McEvoy Discusses Building a Culture of Quality

Continuing our series on excerpts of interviews with iProtean experts, we feature Larry McEvoy, M.D., on driving a sustained culture of quality.


Interviewer: What are the essential tenets of a culture of quality?


Larry McEvoy: I have a formula that simply describes the tenets of a culture of quality: MLN.


M is motivation. Quality is something that should be omnipresent. In other words, people have to be motivated around it.


If you ask most healthcare people, it doesn’t matter if they’re an executive or a physician, an ER nurse, a pharmacy tech, it doesn’t matter, “Do you want to be really, really good at what you do?” Almost all of them say, “Yeah, sure we do.” So motivation is not a problem initially, but once people get into organizations and they start getting exposed to politics and policy and things that can’t get done, and all the tasks and distractions they have, it is really easy to get demotivated.


High quality results from very energized, motivated people who don’t give up. As a board, you want an army of really motivated people who don’t give up on quality. They don’t give up on Mrs. Jones in the middle of the night or on Tuesday morning. And they don’t give up on it systemically.


How do you foster human motivation to sustain this kind of culture? This idea of motivation is a cornerstone that should concern every board. And we do know some things about human motivation. Motivation boils down to mastery; that is, helping people define and pursue what is important for them to be good at. And let’s face it, this is a great thing for quality.


Mastery depends on autonomy, that is, the ability to choose. It doesn’t mean separateness or do what you want. It means the capacity to choose. You want to create environments where teams and individuals can choose how to design as much of their work as possible so that they’re delivering high quality.


Motivation also involves purpose. People really gravitate around meaning, purpose, and connection to the patient, connection to their work, connection to why they want to be in health care. And this is a good thing.


L is learning. People love to learn. They get bored if they just go through the motions every day. The brain likes novelty; we know this from neuroscience. And we learn best when we’re rewarded for taking on a challenge, for effort, even if the effort is not successful, and for getting ready to take on another challenge.


So, this learning environment is something you want in every little interaction you have. If every time a nurse and a doctor, or a team, get together to huddle, or a board gets together, you should ask, “How have we strengthened motivation here? How have we strengthened learning?” If you continue this way, you will be in good shape.


N the exponent. N means that the more times you can create collisions, where people are colliding and they’re increasing their motivation and they’re increasing learning, they will come back.


I talk about this as the casino effect. In Las Vegas, they have all sorts of games, and they have two key aspects to those games. One, it’s an enjoyable experience. It’s an addictive one. It released dopamine in our brain and we say, “I want to come back.”


The other one is, every time they create a collision between you and the casino, there’s a high probability, or some positive probability, it will result in a return to the casino. So they don’t worry about every interaction. If you keep coming back and hitting, sooner or later, money goes to them.


Quality should work this way, too. Every collision should be positive motivation and learning. If you keep colliding, you will get a return in the organization. So, leaders should examine culturally, how do we multiple collisions?


Interviewer: What are the most important things leaders can do to lead cultures from both a modeling standpoint and a design standpoint?


Larry McEvoy: As a healthcare leader, a board, you’re thinking about how to lead a cultural evolution, if you will, an epidemic of better quality thinking and acting. And yet, as the board, you can’t be everywhere all the time. You have to wonder how to “master the math.” Two answers.


Number one is to actually model your own journey. Don’t be a distant board that just sits there and stamps things. Let people see your own journey. “We were pretty results-oriented before; we’re still after results, but we’re learning more and more about what a culture of quality means, how we model our own behavior and how we sponsor that in others.”


Modeling your own behavior as a board means public learning. For example, “We went to a conference; here’s what we learned. Oops, didn’t know that two years ago. Probably if we knew that now, we would do this, this way. We as a board are curious. We’re interested in not being just experts, but learners. And we’re asking other people to learn publicly as well.” This is a powerful, powerful signal from the board.


Number two: the board should start to investigate the architecture of epidemics and movements. Typically in organizations, we have a ruling somewhere from a committee. We pass an edict and then we promulgate it with policies and emails and repetitive things. That is not necessarily the best way to get things going.


There is a whole body of science around how epidemics work and spread, and how networks influence people. And I think it’s worthwhile for the board to get interested and educated about how network science—how the structure of networks actually allows things to travel—and how complexity science—in chaotic circumstances, how things can self-organize and diffuse very rapidly—and how neuroscience—how humans learn and participate—can become something in their organization.


Now those are some heavy topics: network science, complexity science, neuroscience. The goal is to start to understand them in terms of simple practicalities such as how do we understand the networks in this organization and how influence moves. How can we tailor our quality culture to the neuroscience of human learning, human motivation, human contagion of passing things back and forth. Because gossip works for a reason. It’s attractive and sticky and it moves. Quality should be that way as well.


And then there’s this idea of how the board can work with executives and other leaders to understand how to create optimal collisions, and lots of them, so those collisions are sticky, they’re attracted to people, and that those collisions travel and travel and travel. So, instead of asking people to come to a quality meeting, people are joining a quality movement that they find energizing and they can see the results in micro, and they can also see it bloom across the organization as everyone begins to do this.



For more from Larry McEvoy, M.D., watch the iProtean courses Board Mindsets to Drive Value and Physicians and the New Healthcare Business Model. His upcoming course on board’s role in leading quality, will be published later this year.



iProtean subscribers, the advanced Governance course, Committee Effectiveness, is in your library. This course features Barry Bader and Pam Knecht, who cover committee structure and task forces, ideal committee size and composition, independent members, the committee charter, information and reports, and committee evaluation.


And watch for our upcoming course, Population Health and Alternative Payment Models, featuring Marian Jennings and Dan Grauman.


For a complete list of iProtean courses, click here.



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