Starting With Curious

We got our house back last week.  Our sons, who have been storing most of their belongings in our garage and basement for the better part of the past three years, both settled in to new apartments, taking their stuff with them.  Now we just need to sweep up the debris and voila!  No more squeezing past a futon to get my bicycle, or climbing over cartons of books to get to the rake.  It’s like pouring Drano into a clogged sink.

Those who have seen my office know I can’t stand clutter.  This is as true of my virtual space as my physical one.  Which is why a recent article from the Economist resonated with me so much. “Decluttering the Company” describes an unfortunate tendency among business organizations to accumulate structures and processes that simply clog the place up, making it difficult to get anything of value done.  The author lists some of the usual culprits: committees and other governance structures, meetings, and emails.  The problem is not so much with committees or meetings per se.  All these things are to some extent necessary.  The problem is their kudzu-like indestructibility.  Once a committee is formed, or a meeting is scheduled, it is nearly impossible to get rid of.  The result is redundancy, wasted time, and excess complexity leading to lack of clarity about where responsibility and accountability lie.

Organizations that find themselves cluttered up should consider a spring cleaning.  Time to sort through the committees, governance boards, management layers, and standing meetings, and decide which ones still provide value, which ones need to go to the landfill.  Even better is to prevent the clutter in the first place.  Committee charters could include a planned sunset date, unless the members strongly believe that there is still value in it.  At the very least, organizations should build a regular spring cleaning into their processes.  A friend of mine who lived in the same apartment in Chicago for 20 years used to move out and back in again every three years, as a way to force herself to declutter.

Think about our organization.  We have a great deal of activity that creates value for us and for our patients and families.  But we have to admit we have a lot of clutter.  I still have work to do on my garage.  When I’m done, what should I work on next?

Raisin Bran or Honey Nut Cheerios?  Standing in front of the pantry, faced with five boxes of cereal, I was paralyzed with indecision.  I could not for the life of me choose which one to have when I got home from my overnight shift.  It was completely ridiculous: I had just spent nine hours effortlessly making, in some cases, literally life-and-death decisions in the ER, and now I pathetically could not pick among a few not-terribly-different, nutritiously marginal, food-like products.

It turns out, I was suffering from what has been termed “decision fatigue.”  Some really innovative and fascinating behavioral and neuroscience research in recent years has shed light on what is a common phenomenon, and one with widespread implications.  Perhaps the most famous study is one of parole decisions by Israeli judges: investigators analyzed over 1100 cases in a ten month period.  One of the strongest predictors of granting parole was when in the day the case was reviewed.  Prisoners whose cases were heard at the start of a session had a roughly 65% chance of being granted parole, whereas parole was almost never granted to the last cases reviewed.  Parole was far more likely at the start than the end of a session even after controlling for severity of the crime, length of time served, prior criminal history, and ethnicity.

Other research has demonstrated that after a period of repeated decision-making, subsequent decisions become harder.  This is manifest as either indecisiveness (e.g., Raisin Bran or Cheerios), or deferring a decision by defaulting to the fall-back position (e.g., not granting parole).  Not only do people with decision fatigue find it hard to make choices, they also show decrease in willpower, leading to bad choices.  It’s why we often eat or drink too much at the end of a tough day.  These findings are consistent with a theory first proposed by Freud, known as “ego depletion.”  In essence, voluntary mental effort, including making choices and resisting urges, draw on a pool of mental energy.  When that pool is drained, quality of mental efforts is diminished.  Intriguingly, food plays a role; decision fatigue is ameliorated by glucose.  (It’s not just the act of eating – artificial sweeteners do not have the same effect.) For example, parole rates for the Israeli prisoners went up after a morning snack, then drifted down again before lunch.  And back up again after lunch!

The notion of decision fatigue has numerous implications.  Most obvious is for the way we do our work.  Intellectual performance falls off after a period of time.  Potential remedies include frequent breaks; spreading meetings requiring decision-making over the course of a day rather than stacking them back-to-back; not trying to make critical decisions when you are mentally tired or hungry.

Another implication is a societal one.  Self-control is at a low point when ego depletion sets in.  Poor people, who frequently have to make trade-offs that those with more means don’t have to worry about, may be more prone to this.  They make more, and more challenging, decisions in a given day than others.  Choices that may seem trivial or irrelevant to me are depleting to someone who is counting every dollar.  Studies suggest that poverty is not caused by bad choices; rather, bad choices are a consequence of living in poverty.  But we are all potential victims.  It’s one of the reasons supermarkets put all that candy at the checkout line.  It turns out, shoppers who have just spent a half hour choosing among a dazzling array of products are much more prone to give in to the temptation.  (It’s also why, for example, car salesman offer the ridiculous undercoat protection after you’ve had to select the model, color, interior décor, sound system, and various other options.)

