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The James A Vohs Award: ••Spring 2002/Vol. 6, No. 2 |
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Editor's Comments
Shame-Based
Versus Pride-Based Reporting
Introduction How an organization talks to itself about its performance reveals both the organization's own self-image as well as the organization's implicit models of individual motivation and incentive. That is, if you consider what is emphasized in an organization's reports and rhetoric about performance, you can divine a piece of its culture. In a simple sense, culture is to an organization as personality is to an individual. Culture is the shared or modal or dominant set of attitudes, values, and belief systems that shape how things are perceived and understood by the individuals of an organization. Because culture is an aggregation of individual beliefs, culture cannot be a monolithic construct; rather, culture is an everchanging function of the attitudes and values of the individuals who have voice within that organization. Perceptions of the Care Experience When I asked the members of the Care Experience Councila (CEC) to evaluate the care experience provided in their own regions, the ratings from the CEC were not nearly as high as the ratings that Kaiser Permanente (KP) receives from its own patients and members. And the CEC are clear on the reasons for their relatively low ratings: "KP is inconsistent; the care experience is inconsistent; we are not superlative in all places all the time. This is a problem we must address if we are to ever achieve the KP Promise, which we clearly have not achieved today." I have since replicated the same result with other leadership groups within KP Northern California; this perception of organizational performance deficits is not unique to the CEC. When career choices are being made, in my view, the health care industry attracts perfectionists, and perfectionists are never satisfied with their own performance. Beliefs Underlying Negative Reporting Paradigms From what I have observed, there has been no organized grand plan behind performance reporting, so we cannot pick up a charter or value statement and from that discern our reporting philosophy. We can only gain that insight through introspection: What do we emphasize in our self-talk as an organization? What types of belief systems can we infer from our reporting paradigms? Once we are more clear on those, we can then consider whether those emphases and implicit beliefs will get us where we want to be as an organization. Looking at the performance reports that cross my desk--from Program Offices, external agencies, and our own Northern California offices--I think the following logic statements are most pertinent to understanding our ideology:
All the above will drive toward performance reports that focus on, emphasize, and highlight performance deficits, inconsistencies, declines. A few performance stars will be highlighted in order to force the majority to see just how far below perfection they actually are. You will have myriad ways to showcase flaws, and your reports will read like any other newspaper. This is all quite normal. Not necessarily healthy, but normal. Bad news sells. Newspapers print the negative news. Management consultants, when hired, point out what is wrong. The critic is seen as discerning, intelligent, and thoughtful. Persons who point out positive aspects are cast as most probably defensive, unworldly, recalcitrant, or clueless. There are so many forces driving toward negative reporting that it is only natural that a performance reporting system will evolve with a negative slant. The danger lies in its doing so thoughtlessly or unchecked. The Motivational Effect of the Performance Reporting System on Organizational Psyche The greatest danger is that we all may come to believe our own self-talk as actually representative of how our performance does compare with that of our competitors. And if we begin to believe this self-talk, then we may even convince ourselves that tremen dous change and improvement are imperative. We will set difficult and challenging performance targets--aspirational rather than achievable targets, for we clearly need tremendous competitive repositioning if we are to remain viable. We will espouse approaches to reengineer, redesign, reorganize, tear apart, and rebuild our core structures and processes. Initiatives will be trotted out in an endless flow of "flavors of the month." Many leaders will enjoy their 15 minutes of fame prior to being promoted off into oblivion. Thank goodness our organizational foundation in partnership, capitated payments, nonprofit values, physician-managed care, centers of excellence, and integrated delivery and information systems is strong and robust enough to withstand the onslaught. Of course, I exaggerate. A bit. To make a point. Performance reporting can be described on a continuum from "shame-based" to "pride-based," where the caricature above is shame-based. Pride-Based Reporting Pride-based reporting, in contrast, is a system that highlights accomplishments, strengths, and improvements. Pride-based reporting highlights a recovery after a fall, stability despite debilitating circumstances, and movement in the desired direction. Of course, an optimal reporting system is balanced. Yet balance does not come naturally, thus not easily. The natural human and social tendencies drive toward shame-based reporting. Much as constant work is required to combat the forces of entropy so as to maintain order, so too is constant vigilance and effort required to combat the natural inclination toward shame-based reporting. Yes, I think at KP our reporting systems are skewed and slanted toward a shame-based emphasis; moreover, I think this has been organizationally debilitating to our collective self-esteem. What have we done to our collective conscious in the process of our continuous self-flagellation? When you ask a group of organizational leaders within KP whether they believe KP provides an excellent or very good care experience, perhaps 20% will say yes. Yet when you ask the same question of the members and patients who are the recipients of our care, 73% say that the care experience we provide is excellent or very good.1 Why the disparity? Because we have focused so much on our own flaws and shortcomings that those now dominate our sense of self. But can we be an excellent organization if we have that self-image? Do real winners in business also have such an inferiority complex? Can we enact the KP Promise with our current mindset? Or are we just creating more eye-rolling cynicism and self-doubt by even espousing such a high aspiration for ourselves, given where we have convinced ourselves that we are in the total performance picture? It is, in a way, easier to have an inferiority complex than it is to be confident. It is easier (and certainly rhetorically safer) to list the potential reasons for imagined or relative failure than it is to list the game plan to success. If you say you are going to fail and you do, then you were at least right, even prescient. If you actually succeed, then your humility becomes a part of your charm. If you say you are going to succeed and you fail, then you are both a failure as well as being a rather hubristic fool. People are more comfortable being prescient, humble, and safe. In our organization, you will find many more people who agree with you when you criticize our performance. When you laud our performance, you are often the lone voice, and vigorous social pressures are exerted to silence the dissenter, to shoot the messenger. If you have the courage, I encourage you to try the social experiment of saying that our performance