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:
|Positive||If you finish your book assignment, I’ll give you $20||I can’t wait to finish the book assignment – I love to read|
|Negative||If you don’t finish your book assignment, you’re grounded this weekend||I’ll never finish this book – reading is so boring|
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.
This post reminds me of a book Punished by Rewards written by Alfie Kohn published in 1993. The subtitle is The Trouble with Gold Stars, Incentive Plans, A’s, Praise and Other Bribes. The ideas were not very popular when the book was written and still counter culteral now.