Well, picking a cereal for breakfast this morning was easy.  But deciding on dinner is going to be a challenge.

At the ripe old age of 18, my mother was a newly minted RN, fresh out of a two-year diploma program.  Not too many nurses got bachelor’s degrees back then.  Years later – while continuing to work two jobs and raise two kids – she went back to get a bachelor’s (in psychology, not nursing), and eventually a master’s in health administration.  Why?  In large part, I think, because of new requirements.  I certainly don’t think she believed the additional years of school made her a better nurse (she was already an awfully good one).

A study published this year in the Lancet suggests otherwise.  Looking at 300 hospitals across nine European countries found two nursing factors that correlated most strongly with mortality rates.  One was the nurse:patient ratio.  The other was the proportion of nurses with a bachelor’s degree.

Knowing how important the quality of nursing is to the overall quality of care, this is perhaps not surprising.  Nurse education is one of the many criteria evaluated by the American Nurses Credentialing Center’s Magnet Recognition program.  (CHW was verified as a Magnet hospital for the 3^rd straight time in 2014, a distinction held by only about 1% of all hospitals in the country.)  Over 76% of direct care nurses at children’s have at least a bachelor’s degree, and nearly a quarter have some form of national specialty certification.  Among our nursing leaders, 72% have a graduate degree.  This is one of the reasons we are able to deliver the best and safest care.

Not only are our nurses well educated, many of them are educators themselves.  I recently read through our annual advanced practice nursing report, which presents an impressive array of teaching and research being done by our many talented APNs.

The Lancet study doesn’t show why nurse education level is associated with better outcomes, but some speculation includes a greater ability of university-trained nurses to interpret sophisticated monitoring data, and a greater willingness to question the traditional hierarchy to raise safety concerns.

My mother is certainly proof that one doesn’t need a bachelor’s degree to be an excellent nurse.  (She’s also proof that you don’t need a degree to challenge authority.)  But when it comes to education for nurses, the data show that more is better – and kids deserve the best.

A couple of years ago I was visiting another hospital.  In the course of a day, I separately witnessed two senior leaders stop to pick up a small piece of litter on the ground.  I was immensely impressed that a busy executive would literally stoop to that, and I told each of them so.  The first one replied, “I really can’t stand to see things like that.  I know it’s a little thing, but it feels good when the place looks neat and clean.”  The second executive said, “It’s important to set a good example for others.”

At the time, I thought both spoke to a commitment to excellence.  But now I wonder about the differences in motivation, and the implications for all of the work we all do.  The first response spoke to an internal motivation, self satisfaction, while the second was an external motivation – what others would think.  A lot has been written about the relative impact of different sources and modes of motivation, with an emerging consensus that much of what we do to drive changes in behavior is at best ineffective and potentially harmful.

As a clinical epidemiologist, I like to define everything in life as a series of 2 by 2 tables.  Here it is for motivation:

Conventional practice (at least in America) in business, and increasingly in education and other fields, is to rely on external motivations – rewards and punishments – to drive results.  Among external (also called instrumental) motivations, it is generally believed that positive is more effective than negative: you attract more bees with honey than with vinegar.  But increasingly, research shows that external motivations for individual performance are at best modestly successful.  One recent study of West Point cadets found that not only is internal motivation a better predictor of success than external, but that even among those with strong internal motivation (e.g., belief in service to country), the addition of an external motivation (e.g., wanting to please a parent, desire for free education) was correlated with worse performance.

In health care, there is a growing shift toward “pay for performance,” and results so far have been mixed.  Some even worry that adding this external motivation can undermine the intrinsic motivation to do the right thing for patients that virtually all providers embody as a core principle.

Rather than devising rewards and punishments for performance, we need to leverage the intrinsic desire to do good (benefit to others) and to do well (personal excellence) that most of us have.  It’s the difference between compliance and commitment.  But even the latter can be broken down further.  Fred Lee, in his book If Disney Ran Your Hospital, talks about a hierarchy of motivations.  At the lowest level is compliance: doing what someone makes you do.  Even doing something for a reward is a form of compliance, albeit one with a smiley face instead of a frowny one.  The next level up is willpower, or doing what you believe you should do.  This is what that second trash-cleaning executive did.  It’s a step toward commitment, but not as far as imagination, which is doing what you want because you feel like it.

The vast majority of people in health care are motivated by imagination, by deeply wanting to give our patients great care and a great experience.  Certainly we like to be recognized when we do good – it’s one way to know we are doing well.  But we must be cautious about using external motivators, whether positive or negative.  I want to be part of an organization where everyone would stop to pick up a piece of litter, even when no one is looking.