Having been an improvement advisor with many quality improvement initiatives and collaboratives, I have observed that stories about successful initiatives too often leave out major relational barriers that got in the way as well as the critical interventions necessary to overcome them.

That important details about relational challenges so often remain hidden is not a small problem. Evidence points to relational issues as a major cause of lack of expected success of innovations within and across organizations despite using the same quality methods and technical designs.

Here are two brief stories of improvement initiatives told at conferences in which relational barriers and success factors emerged only when I later talked individually with the presenters.

Story #1

An executive in charge of quality improvement used 30 slides to present a workshop on his organization’s successful integration of Lean thinking. All of the questions from the audience focused on Lean methodology. When I later talked to him, I told him, “I noticed one slide on physician engagement. What was the importance and sequencing of that relative to the work on Lean?”

He said, “We spent ten months in meetings with all the physicians to talk about our plans before we ever touched the work on Lean. We worked through some tough conversations. Now that you bring this up, I have to say this first step with physicians was crucial to our overall success.” As he talked, I was startled at how such a big issue had remained barely mentioned and in the background, even with the participants.

Story #2

A director of a primary care clinic led their first-ever involvement of two patients on one of their quality improvement work teams. At a conference presentation, she told what seemed to be a great, straightforward story of success with how-to tools for helping patients feel comfortable working with clinical staff.

Later, meeting individually with the director, after about 20 minutes, I discovered their first team meeting with the patients had been “disastrous.” One patient revealed with anger that a relative of his had suffered significant health problems several years prior due to clinic error. Unfortunately, the clinic staff got defensive, and the meeting ended badly. The director said, “I can’t believe that I have forgotten how bad that was. I even considered giving up.”

With this director, I elicited further details about how she had helped her team recover remarkably well from this “disaster.” Anticipating and managing such inevitable, unexpected hurdles that occur in human affairs was a crucial learning left out of the presentation.

There are multiple reasons why such stories leave out the relational challenges and interventions in the process of improvement initiatives.

• Our professional and social culture values science and technology over relational issues.
• Getting at sufficient detail about relational issues requires a higher degree of safety in conversation. It is not unusual to need 1:1 interview time.
• Obtaining good relational stories requires asking for behaviorally specific information which is not a commonly practiced skill.

Another factor is that both of these stories are likely examples of a flaw in remembering that can occur once we know the outcome of a situation called “hindsight bias.” Once a tough relational issue resolves, we tend to forget the level of stress and unpredictability in the original situation. So, outside of full awareness, those events may not be considered important enough to report. Unfortunately, we also then do not recognize our own level of skill and courage that was necessary for success.

Telling relational stories more often will require no less than a wide-spread change in professional culture. But, there is at least one important step we can all take now — in meetings to review the progress of improvement initiatives, we can always integrate at least one or two questions about relational issues. For example, we might ask about the state of relationships and communication and if barriers to change are present. Or, we can ask about the level of enthusiasm for the change and what factors are making it higher or lower than expected.

In our quality improvement world with so many elegant frameworks, models, and tools, I know that methods to address relational issues can seem quite simple and commonplace — such as active listening and asking questions. But to apply these skills consistently requires very high levels of discipline, courage, determination, and persistence. To help sustain these qualities, we need the best possible stories about relational challenges to learn from.

Neil Baker is a physician and founder, Neil Baker Consulting and Coaching.

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