presentatie fred lee part 1+2 maart 2009
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Some Things You Would DoSome Things You Would DoDifferentlyDifferently
Fred Lee
3 Key Premises
We have reached the ceiling in how muchwe can improve patient satisfactionscores with our current approach.
We cannot go from good to great in patientperceptions by copying and deployingwhat they do at service companies likeRitz-Carlton or Nordstrom’s.
Culture is driven by management systems,not workers or values.
Table of Contents
1. Focus on What Can’t be Measured2. Make Courtesy More Important Than Efficiency3. Regard Patient Satisfaction as Fool’s Gold4. Measure to Improve, not to Impress5. Decentralize the Authority to Say “yes”6. Change the Concept of Work from Service to Theater7. Harness the Motivating Power of Imagination8. Create a Climate of Dissatisfaction9. Cease Using Competitive Rewards to Motivate People10. Close the Gap Between Knowing and Doing
If Disney ran your hospital you would…
If DisneyRan Your
Hospital YouWould...
1.1.Focus on What CanFocus on What Can’’t Bet Be
MeasuredMeasured
On Measurement
“Not all that can be counted, counts. And not all thatcounts can be counted.” -- Albert Einstein
“The most important figures one needs for managementare unknown and unknowable…(invisible alsoused)…What is the value, for instance, of the multiplyingeffect of a happy customer and the opposite effect froman unhappy customer…(or the) Loss from inhibitors topride of workmanship?”
-- W. Edwards Deming, Out of the Crisis, p. 122
Measurement
Outcomes Perceptions
Clinical Financial Satisfied Loyal fanGood to Great
PERFORMANCE IMPROVES Total Quality
Reputation improves
Place of choice
Productivity improves
Customers sing our praises
Costs go down
Processes improve
Outcomes
Perceptions
Impact of PI on Total Quality
AnalyticalSkills
EmotionalSkills
Talent
You can’t manage perceptions in thesame way you manage outcomes.
Objective, MeasurableCreated by teamsMap and study process stepsImprove technical competence“Zero defects” thinkingBased on what you doEliminate carelessness
Subjective, ImpressionsCreated by individualsTake action -- just do it!Inspire attitudes and behaviors“Best possible” thinkingBased on what you sayEliminate avoidance
Outcomes (left brain) Perceptions (right brain)
80% of our PI scores 80% of our PS scores
If DisneyRan Your
Hospital YouWould...
2.2.Make Courtesy MoreMake Courtesy More
Important ThanImportant ThanEfficiencyEfficiency
1. Safety2. Courtesy3. Show4. Efficiency
Disney’s Quality Priorities
PERSONAL EXAMPLES
Personal efficiency vs. Accessibility
Job efficiency vs.Saying “yes”
Process efficiency vs.Responsiveness
How do you make courtesymore important than efficiency?
Paradox: Customer First is More Efficient
Results in overallorganizational
inefficiency
Results in overallorganizational
efficiency & teamwork
unit efficiency first courtesy first
internal focus
unresponsive
compete for resources
external focus
responsive
share resources
If DisneyRan Your
Hospital YouWould...
3.3.Consider PatientConsider Patient
Satisfaction FoolSatisfaction Fool’’ssGoldGold
Wilderness Lodge
In Commercial BusinessesResearch on satisfaction shows…
On a scale of 1 to 5, people who mark a 4 aresix times more likely to defect to thecompetition than those who mark a 5.
Harvard Business Review, Nov-Dec, 1995
Why is it so hard to raise our scores?
+2+1 0 -1 -2 -3
4
Meeting expectations = 0
Satisfied = 0
Satisfied patientshave no story to tell
Hampton Inn, huddle
It’s the same as zero!Neither good nor bad.
Patient satisfaction is a fool’s gold.
Singing our praises…Caring, Cared, Cares +32Kind, kindness +24Compassionate +15Help, helpfulness +15Comfort, comforting +13
Friendly +8Professional +9Attention, attentive +7Concerned +6Listens +4
Loving +3Sweet +3Respect +3Quick +3Polite +3Patient +3
CommittedWarmUpbeatGenerousSoftnessPleasantSupportive
CheerfulInformativeCompetentEfficientProficientPromptHardworkingCourteous
Understanding +2Thoughtful +2Knowledgeable +2Smiling +2Bedside manner +2Empathy +2
Tender +1Takes time +1
SensitiveReassuringSelflessGentleNiceConscientious
Hire
Require
Inspire
4
3
1 & 2
5
Fire
Staff Motivation
PatientEvaluation
Staff Performance
The Three Levels of Care
Judy
Courtesy
Compassion
Competence
Courtesy
Compassion
CompetenceIncompetence
Rudeness
Indifference
Enemyis not..
