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"Continuous quality improvement should be our common purpose, our North Star to guide us regardless of payment models, policy shifts, leadership changes, or other uncertainties."
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In Difficult Times, Strive for Mutuality

By Derek Feeley | Tuesday, February 13, 2018
In Difficult Times Strive for Mutuality

People attend an event like IHI’s National Forum because they’re passionate about quality improvement, and looking for ideas, vitality, and ways to develop their networks. It’s a lively and inspiring event to be part of, and a great way to reenergize in December before kicking off a new year of work.

But even at the Forum, amid all that positive energy, people expressed uneasiness.

It’s a feeling that’s lingered in early 2018. The financial environment — especially payment reform in the US — is unsettled. The political environment in many countries is in turmoil. Demographics are challenging, especially as providers try to develop new care models for aging populations with chronic conditions.

These are difficult times for leaders, and difficult times mean facing tough choices. Where should we focus our attention?

In times of uncertainty, there’s a temptation to concentrate solely on the bottom line. It can seem simpler than the other demands on our time and energy.

The bottom line is important, and leaders can’t ignore it. But the best way to make sense of all the complexity and instability in health care is to keep people in our organizations focused on what is most meaningful to them, gives them a sense of mission and purpose, and engages their hearts as well as their minds.

I can think of no better place to focus than improving the quality of care for patients. Our customers want and need high-quality care, and we know from our experience that people with the skills to fully engage in quality improvement feel a sense of pride, purpose, and self-fulfillment. With signs of burnout everywhere, quality improvement is more important than ever — and so is something I like to call mutuality.

What is mutuality?

Mutuality is about trying to find a win-win. It’s about refusing to make tradeoffs between things that we may typically see as in competition or conflict. For example, instead of wondering if we should prioritize the patient experience or the engagement of our staff, we need to pursue mutuality and do both because they are reciprocally beneficial.

When we give clinicians the skills and opportunities to lead the improvement work that matters most to them, we get higher levels of staff engagement and joy in work. Where levels of staff engagement and joy in work are highest, so too are levels of patient engagement and satisfaction. Clinicians who make the effort to understand what matters most to patients also see their work satisfaction rise.

There are three main components to mutuality, and it’s worth noting how each applies to quality improvement:

  • Power – A cynic might view sharing power as losing power, but I believe it should mean giving up some control to get more important benefits in return. For example, many experienced quality improvers can tell you about QI projects they put hours — maybe even months — of time into developing only to have them fall apart once they were put in the hands of the clinicians closest to the patients. Why? Because such projects are too often developed without the leadership — much less the input — of the people responsible for implementing the improvement. They might not even agree about the changes they’re supposed to put into action. But if you ask, they will tell you what changes they think will mean the most for their patients. They’ll also be the fiercest advocates for improvement if you give them decision-making power and the skills and support to make change happen. In this context, sharing power means maximizing the assets of all the people who contribute to our systems by building on their strengths and giving them opportunities for growth.
  • Partnership – Partnering with patients means going beyond person- and family-centered care. The very methods of quality improvement —iterative testing, generating of ideas for change — if done in partnership between patients and staff, can create mutually beneficial outcomes. If we have the kinds of conversations between patients and clinicians required for shared decision-making, for example, the evidence indicates that we get better outcomes and even reduced costs. It means co-designing care by identifying both problems and solutions with — not for — patients to improve the quality and experience of care.
  • Purpose – Purpose is an anchor that keeps us moored in times of change and flux. There is great power in committing to a common purpose. Continuous quality improvement should be our common purpose, our North Star to guide us regardless of payment models, policy shifts, leadership changes, or other uncertainties. There are many opportunities for improvement in health care. We can’t make all the changes necessary without engaging staff and clinicians at all levels of our organizations, in partnership with patients and their families.

Now is the time to recommit to quality improvement and look for opportunities for mutuality. There are enough tough choices we need to make in the current health care environment. Let’s not make choices and tradeoffs when they’re not necessary. Instead, let’s figure out where agendas overlap and intersect, and go after the quality improvement aims that benefit both patients and providers.


Derek Feeley is IHI President and CEO. He will be faculty for the Finding and Creating Joy in Work virtual training beginning September 11, 2018. He is also co-author of the IHI Framework for Improving Joy in Work.

Editor's note: Look for more from Derek Feeley  (@DerekFeeleyIHI ) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.

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