The Power of Intrinsic Motivation in Improving Healthcare

"Most companies have it all wrong. They don’t have to motivate their employees. They have to stop demotivating them.” - Often attributed to the late W. Edwards Deming

I believe strongly that most everybody wants to do quality work. This was true at General Motors 20 years ago and it's been what I've seen in healthcare over the last ten years.

People want to feel pride and joy in what they do. They want to work in a system that allows them to do great work. As legends like W. Edwards Deming and contemporary authors like Daniel Pink have pointed out, intrinsic motivation is a powerful force.

Sadly, most organizations are incredibly effective at squashing people's intrinsic motivation. Employees are told to be quiet and just do their jobs. They're told improvement isn't their responsibility. They're told to "check their brains at the door." When they do try to point out problems and opportunities for improvement, they far too often labeled as troublemakers or complainers.

People learn to keep their heads down and avoid trouble. So, organizations suffer. In healthcare, this also means that patients suffer harm and death caused by preventable errors that aren't fixed because people are afraid to speak up.

Franciscan St. Francis, a three-hospital system in Indianapolis, has a very different type of culture. Since 2007, they have formally practiced a methodology called Kaizen, creating a very strong culture of continuous improvement (as Joe Swartz and I wrote about in our Healthcare Kaizen books).

Kaizen isn't simply a set of tools or methods. It really starts with leadership and culture. It starts at the top, with CEO Bob Brody and other senior leaders setting a tone, leading by example, and encouraging and celebrating even the smallest of hospital improvements. Organizations like Franciscan have learned they don't have to "incentivize" people to improve, nor do they have to offer big rewards for innovative ideas.

Nurses and staff improve... because they want to! They participate in improvement because it helps their patients and their colleagues. Management doesn't need to micromanage improvement or be overly controlling. Sometimes they have to just get out of the way.

See this video with Rhonda and Julie, two nurses in the endoscopy department. They talk about the "culture of staff input into everything" in this video:

Rhonda says, in part (read the whole transcript here):

The biggest thing, the culture down here is staff input into everything. It's massively different than anywhere else I've ever been. They want staff trying to figure out how you can fix things."

And Julie adds:

They allow us to implement things. You can [submit Kaizen ideas] until the cows come home. But if your department itself and the managers don’t allow you to implement it and see if it will work, then there’s no point in it. But [our manager] allows us to do that."

Staff input doesn't mean that managers are not longer involved. The role of managers is incredibly important, but it shifts from being a judge (saying "yes" or "no" to ideas) to a facilitator who helps solve problems by developing people. You find problems, discuss them and talk about possible solutions, then you test ideas to see if they work. It's a simple, non-bureaucratic, scientific approach. Then, you document the improvements, recognize people, and spread the ideas.

In this next video, Rhonda and Julie describe a small improvement that improved the patient experience and saves $30,000 a year without cutting corners on patient care and quality. They switched from "flavored snot" to applesauce for a particular patient swallowing test.

Rhonda says, in part, about her manager (read the whole transcript here):

I can’t say that she’s ever pushed back and said, “I don’t think that’s a good idea.” No, “Try it and see if it works. If it doesn’t work, we tried it.”

When managers say things like "that will never work" or "that's a terrible idea," people get demoralized. They stop participating in improvement and they stop speaking up. Instead of simply approving or rejecting suggestions, as in a traditional suggestion box system, managers encourage employees to identify problems as the starting point. Then, they work together to brainstorm and test possible solutions in a structured "Plan-Do-Study-Adjust" (PDSA) model (a.k.a. PDCA) that we learned from Dr. Deming.

One downfall of suggestion box systems (as written about by Robinson & Schroeder in their book Ideas Are Free) was the promised sharing of a percentage of cost savings with employees who brought forward suggestions. This "quid pro quo" makes sense on the surface, but it also destroys intrinsic motivation (as Pink wrote about so well in his book Drive). Incentives work, but they have side effects. These side effects include people fighting and arguing with each other (and with management) over the value of ideas, instead of focusing on improvement.

Franciscan St. Francis has brilliantly learned how to tap into the intrinsic motivation of their staff. That's how they have implemented over 23,000 improvements since 2007. They have saved over $6 million dollars (as validated by finance), but the key is that they're not obsessively focused on cost savings (as I wrote about here about a hospital I have coached). Leaders emphasize that staff should focus on improving patient care and creating a less frustrating workplace. And, then cost reduction will follow... but as an end result, not a primary goal.

People always ask me if it's "fair" or a good idea to share savings with staff. When I asked Rhonda and Julie if they should have shared some of the $30,000 annual savings, they were almost offended by the question (if not a little confused) because their intrinsic motivation is so strong. Watch:

They say (read the transcript):

It’s a better working environment, and your job’s smoother and stuff. I don’t even think of it as you should get anything else... Yeah, it keeps patients from vomiting on me... Happier staff, happier patients, happier visitors... Honestly, that’s why we work here."

OK, so we don't all have jobs where we might literally get vomited on. But, too many employees feel vomited on in a figurative sense... because their leaders are not listening to their ideas and are not helping them improve. Intrinsic motivation is a powerful thing... if leaders figure out how to use it (in mutually beneficial ways), rather than wasting it or destroying it.

Mark Graban (@MarkGraban) is a consultant, author, and speaker in the “Lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. He is also the VP of customer success for the technology company KaiNexus. Mark blogs most weekdays at www.LeanBlog.org.

Do you want to see this culture of continuous improvement in person? Join Mark Graban & Joe Swartz as they help host a special visit and workshop at Franciscan St. Francis Health. You'll see departments with a Kaizen culture, you'll hear from managers and executives, and you'll get to discuss your own plans and efforts for creating and sustaining this powerful culture. Learn more and register.