This is about
Three enemies of caring
Judging
Avoidance
Carelessness
EnemyIs…
What I Feel
What I Say
What I Do
If DisneyRan Your
Hospital YouWould...
6.6.Change the Concept ofChange the Concept ofWork from Service toWork from Service to
TheaterTheater
Disney is not a service and neither are we.
Commodities
Extract
Goods
Make
Services
Deliver
Experiences
Stage
O V
E R
T I M
E S
ince
1900
Joe Pine, The Experience Economy
The progressionof economicvalue
Entertainment?
Theater is about life –comedy and tragedy.
Hospital:Meeting the emotional needsof a family suffering a tragedytogether.
Disney:Meeting the emotional needs ofa family to have fun together.
A hospital without compassion is like Disney without fun.
Focus on the patient’s experience, not our service…
Companies stage an experience whenever theyengage customers, connecting with them in apersonal, memorable way.”
“They actually occur with any individual who hasbeen engaged on an emotional, physical,intellectual, or even spiritual level. The result?No two people can have the same experience – period.”
B. Joseph Pine II, The Experience Economy
At the Wilderness Lodge
Think Disneyexperience, not justdepartment or hotel
service.
Think patientexperience, not just
department or hospitalservice.
OrOr……
Our Service Or Their Experience?
High anxiety Pain
No PainLow anxiety
CourtesyWhat you sayNo clinical effect
CompassionWhat you feelClinical effect
Depends on the emotional needs of the patient.
Service paradigm Experience paradigmOR
THE DIRECTOR:
Start by describing the experience you want the guest
to have (see, hear, and feel) and how to make each
scene memorable.
Cast for the talent to play the role called for in the guest
experience, rather than just the skills to do a job.
Clarify each person’s role in creating a memorable
experience and get their commitment to their role.
Borrowing from Theater
THE ACTOR:
Actors learn how to be real by becoming emotionally
engaged with their character.
Actors rely on sense memory and imagination to become
real in their role.
Borrowing from Theater
Acting is not pretending…Eric Morris, No Acting,Please (first sentence)
Acting is the art ofcreating genuinerealities on the stage.No matter what thematerial, the actor’sfundamental question is:“What is the reality andhow can I make it real tome?”
Acting must “come froma real place.”
To paraphrase…
Care giving is the art ofcreating genuine realitieson the hospital stage. Nomatter what the event, thecaregiver’s fundamentalquestion is: “What is thereality of this patient’sexperience, and how can Imake it real to me?”
Compassion also must“come from a real place.”
Theater changes the service paradigm…
From patient satisfaction –to a fan with a story to tell
From just being courteous –to engaging the guest
From our service excellence –to their memorable experience
Theater changes the service paradigm…
From hiring for the skills to do a job –to casting for the talent to play a caring role in the guest
experience
From teaching body language –to teaching acting principles(being real through imagination)
Knowing how is not the problem…
Like losing weight, our problem is not withknowing how. When we want to enough,we figure out how and learn by doing.
Our problem is with being committedenough to do what it takes every day, anddo it permanently, not just in short burstsof inspired energy.
W. Edwards Deming might add…
What is the value ofa committed
ensemble of caregivers who have
becomecompassionatelyengaged in the
patient’s experience?
In The BoxYou can’t get different results by doing more of
the same old things in the same old way.
Centralized ControlUnit Efficiency Focus
Silo mentalityPercentile ranking
Compliance cultureOutsourced coachingCompetitive rewards
Just tomention afew…
Correlating patient and employee satisfaction.
PREMISE: Excellence is Fun
There is nothing like excellence to improve morale.
Anything done poorly is hard work and a real drag.Persistent mediocrity is discouraging, depressingand saps all our energy.
Anything done at the level of excellence or in thepursuit of excellence with a great coach is FUNand energizing.
