be at least a little competitive, having been through the process of medical school admissions, residency matching, and finally entering their fields. Some will be motivated by seeing their performance against their immediate peers, such as partners or hospital data, more than they will be motivated by national benchmarks. Those individuals love real-time reporting or as close to real-time as their technology will allow. They may be more willing to participate in operational tweaks to streamline outcomes and have a vested interest in being part of the solution. Others who are less competitive or unsure of their own abilities tend to shy away from those frameworks, needing more individual coaching or peer-to-peer involvement to be successful.
This spectrum varies across specialties as well. Some have been used to publicizing complication rates for some time, where others find this brand new. One has to be careful with competition though, especially when you’re dealing with top-caliber people and processes. I am working with one organization where all of their providers are routinely in the top decile for various care metrics, if not in the top 3-5 percent. Pitting them against each other isn’t going to be productive from an efficiency (or psychological) perspective.
There’s no magic recipe or secret sauce on how to incentivize people. The best advice I can offer an organization is for them to spend time and energy consciously thinking through these concepts and working with their managers and employees to find a solution that will motivate them to excellence. Assuming it’s one size fits all is a mistake but one that I see all too frequently, as is assuming that people are just intrinsically motivated to do the right thing.
How does your organization motivate people? Email me.
Email Dr. Jayne.