Accountability and reliable promises, pt. 3

Part 3 in a 3-part series

In the first two parts of this series, we used the example of nurses filling foam canisters in hospitals (to increase the odds of hand washing that protects patients from infection) to demonstrate what it takes to build accountability in an organization. Accountability requires promises, which in turn require effective requests (or offers) and acceptance of those requests. If the goal is for everyone involved to follow a similar process, i.e. standardized work, then it’s important that they all explicitly promise to do this. But what do you do if a nurse isn’t following standardized work? According to Mark Graban, the first thing to do is to ask why. He proposes asking the following about a surgeon who fails to follow “universal protocol” before a surgical case, but the same applies to nurses who fail to refill canisters.

We can ask:

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  • Is it a case where the person CAN’T do the work properly?
    • Do they not know how? This might be a systemic training problem. The individual can’t be held accountable for that.
    • Does the person not have the right resources? Maybe they WANT to do it right, but they just can’t. Leadership needs to help eliminate those barriers.
  • Is it a case where the person WON’T do the work properly?
    • Is the situation one where the person truly has a choice and they made a bad choice?

These breakdowns in the delivery of a promise all stem from a promise that (we’ll assume for the moment) was effective but not reliable. As we’ve seen, an effective promise requires clear conditions for satisfaction, a clear timeframe, a specific speaker and listener, and a background of obviousness. A reliable promise requires more, namely a grounded assessment that the nurses are sincere, competent, and reliable. We can unpack Mark’s analysis using these terms:

  • Wants to but doesn’t know how. My translation: the nurse is sincere but not competent. This could be a systematic training problem, but I’d call it a systematic competence problem. Whether lack of training is the cause of insufficient competence is an open question. (After all, there are many ways to build competence: shadowing, mentoring, deliberate practice with feedback, and of course formal training.) Once we identify competence as the issue, here is the next question I’d ask after discovering that one or more nurses are not competent at a process: who assessed that these nurses were competent to begin with, and what was the grounding for their assessment?  In a similar vein, who will be responsible for making these assessments in the future? The reason to ask these questions is that a promise goes from effective to powerful when the “customer” of that particular request (in this case, the manager) assesses the people being asked (in this case, the nurses) as competent—and has solid grounding for this assessment! To put it more simply, a powerful promises requires that the manager trust the competence of the nurses to fulfill this particular promise.
  • Wants to and knows how but lacks resources. Here I would say that the nurse is sincere and competent, but neither the nurse nor the manager has made a grounded assessment of the nurse’s reliability at fulfilling this particular promise. One question to ask: did anyone make an explicit assessment about resources needed, and how well grounded was this assessment? If the nurse knew that they needed resources but didn’t declare this need, why didn’t they? Or was it instead the case that the nurse spoke up about resources but then nothing happened, i.e. the manager didn’t offer to provide resources nor did the nurse request it?
  • Doesn’t want to do it. Here we can say that the nurse’s promise is not sincere. Behind the public acceptance of the request is a contradictory private thought, e.g. there is no way I’m going to do this. OI’ll do this but only in X situation. Saying that someone is not sincere in making a promise does not mean they are a bad person or even that they are dishonest or untrustworthy. It means that at a particular moment when the agreed to fulfill a promise, what they said did not match what they were thinking and feeling.

Hopefully, my riff on Mark’s example illustrates why genuine accountability is often challenging: there are so many ways for the mere act of making a promise to break down!

In future posts, we’ll take this a step further. We’ll ask: why is it that even reliable promises break down in their delivery or in the assessment of results? Hmm….