Overcoming InertiaVision of
“could be”Knowing“how to”
OrganizationalInertia
Dissatisfactionwith “as is” + >+
Comfort zoneForce of habit
Must begreater
than
The WallCommitment
Inoculation
Impr
ovem
ent
Compliance
LoyaltySatisfaction
OwnershipAutonomyExcellenceEnthusiasmTeamwork
Time
Program
Old Paradigm to New
Service excellenceStarts at the top
LeadershipEmpowermentAccountability
ComplianceDo by learning
Memorable ExperienceStarts anywhereCitizenshipOwnershipResponsibilityCommitmentLearn by doing
Fallacy of asking, “How?”
“Asking How? Is a favorite defenseagainst taking action.”
Peter Block, The Answer to How is Yes
Knowing how is not the problem…
Like losing weight, our problem is not withknowing how. When we want to enough,we figure out how and learn by doing.
Our problem is with being committedenough to do what it takes every day, anddo it permanently, not just in short burstsof energy.
3 Key Premises
We have reached the ceiling in how muchwe can improve patient satisfactionscores with our current approach.
We cannot go from good to great in patientperceptions by copying and deployingwhat they do at service companies likeRitz-Carlton or Nordstrom’s.
Culture is driven by management systems,not workers or values.
Baldrige CriteriaCategory: Patient Satisfaction
APPROACH: How will we talk about goingfrom good to great in patient perceptionsthat is inspiring and motivating for our staff?
DEPLOYMENT: Who will lead out, and howwill we generate commitment throughout theorganization at every level?
RESULTS: How will we get, track, and usefeedback?
3 Key Premises
We have reached the ceiling in how muchwe can improve patient satisfactionscores with our current approach.
We cannot go from good to great in patientperceptions by copying and deployingwhat they do at service companies likeRitz-Carlton or Nordstrom’s.
Culture is driven by management systems,not workers or values.
Baldrige CriteriaCategory: Patient Satisfaction
APPROACH: Going from good to great by usingthe experience approach rather than a serviceapproach. Moving from the good of…
to
to
to
Our service
Dept Efficiency first
Hardwired courtesy
Patient’s experience
Dept Courtesy first
Emotional support
Baldrige CriteriaCategory: Patient Satisfaction
DEPLOYMENT: Involving everyone. From just…
to
to
to
Committees Departmental ownership
Educators training Managers coaching
Hardwiring service Inspiring compassion
Baldrige CriteriaCategory: Patient Satisfaction
RESULTS: Use feedback that motivates. From…
to
to
to
Satisfaction (avg.)
Courtesy / service
Quantitative (data)
Loyalty (% top box)
Compassion / healing
Qualitative (stories)
If DisneyRan Your
Hospital YouWould...
2.2.Make Courtesy MoreMake Courtesy More
Important ThanImportant ThanEfficiencyEfficiency
Pillars are Equally Important
SERVICE • PEOPLE • QUALITY • FINANCIAL
1. Safety2. Courtesy3. Show4. Efficiency
Disney’s Quality Priorities
What’s missing for patients? Internal customers?
Hospitals Need To Add Compassion1. Safety/Quality
Evidence based medicine.Zero defects / Reducing variation (Deming)
2. CompassionEmotional support as best clinical practice, affectingstress, anxiety, pain, and the immune system.
3. CourtesyConstantly seeking out guest contact. (Disney)
4. PresentationWe are always on stage.What will the audience see, hear, and feel?
5. EfficiencyUnit efficiency vs. courtesy and overall efficiency.Reducing the cost of poor quality (Deming)
Two Biggest Barriers to InternalCustomer Service
2. Poor teamwork, by which they mean:• competing for resources• unresponsive, unhelpful processes• silo mentality, workarounds
1. Poor communication, by which they mean,“Someone in another department makes adecision that affects us without consulting withus first.”
Deming Principles
EFFICIENCY: Calculate the COPQ (costof poor quality) in each step of theprocess.
When the process breaks downWorkaroundsRedundancyUnclear responsibilities
QUALITY: Reduce variation
Paradox: Customer First is More Efficient
Results in overallorganizational
inefficiency
Results in overallorganizational
efficiency & teamwork
unit efficiency first courtesy first
internal focus
unresponsive
compete for resources
external focus
responsive
share resources
What is a grand slamin performance?
