What We Learn in the Banana Measuring Game

Lauren Macy, Improvement Advisor, IHI
Rebecca Steinfield, Improvement Advisor, IHI

Lauren Macy: So, Rebecca, we just finished playing the banana measurement game and I wanted to hear from you and some of your experience around what are some of the key learnings that you've seen teams come away with after playing this game?

Rebecca Steinfield: Sure. So in my experience, there are sort of two points at which the teams learn. Right? So they learn a lot when they're actually trying to write the operational definition the first time. And then they learn again when they get the other team's operational definition and they compare it to theirs.

Rebecca Steinfield: So when they're writing their definition, they learn all kinds of things about the different perspectives in their team. And when they think about the banana, which at first glance seems like a simple thing to measure and they realize how many options they have. Right? That's eye opening for them. And they also learn about the sort of difficulty of actually writing down in words what seems obvious when you do it.

Rebecca Steinfield: Then they get the other teams operational definition and they realize all the problems with theirs. Right? So they want to run over and correct theirs, but you don't let them do. But they see things like, oh, I left out the unit of measurement. I forgot to say measure in inches or I forgot to say which part of the banana I was measuring. Some teams can get very, very precise in their measurement. I've had teams with seven different measures of the banana. And while other teams will come up with one or maybe two. So that comparison is really helpful for helping people learn. And then when they talk about the experience afterwards and they compare why they made their decisions, and they really start to understand the importance of understanding the purpose of the measure in making the decisions.

Rebecca Steinfield: So they compare, for example, why would you have seven measures for the banana versus one? Sometimes the team that had seven thinks, why wouldn't you have seven measures because it's precise. And when they start to understand, well, do you need them all? Is the investment of time and resources in collecting the seven dimensions of the banana worth the effort? And those are interesting conversations to folks.

Rebecca Steinfield: So Lauren, how do you see the lessons of the banana measuring game translated into the real world?

Lauren Macy: Recently, I had a phone call with the team that I support where there's people from different countries, all trying to measure the same thing around mental health. And one of the indicators is around patients dropping out of care. And trying to figure out what that meant to everyone on the call was really interesting because to some people, it was that they hadn't seen a patient for three months and then to other providers on the call, it was that they hadn't come for one week or they had missed the referral.

Lauren Macy: So talking through those points was really enlightening to the rest of the group. And we were able to arrive at a decision together around what that dropout qualification would be. And I think that was really important for us as a team to go through that process. And after having collected the data for a couple of months, thinking that through a bit more, we were testing out, basically, the measurement and seeing how it fit in these different settings.

Lauren Macy: Another example has been around really defining the start and end of a measure. So thinking that through. If you're collecting something weekly, are we talking about the work week? Are we including the weekend? Is it a Sunday to Saturday? Or is it just clinic days? If you run that on Tuesday and Thursday, just collecting those. Really spelling all of that out has been really important to get consistency in your measurement so that anyone who is collecting the measure will collect the same thing that the last person did. So making sure that you define the data source, making sure that you define the start and end of the banana or whatever it is, the time period that you're measuring and laying that out very clearly in the real world, I think, is really important.