is laudable in a group of KP managers and then watch what happens. Credibility and Engagement There are two reasons to avoid shame-based reporting as the sole or dominant focus for a reporting system. One reason relates to the motivational effect the system has on our organizational psyche, which I have described above. The other relates to the credibility, and thus organizational acceptance, of the system itself. A balanced reporting system is credible, emphasizes that there are multiple ways to "win," and acknowledges the adversities in our external and internal environments that can make decline predictable and stability and recovery laudable. As such, a balanced system is one that engages the full audience. A performance reporting system that emphasizes only a few winners and stars and that relegates the rest of the organization to the onerous position of simply "not measuring up" fosters disengagement. And not just from the performance reporting system but from the organizational strategies and imperatives that the reporting system is supposed to support. Disengagement manifests as cynicism; uninspired and superficial compliance with new programs and priorities; "gaming" the system, or figuring out how to look good on the numbers; and a whole complex of behaviors that we have labeled "whining," that is, explaining in detail why we are not as good as Hawaii or Marin County and why we will never be as good. If the bar is set at a level that the jumpers perceive to be impossible, nobody will even try. Why bother? At risk of carrying the organizational culture/individual personality metaphor too far, the psychological state looks like depression and brings with it a cynical lack of belief in organizational leaders and organizational direction, for our individual self-doubt is projected onto our leadership. Disengagement and its Undoing If your performance reporting swings too far off-center toward shame-based, the system begins to lose credibility, and the audience disengages. We know that we enjoy enviably high member loyalty and that we are a very successful health care organization with excellent quality outcomes. If our performance were really poor, then we clearly would not be able to stay in business. Yet we do stay in business, members write us thank-you letters and bring gifts to doctors and staff, and we are doing well. Of course, one can always improve, and just because we are doing well does not mean we are going to relax and stop trying to further perfect our performance. In fact, there is an entire literature in motivation that clarifies that positive feedback about performance is itself motivational and inspiring--that satisfied customers create satisfied employees, that the customer-employee satisfaction loop is a circular and continuous causal cycle rather than unidirectional. If the performance reports and analyses are too far out of line with the perceived operational reality of the organization's members, then the reports will be dismissed as invalid, useless, a waste of time. The intended audience will disengage. Above all else, any performance reporting system must keep people engaged if it is to be effective as a steering and calibration tool for performance. There are clear signs when the audience begins to disengage. In KP, the word "invalid" is used to dismiss a report or an analysis. Although "validity" in a statistical sense has a precise definition of content, construct, predictive and concurrent statistical properties, "invalid" at KP simply and emphatically means, "I do not believe this report. It is poppycock. Make it go away." Performance reporting functions need to aggressively listen to the reasons behind that word "invalid" if they are to understand what reports need to do and be to be accepted. I have watched our organization in Northern California and what its constituents have asked for in reports. They want to be compared with their comparable peers. They want a level playing field in their competitions; they want "apples-to-apples" comparisons. This is all appropriate. PMPM costs cannot be compared without considering regional pay differentials, MD tenure, patient health, and scope of practice--to name a few factors. Yet even after all possible adjustments have been made, some people still will not engage. Given that nothing is ever exactly the same, this belief in incomparability, thus uniqueness has merit and must be honored. At this point, one needs to move away from comparisons with others and embrace a reporting system "for the rest of us." Many among our intended audience will not engage with a report that portrays them as inadequate; ranks them in the lower third; or characterizes them as mediocre, average, or not significantly different from others. Such odious comparisons can be avoided if one leaves them off the page and focuses only on the entity in question. Clearly the best "apples-to-apples" comparison is the comparison of yourself to your own baseline over time. Barring schizophrenic breaks or nonseasonal mania (seasonal mania can be accommodated in reporting formats), such a comparison needs no correction or adjustment to be acceptable. And acceptance of the report as valid is fundamental to an effective reporting system. Certainly some will be motivated by the race, by the challenge of being "number one" or "top third" or "high performer." But the majority of our departments in Northern California, or our medical centers, or our regions are not in that position and cannot be because only one can be number one, and only one third can be in the top third. All still need to engage, but some will do better in a different kind of competition. To rely on rank order finishes, reaching the top, being as good as the best clearly engages the elite. But a country cannot rely on the Olympics as its only program to achieve national physical fitness among its citizens. The majority are not engaged, except as onlookers; and KP--or any organization, for that matter--cannot afford to leave its majority on the sidelines. Conclusion The performance reporting process needs to bring everyone into the fold. It needs to acknowledge performance stars who have high scores, stars who improve steadily, and those who pull themselves back up after a fall. It needs to be aware of and to acknowledge stars who maintain stability in the context of adversity, for that is also a difficult and laudable feat. We need to aggressively search for, articulate, and emphasize our areas of strength and achievement if we are to build the sense of organizational pride and confidence that is required to achieve the excellent aspirations that we espouse. We cannot afford to relax back into the comfortable position of continual self-doubt and nitpicking criticism--of "yes , but" reporting. "Yes, that was a nice improvement, but you still have fundamental problems with x, y, z." As an organization, our energies need to be focused externally on the competition rather than engaged in internal finger pointing, blame casting, and excuse making within our ranks. If we are to be an excellent organization, our self-talk must be pride-based. Yes, it is circular and self-reinforcing. We must think we can if we are going to try with confidence. And when we achieve the goals we set, that in itself inspires more confidence, and we continue. We cannot achieve the KP Promise if we continue to be exceptionally fluent, articulate, and forceful in describing our flaws and shortcomings while we are meek and hesitant when and if we mention our strengths and accomplishments. This above all-- to thine own self be true, And it must follow as the night the day, Thou canst not then be false to any man.
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