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So What?

You’ve finished reading Janet Brown’s Healthcare Quality Handbook from cover to cover.

So what?

Your department has over 5,000 policies and procedures.

So what?

Your organization collects bucket loads of data.

So what?

Each Work-Related Activity Needs a Meaningful Purpose

When it comes to work, everything you do must be goal-oriented. This may seem quite obvious in theory but it is only sometimes seen in practice.

First, let me be clear on something. This piece is only concerned about work-related matters. Examples would include any of the above, i.e. CPHQ certification, development of policies and procedures, and data management. We are not talking about frivolous stuff, like walking the dog, baking a cake, or your next European vacation. We’re talking about the business end of things—the stuff that ultimately saves people’s lives, improves your organization’s bottomline, and sees you being promoted and/or headhunted for your dream job. Let’s forget about the other (trivial) issues for now.

People who work, or who have worked, with me know that I’m obsessed with knowing why we are doing what we are doing. This is a really important question for me personally because I have a lot on my plate, only 24 hours in a day, and only so much I can delegate. Knowing the purpose of my activities helps me decide:

  1. Whether I should accept the job or pass on it;
  2. How it should be prioritized; and/or
  3. What I need to do to get the job done efficiently and in the shortest possible time frame.

In other words, knowing the goals:

  • Allows me to select the jobs that contribute to my mission;
  • Improves my effectiveness and productivity; and
  • Gives me time for recreation.

I can do all the things I want to, and get them done with satisfactory results and with minimal stress in the 19 waking hours or so I’ve got during the day.

Many people in healthcare organizations have little idea why they do what they do (besides the fact they need to pay the bills and the same thing has been done in exactly the same way for the last 30 years).

Many healthcare organizations have little idea why they get their employees to do what they do.

Policies and Procedures

I sometimes ask staff in nursing departments and quality management departments for their purpose behind their library of policies and procedures. I often get a blank look in response, as if the answer was obvious. However, the reason for having numerous policies and procedures, often the pride of some department heads and other management staff, is not entirely clear, both to themselves or to other parties.

Frequently, managers cannot articulate, in a succinct and logical manner, the reason for their department having a mountain of policies and procedures.

When pressed, these same individuals may offer “quality improvement” as “the reason.” I’m rarely convinced; the response usually comes across more like an afterthought instead of a deliberate course of action.

In general, policies and procedures guide operations so that the organization can get closer to reaching its vision. Each should have a clear reason for its existence, and the people who own or who developed the document should be able to articulate its existence in language that everyone can understand.

Simply having a lot of policies and procedures doesn’t help an organization go anywhere, especially if management has no teeth to implement them or if staff are unaware of their existence.

Even if there is a stated “reason” for a policy or procedure, it doesn’t necessarily justify the work required to create it—read the “So That…” test below.

By the way, the best quality professionals in healthcare (most of whom manage the best quality management departments in my experience) attempt to minimize the number of policies and procedures in circulation within their organization, by getting rid of superfluous or obsolete ones, or consolidating current ones. On the other hand, the least effective, least efficient, and least successful managers I’ve come across spend a lot of time creating more and more policies and procedures (the majority of which sit on a shelf somewhere, without being implemented). As glorified wordsmiths, these individuals do not add value to their organization.

Data Collection

As suggested in a previous article, many organizations collect tons of data. However, a frequent problem is the absence of a clear purpose for collecting the data, which almost certainly means a waste of staff time and effort because all the work in data collection has a next-to-zero chance of contributing to positive results. Data collection is meaningful only if it has a well-defined purpose.

Reading Janet Brown’s Book (or Any Other Book)

“Why did you read every page of Janet Brown’s book?”

The response is usually one of the following:

  • “Because I read somewhere that I need to study the book for the exam.”
  • “Because my friend read it and she passed.”
  • “Uhhh… you mean I didn’t need to read that thing?”

None indicate a clear purpose.

Like the example with writing policies and procedures, even if there was a stated purpose for reading the entire tome, it doesn’t necessarily justify the work.

The “So That…” Test

Anyone can blurb out an excuse a “reason” for doing anything, especially if it keeps them in their cushy job.

Hence, finding a purpose for any activity in a healthcare organization shouldn’t be a problem (though it often is).

Suppose a “purpose” is put forward. There needs to be a way to determine whether it makes sense.

Enter the “So That…” test.

Here’s how it works.

Example No. 1

Question: “Why do you do CPHQ training?”

Answer: “I’ve trained hundreds of individuals to become kickass CPHQs so that they can assist their organizations achieve their quality objectives with the least amount of resources and in a timely manner.”

Example No. 2

Question: “Why did you participate in Failure Mode and Effect Analysis in Hospital X last week?”

Answer: “I participated in FMEA on the medication reconciliation process in Hospital X last week so that far fewer patients will be harmed by errors in medication reconciliation.”

Example No. 3

(Because all good things come in 3s.)

Question: “Why did you accept a job in South Asia recently when you have (more than) enough work closer to home?”