WIN on quality (you reduced variation)
WIN on efficiency (your reduced overall costs)
WIN on customer satisfactionWIN on staff job satisfaction
Budgeting Process Questions
3. Have you discussed your plans withthem and gotten their agreement thatthis way is the most efficient overall?
2. Will anything you do affect anotherdepartment? If so, explain.
1. Where and how will you reduceexpenses this year?
ConversationWhat do you do for your ownefficiency that frustrates otherdepartments or patients?
If you changed it to be morecustomer friendly, estimate the costto your department, then estimatethe cost benefit (value added) tothose you serve.
How would your people like thechange?
If DisneyRan Your
Hospital YouWould...
6.6.Change the Concept ofChange the Concept ofWork from Service toWork from Service to
TheaterTheater
Disney is not a service and neither are we.
Commodities
Extract
Goods
Make
Services
Deliver
Experiences
Stage
O V
E R
T I M
E S
ince
1900
Joe Pine, The Experience Economy
The progressionof economicvalue
Theater is about life –comedy and tragedy.
Hospital:Meeting the emotional needsof a family suffering a tragedytogether.
Disney:Meeting the emotional needs ofa family to have fun together.
A hospital without compassion is like Disney without fun.
Our Service Or Their Experience?
High anxiety Pain
No PainLow anxiety
CourtesyWhat you sayNo clinical effect
CompassionWhat you feelClinical effect
Depends on the emotional needs of the patient.
Service paradigm Experience paradigmOR
THE DIRECTOR
Start by describing the experience you want the guest
to have (see, hear and feel) and how to make each
scene memorable.
Cast for the talent to play the role called for in the guest
experience, rather than just the skills to do a job.
Clarify each person’s role in creating a memorable
experience and get their commitment to their role.
Borrowing from Theater
THE ACTOR:
Actors learn how to be real by becoming emotionally
engaged with their character.
Actors rely on sense memory and imagination to become
real in their role.
Borrowing from Theater
Video clip: Connie
1. What is Connie’sproblem? What does herbody language and toneof voice tell you?
2. Make a list of behaviorsyou wish Connie wouldfollow.
Coaching Tips1. Plan your coaching sessions, do not “wing it.”2. Ask leading questions to get the other person to say
to you what you wanted to say to them. Rememberthe mind instinctively “reacts” to statements.
3. Use imagination to get them to put themselves inother peoples’ shoes, or your shoes.
4. Listen and reflect back all important points beforeresponding.
5. Say, “I need a person in your position whowill________” not, “I need you to__________”
6. Add, “…and I wish it could be you.”
If DisneyRan Your
Hospital YouWould...
7.7.Harness the MotivatingHarness the MotivatingPower of ImaginationPower of Imagination
What determines our response to stimulus?
S I RStimulus ResponseImagination
EmotionsFight or Flight
EmpathyBody languageTone of voice
Freeway
(pain & fear) (empathy)
All growthhappens
here
Four Levels of Motivation
11
22
33
44 Habit(based on character)
Compliance(based on authority, rewards, threats)
Imagination(based on feelings)
Will Power(based on values and beliefs)
Strongest
Weakest
Handling an Upset Customer
Listen
Apologize
Solve
Thank
Disney Teaches:(Left brain approach)
There’s a better way…
Dealing With an Irate Person
Stay Calm
Listen
Empathize Cool Off
Explain Listen
Thank
Ventilate
When someone goesballistic…
If DisneyRan Your
Hospital YouWould...
9.9.Stop Using CompetitiveStop Using Competitive
Rewards to MotivateRewards to MotivateStaffStaff
Some characteristics of high IQ typesthat make for poor manager coaches.
• Don’t listen because they are used to knowingmore than others, and love to prove it.
• Underdeveloped EQ (emotional intelligence),not needed for academic success.
• Success built on critical analysis, therefore tendto critique ideas, rather than consider or trythem, which tends to kill creativity and
“thinking outside the box.”
Some characteristics of high IQ typesthat make for poor manager coaches.
• Stingy with compliments, because they don’tneed them. For the exceptional one only.
• Have a greater need to be “right” than “liked.”
• Highly judgmental, so tend to lack the empathy& tact needed in a collaborative world.
• Succeeded in an independent, competitive environment (school), so think individual competition succeeds everywhere.
