Power of Information
Surprising impact of increasing information flow in
a project to restructure a medical center's quality efforts
Told by: Paul Plsek
leaders in a large, medical center hospital asked me to help them re-structure their
quality management efforts. The told me that the organization had a traditional quality
assurance (QA) system, coupled with a more modern continuous quality improvement (CQI)
The leaders felt that the first step in this year long project should involve me doing
a series of interviews to assess the current quality efforts. To their credit, they
insisted that I interview some 50+ people in the organization and form my own
recommendations about what needed to be done, rather than relying on their assessment.
They were convinced that the quality efforts were fragmented and not very effective, but
they wanted me to decide for myself. They also admitted that communication within this
traditional, hierarchically structure organization was not always the best it could be. I
might learn something very different, they felt, by talking directly to the people who do
In my proposal to them, I
structured the work in two parts. I would do the organizational assessment and make my
recommendations. They would pay me for this work. After receiving the report, they could
then decide whether or not they wanted me to continue working with them to help plan for
the implementation of changes based on the recommendations in the report.
Without going into detail,
let me say that my report confirmed the administrative leaders views that quality
efforts were fragmented. Physician leaders associated with the organization were also
unhappy with the situation. Physician-staff and cross-departmental teamwork within the
organization was weak and in need of attention. Among other things, I recommended that the
many separate physician-only and staff-only quality committees be disbanded and replaced
with physician-staff quality groups who could look at issues in a more holistic fashion.
Physician and administrative leaders agreed that working together sounded better, and was
potentially more efficient, than working separately.
To wrap up this part of the
Tale, let me simply say that we arrived at a mutual agreement that the organization was
ready to work on the changes I had recommended, and that I would continue to work with
them. The planning for the changes in the quality system is a work in progress at the time
of this writing.
As a fascinating side street in
this Tale, I want to report on a strange CAS behavior that I observed. I asked the senior
administrator who was my contact to distribute a draft version of the report to all the
people I had interviewed for their comments before I finalized it. She agreed to do this.
I later learned that this was unprecedented. People in the organization had been
interviewed on issues by outside consultants before, but never had they seen a copy of the
consultants report, much less a draft version upon which they could comment.
While it might seem that this
"new thing" of open information sharing would be a positive and refreshing
development, it had a decidedly dark side to it. Managers began taking pot-shots at their
colleagues in the quality departments (there were two quality departments, one supporting
the QA efforts and one supporting the CQI efforts). The organization was in the throes of
its annual budgeting exercise where cuts were needed. Since the outside consultants
report indicated that the quality system was ineffective, perhaps the needed budget cuts
should come out of the quality system. As I understand it from reports from several
people, some downright nasty comments were made, citing the draft report as evidence. I
spoke to several members of the quality department who said that they agreed with the
information in the report and acknowledged that I had written it in a positive,
"lets improve the system" tone. They told me that they were angry at their
colleagues, not at me.
Regardless of who they
were mad at, two members of the quality department supporting the CQI efforts resigned to
seek jobs elsewhere. My conversations with both of them after they left indicated that
they just didnt see any hope for the organization and they didnt want to put
up with the aggravation. They both felt that there were better opportunities elsewhere.
(Both were in their 20s, bright, and energetic.) The department director left a few months
later. I have not spoken to her since she left. In conversations before she left, I could
never tell whether or not she blamed me for the abuse she was taking. She said she
didnt, but I still have an awkward feeling about it. She clearly didnt like
talking about it, and I suspect that her inability to deal openly with what was happening
made things more stressful for her. The stress just built up until she decided to leave.
Two members of the department supporting the QA-side, including the director, left a few
months after that (although there were other reasons beyond the sniping that had emerged
based on the draft report). Only two of the seven people devoted to quality activities at
the beginning of my relationship with the organization are still there.
I had no idea that my
long-standing practice of asking the people I had interviewed to comment on my report
before I finalized it was unprecedented in this organization. I did not know that I was so
dramatically increasing the information content of the system, relatively speaking. My
mental model discounted the input from the management team at the beginning of the
engagement. And later inputs raised no visible red flags for me. For example, I did
mentioned my intention to send around a draft report in my comments at the end of each
interview. But I got either no reaction, or a comment like, "Oh, that will be
nice." No one told me that this was absolutely unprecedented. My contact within the
organization who distributed the report also gave no indication that this was unusual.
Perhaps this is one of Gareth Morgans organizational "gulfs," that no one
acknowledges openly. You can bet that I will inquire more directly about this in the
I stand by the report as written
and would not change anything about it. It was a factual reporting of what I was told; it
was a good analysis of what is needed based on my professional experience with quality
systems; and it was written in a non-judgmental, "lets fix the system"
tone. The people who left made adult, individual decisions to leave. I am comfortable with
my role here. I will in the future, however, be much more cautious about the timing and
mechanism of release of such information in a CAS that is not accustomed to receiving it.
Copyright © 2001, Paul E. Plsek