This morning I opened my email inbox to find two unread excellence reports. The first was from a consultant surgeon. He had reported excellence in his theatre staff for staying late to finish some cases. The patients had benefited from this sacrifice and the consultant surgeon wanted to say thank you. He could have gone to each individual and said thank you directly – perhaps he did – but he chose to make it more formal by reporting this through our excellence reporting system. The second report was from a nurse who had cited the Chief Executive Officer of the trust for excellence in dealing with a particular issue in her department.
Both of these reports were essentially a formal notification of thanks. At first glance neither of these reports contain much ‘actionable intelligence’. These are just thank you letters between members of staff. All very nice, but where’s the learning?
The key to these reports is their sincerity. The excellence reports require free text entry, so the reports are written in the words of the author. There is no forced categorisation; no drop-down menus. Just free writing. This allows the sincerity to shine through. The reports are delivered verbatim to the reported staff member. So the theatre staff and the CEO will soon be receiving the same copy of the reports I read this morning. What will their reactions be? How will they feel?
My bet is that they will feel appreciated. Appreciation is different from reward. Appreciation is being positively noticed (or not being ignored, depending on your perspective). This taps into intrinsic motivation and makes us more likely to want to repeat our actions. Reward, in contrast, is an extrinsic motivator; a carrot, from the stick and carrot concept. Reward works to a point, but ultimately we tire of these motivators. Reward and punishment are management concepts from the industrial age, and they are now outdated.
Don Berwick recently wrote an opinion piece about eras in healthcare. http://jama.jamanetwork.com/mobile/article.aspx?articleid=2499845 He proposes that there have been two historical eras in healthcare: era 1, characterised by professional trust and prerogative; and era 2, characterised by accountability, scrutiny, measurement, incentives, and markets. He suggests that it is time for era 3: a moral era. The article contains nine suggested changes to move to the next era, one of which is to protect civility. Berwick writes, “Medicine should not…substitute accusation for conversation”. Whilst this may seem obvious, the truth is that it is often forgotten in reality. Under pressure, civility is often one of the first things to buckle.
How can we protect civility? A starting point would be to encourage a culture of appreciation for our colleagues. “Thank you” and “well done” are usually followed by positive dialogue which can form a strong foundation for learning how to improve. Indeed, the recognition of good practice is likely to increase the prevalence of further good practice. It may well be the simplest quality improvement intervention there is.