Answer: “I welcomed the opportunity to work with healthcare professionals in South Asia so that patients in that region may benefit from world-class practices in healthcare quality management, e.g. lower morbidity and mortality associated with healthcare.”

“Will the Patient Buy It?” Test

By applying the “So That…” test, you should be able to recognize weak “reasons” for doing things. If it is still not clear, ask yourself this question: “Will the end customer be willing to part with their hard-earned money if they heard the reason for you doing what you are doing?” This is what I call the “Will the Patient Buy It?” test.

For example, do you think the end customer (= patient, in healthcare) be willing to pay (my clients or students) if I gave them these reasons for doing what I do?

  • “Assist organizations achieve their quality objectives efficiently and in a timely manner”
  • “Far fewer patients will be harmed by errors in medication reconciliation”
  • “Lower morbidity and mortality associated with healthcare in South Asia”

Do I hear a resounding “Yes”? (See why I get paid the big bucks?)

Let’s compare these “so thats” with others that people may suggest to be their reasons for doing things:

  • “I read (Book XYZ) so that I will pass the CPHQ exam.”
  • “I have a zillion policies and procedures so that people will know how to do their job better.”
  • “I collect data so that quality will improve.”

Unlike the “so thats” for my activities above, these “purposes” don’t make sense. What’s the difference? Scientific evidence.

Scientific Proof of a Link Between Process and Purpose

In each of the three examples of my work above, I can back up my reason for doing them will hard evidence, i.e. data and facts:

  • My CPHQ training: proven results, with 100% pass rate among my private students.
  • FMEA on medication reconciliation process: proven results, with zero incidents following implementation of action plans
  • Introducing world-class practices in a developing nation: proven results; work by the World Health Organization and others has shown that evidence-based practices, e.g. in hand hygiene and surgery, lead to significantly better outcomes in developing countries

In other words, the link between the process (what I do or intend to do) is linked to the desired outcome (the end result I want to achieve) by scientific evidence.

Now let’s compare these examples with other scenarios:

  • What evidence is there to show that reading Janet Brown’s book (or any other book) alone improves the chance of passing the CPHQ exam? In fact, the converse may be true: the pass rate among persons who never touched Janet’s book is the same or slightly higher than that among persons who used the same book exclusively. (Please note that you should exercise caution when interpreting these data due to potential confounding factors, e.g. a large proportion of those persons who never used Janet’s book were my students; they were highly motivated and had access to resources we provided.)
  • What evidence is there to show that having lots of policies and procedures alone improved patient outcomes? How often do we see hospitals, despite all the relevant policies and procedures, experience inferior outcomes in healthcare-associated infections, wrong-site surgery, and fatal medication errors?
  • What evidence is there to show that data collection alone leads to sustained improvement? Admittedly, sometimes dramatic improvements can be observed when management decides to monitor a process or outcome. But these positive results are often short-lived, i.e. the Hawthorne effect. Collecting data per se does not lead to better results, but it certainly consumes a lot of time, effort, and money.

Is the Purpose Meaningful?

A common reason for activities performed by organizations and healthcare professionals is hospital accreditation. At least that’s what they tell me.

Does this make sense? Sure it does. They are saying that they need to collect data, write policies and procedures, and have meetings so that they may be accredited by Joint Commission International (JCI) or whatever other accreditor.

However, is this purpose meaningful? I doubt it.

So let’s apply my simple test for meaning in purpose: the “Will the Patient Buy It?” test.

Will the end customer, i.e. the patient, pay more for you (or your organization) to collect data, write P&Ps, and sit in meetings, so that your organization can be accredited by Joint Commission International? I don’t think so.

Will the end customer, i.e. the patient, pay more for you (or your organization) to collect data, write P&Ps, and sit in meetings, so that some manager(s) can look busy and keep their comfortable (but ineffective) job? Probably not.

Is the Purpose Meaningful to the Patient?

Try proposing another purpose for the same activities (and please be genuine about it): Will the patient pay more for you (or your organization) to collect data, write P&Ps, and sit in meetings, so that they may be less at risk of being infected, operated on the wrong body part, or even killed by their healthcare?

I suspect the patient may be more agreeable if the purpose behind your activities is more meaningful to them.

Is the Purpose Meaningful to the Staff?

Having a meaningful purpose will help to motivate employees. Most professionals who enter healthcare have an altruistic desire to help people. Giving them a purpose that supports this desire—and articulating it clearly—is usually sufficient to keep the workforce highly motivated, even more so that with financial incentives.

Think about this: how motivating is doing something for accreditation?

In contrast, do you think a doctor or nurse will be motivated if they know they are doing something to save their patients’ life or to prevent them from being injured during the course of their care? I think so.

Conclusion

By applying the “So That…” and “Will the Patient Buy It?” tests, you will be able to evaluate:

  1. Whether there is a purpose behind the activity in question; and
  2. If the purpose is meaningful.

Having a clear and meaningful purpose in each of your activities will help you become more successful, more relevant, and more satisfied in your work.

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