Add three Requirements for Promotion(High IQ = To get an “A”)
1) Has this person shown an ability to inspire,coach, and motivate others without resortingto threats and bribes?
2) Has this person demonstrated a commitmentto customer service that is verified bymeasurable results or feedback?
3) Does this person understand and talk aboutour focus on the patient’s emotionalexperience, not just courtesy standards?
In theater it’s an ensemble, not a team. Describe the characteristics of an ensemble
All are on the same page, take turnsbeing the soloist, and support each other.
Can improvise but must know the tuneand the rhythm to stay in sync.
Joy is in the playing, and making amemorable experience for the audience,not in competing with each other.
Success is in the overall performance, notin winning or losing.
Do not need a “leader” to become great.
Which Model is More Usefulfor Hospitals?
• The thrill of winning• In competition with others• To defeat another team• And win their trophy
• The joy of performing• In concert with others• To engage an audience• And win their applause
In theater, an ensembleis motivated by…
In sports, a teamis motivated by…
What does the applause of a patient sound like?
Paradox of Competition“You can’t have the fruits of cooperation froma paradigm of competition.”
Steven CoveyA basic drive in somepersonalities…especially males.
A healthy source of motivationbetween organizations,dysfunctional within.
Separating Recognition from Competition
Stories:• TWA attendant• ED compliment cards.• Boys and the old man
Employees want recognition for good work, notcompeting with other members of their team.
Employees are hungry for appreciation, not contests.
They want more individual, spontaneous praise, notmore trophies or coffee mugs at special events.
According to virtually allthe research on motivation..
Extrinsic rewards tend toextinguish intrinsic motivation, andwith it the values the rewards wereintended to encourage!
See Punished by Rewards by Alfie Kohn
What is gained by…
Searching only to reward the “best” and not the rest?It makes all but one feel like losers.Hampers teamwork.Fosters jealousy and sabotage.
Rewarding only those who do something unusualthat goes above and beyond? How about those whoare…
Always cheerful?Always responsible?Always dependable?
InstantFeedbackCards
If DisneyRan Your
Hospital YouWould...
10 .10 .Close the Gap BetweenClose the Gap Between
Knowing and DoingKnowing and Doing
Lee Performance Evaluation Grid
PEOPLECompassionate
CourteousHelpful
ATTITUDE
TASKAccuracy / Speed / Consistency
DELIVERABLES
51 2 3 41
3
4
5
2
Shaded zonemust change orleave.
Focus on andpraise relatingand doingstrengths.
Work aroundweaknesses.
STAR
Expert
Friend
Average
Overcoming InertiaVision of
“could be”Knowing“how to”
OrganizationalInertia
Dissatisfactionwith “as is” + >+
Comfort zoneForce of habit
Must begreater
than
––––––––––––––––––––––––––
FeedbackData
Organizational ChangeModel (Fred Lee)
“could be”
performance“as is”
––––––––––––––––––––––––––
FeedbackData
Organizational ChangeModel (Fred Lee)
“could be”IN
ER
TIA
performance“as is”
Manager
–––––––––––––––––––––––––
FeedbackData
Organizational ChangeModel (Fred Lee)
performance
INE
RTI
A
communication
servicestandards
Leadership Commitment
“At the moment of commitment, theuniverse conspires to assist you.”
Goethe
Manager commitment
–––––––––––––––––––––––––
FeedbackData
Organizational ChangeModel (Fred Lee)
performance
INE
RTI
A
communication
servicestandards
ModelingRelatingCoachingLearn by doing
10 Key Ideas To Start Immediately1. Have a daily huddle to value and encourage staff, and
share best practices.2. Determine how to seek out and use feedback on
frustrations (rounding).3. Do discharge phone calls to patients within 48 hrs.4. Do the avoidance exercise (the enemy of courtesy).5. Focus on the patient experience, not our service.6. Use patient letters and comments instead of numbers to
motivate and generate specific ideas for improvement.7. Talk to each about “your role in the patient experience.”8. Make courtesy more important than efficiency, especially
in the support services.9. Ask, “Why is it easy to feel compassion for some
patients and not others?” (Judging)10.Teach the ballistic curve in dealing with anger.
Ownership
What is the value ofa committedensemble of
caregivers who havebecome
compassionatelyengaged in the
patient’s experience?