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Grieving Over Quality Improvement

by Rick Blizzard

The premise of many "quality improvement" initiatives is that we should seek to constantly improve our job performance. While this sounds reasonable in the abstract, it's a different proposition when applied specifically to me or any other person. I may take great pride in my performance and am absolutely certain I am doing the best job possible -- but when someone tries to tell me how I could do better, I become defensive. The same situation applies for healthcare workers committed to the mission of providing quality patient care. The key to successful quality improvement is overcoming this innate defensiveness and making the quality-improvement process a positive experience.

Gallup has for decades been helping hospitals track and improve intangible factors related to patient care, so we know as well as anyone that any quality assessment contains its share of bad news. For example, Gallup may track patient ratings of a hospital staff's care and compassion -- a crucial measurement in patient service. It is very disturbing for a staff member to receive less-than-satisfactory scores on this measure -- a typical first reaction is: "My patients say I am not a nice person. I don't see how they could say that about me." How can that defensiveness be best overcome so that the staff can use the data to successfully work on improving performance?

Learning From the Phases and Tasks of Grief

In working with healthcare staff on quality improvement, I am often struck by the parallels between the ways staff members deal with poor quality-improvement scores and the way people deal with the death of loved one. Using Dr. Elisabeth Kubler-Ross' well-known psychological model on the stages of accepting death (as discussed in the best-selling book, On Death and Dying), what can we learn about the stages of accepting poor quality-improvement scores, and how to use these scores to spur improvement?

Stage One: Denial

Death: Shock and difficulty accepting the loss. May be expressed as "No, not me."

Quality Improvement: Denial of the patient survey results. Staff may argue that the number of patients included in the survey was too small to get an accurate reading, the patient sample was biased, or the survey questions were biased, inaccurate, or not actionable. To move beyond this stage, the measurement system must have a sound methodology -- valid sampling, a reasonable rate of patient responses to the survey, and tested questions that are reliable and proven to relate to the desired outcomes. Staff should be educated about the approach prior to taking the survey and in conjunction with the presentation of results.

Stage Two: Anger

Death: Blame is directed at others. May be expressed as "Why me?" or "Why not someone else?"

Quality Improvement: Anger with the scores, the patients, other employees/departments, and the person presenting the scores. A member of the nursing staff may say, "It's not me [the nurse] -- it's the care assistant they [the patients] were talking about," or "Patients are unhappy because they have to wait so long in the ER before they come to our unit." A possible solution is developing multidisciplinary teams in which staff from different units share perspectives, reducing the knee-jerk tendency to blame others for low scores, and enabling different units to work together on improving performance.

Stage Three: Bargaining

Death: A temporary truce when the individual hopes the loss will go away. Individual may imagine what he or she could have done to prevent the loss.

Quality Improvement: "It must be wrong, but I will try harder and pay more attention." Staff members may believe that simply redoubling their efforts will make the problem go away without any further action or disruptive change. Yet without actions to correct the underlying problems, the conditions that necessitate quality improvement are unlikely to go away.

Stage Four: Depression

Death: Sadness when the individual finally admits, "Yes, it is real."

Quality Improvement: Disappointment, and a feeling of powerlessness and inability to change the results. To overcome this, the team must build on the positives. First, recognize and celebrate strengths. Focus on what people do well. With ongoing measurement, recognize and celebrate improvement to establish patterns of success.

Stage Five: Acceptance

Death: The loss is accepted. While this may be a difficult time, the foundation for moving forward is established.

Quality Improvement: The potential for improvement is accepted and staff members begin to actively participate in the improvement process.

Key Points

The biggest barrier to quality improvement efforts is the natural defensiveness of staff who initially see the process as negative. The grief model gives an outline of the phases through which we must move to be ultimately successful. The keys include having a valid measurement system with which staff members are familiar in advance, and a positive environment that recognizes the importance of strengths and celebrating successes.

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