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Making improvement interventions happen—the work before the work: four leaders speak
  1. Paul Batalden
  1. Correspondence to Dr. Paul Batalden, The Dartmouth Institute for Health Policy and Clinical Practice, The Geisel School of Medicine at Dartmouth, Lebanon, NH 03766, USA; paul.batalden{at}

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Masterful work requires preparation. This anticipatory thinking, rehearsal, attention, reflection, real-world grounding can be done in many different ways, but it must be done well. Paul Batalden asked four expert leaders how they prepare for making improvement interventions happen. What they reveal provides inspiration, guidance and practical knowledge.

Nana Twum-Danso is professionally qualified as a public health and preventive medicine physician. She led a nationwide quality improvement project in Ghana, her home country, for 4 years before joining the Gates Foundation in 2012.

“ don't want to come across as being unrealistic, but you want to encourage them to be ambitious, to become a member of something which will give them pride.”

Maxine Power is professionally qualified as a speech therapist from the UK. Over the last 3 years, she has led the safety work stream of the National Health Service (NHS) national Quality, Innovation, Productivity and Prevention to improve quality and contain cost.

“I try to help each person to see the situation from the perspective of others… put a disrupter into the collective mindset to get different thinking.”

Christine Goeschel is professionally qualified as a nurse and implementation scientist. At Johns Hopkins School of Medicine, she has coordinated multiple large-scale group collaborative projects to improve health systems.

“I try to get deeply connected to the system settings where patients and health care meet, to better understand the realities or the ground truths of quality and safety efforts that live within them.”

Andrea Kabcenell is professionally qualified as a nurse. For the past 18 years, she has worked at the Institute of Healthcare Improvement, USA, where she has directed 13 breakthrough series collaboratives and several large demonstration projects aimed at improving patient experience and clinical outcomes.

“...adopting humility goes a long way and people seem to understand that it would be okay to adjust our plans in the future, but if we have them now, we can get started.”

Batalden: When you do this work, what do you do to prepare yourself for it; what is the work before the work?

Leaders say:

  • Identify the multiple—and possibly competing or conflicting—goals for your project, and to whom those goals matter.

  • Figure out the best people to help with this project, and how to mobilise people around a shared goal.

  • Get clear on the scope of the work and make sure the resources are in place.

  • Build on learning from previous projects, and draw strength from experience and knowing your own strengths.

Kabcenell: I often begin by wrapping my head around what the aim is: the stated aim and the real aim, and how it fits into someone's strategy. I think about what the team needs to achieve, how it fits with the big picture or any bigger goals. I get to know the people involved and whatever context that is going to be really important. We list the political (small ‘p’) issues in any given project: who would be happy about this, who would be sad about this, who wins/who loses. I try to get clear about what resources are available and I try to ‘front-load’ resources, over staffing. So even before the planning I think about the people I know who might be helpful, the people who might have had experiences like this, actual resources designated for the project as well as resources that I have in my world that would help make this go well.

Goeschel: I've changed over time. I used to cull the literature to really understand as deeply as I could what was being written by experts about what we could do to improve. Now after finishing a doctorate and moving to academia, I also try to get deeply connected to the bedside in hospitals, to better understand the realities or the ground truths of quality and safety efforts within them. I look at my calendar and try to block out more time than I think I'm going to need. I make promises to myself to take care of myself—though I'm not always successful. I look at the people around me who will be involved and who might be ready for a bigger, more expansive role than what they have done in previous projects.

Power: The first thing I ask myself, “Am I the right person to be leading this work?” Then, “Are there things that I know, have learned, or that I have experienced which potentially will bring value to the challenge that lies before us?” Invariably there are some things I don't know or skills I don't have, and I am left thinking, “Who else, who are the people we need to be talking to before the work even starts?” Who will help us get a sense of what the context is? How is this connected to my core values? I know that if that is true, it will be significantly easier to work with this team, this project. I also try to be clear about who are the other people who want this improvement.

Twum-Danso: I begin by preparing myself psychologically for the initial reaction—sometimes negative, neutral, or “here we go again, something new to try, something new to create more work for us.” I try to help people to think about the future in relation to the status quo: the frequency of death, missed opportunities or whatever the problem may be as related to what might be possible in an improved situation. But you have to do this in a balanced way … you don't want to come across as being unrealistic, but you want to push them to be ambitious, to become a member of something which will give them pride. It's hard, really hard to do this work well.

Batalden: Dwight Eisenhower said that plans are worthless but that planning is essential. How do you do planning for improvement interventions?

Leaders say:

  • Articulate a compelling vision of what the improvement will achieve—one that appeals across many audiences.

  • Identify: where have we been, where are we now, and where are we going?

  • Think about how things can look different in 5 years time, and what could go wrong as well as right on the way.

  • Plan—with timelines—but make sure you do as well, and remain wide open to the possibility that your plan may need to be revised.

  • Really get to grips with the context in which you are working, including the cultural and logistical environment and the other players in the field on whom you may depend.

  • Focus on getting the operational detail right.

  • Listen hard at the beginning, and keeping listening as the plan unfolds so you learn how to make it better.

Goeschel: I frequently say that we have to be really comfortable with complexity but realise that chaos sometimes puts us over the edge. So allowing the development of a plan, a framework of what we hope to achieve, how we expect it to happen, who we think needs to be involved, what our going-in assumptions are and how we think we are going to get the data that we need to support our knowledge that improvement has or has not occurred is critically important. But after we have a plan that the project team can acknowledge, it may be even more important to capture where we are actually going—giving ourselves permission to start discovering all that we missed and being open to the possibility that we have been completely off course, or that we need to listen even more carefully to those with whom we are working. In academia, we have a lot of people who think that the ‘work’ is to just do the plan. On the flip side we also have several people who would love to talk forever about the various plans we could have—never doing anything. So, I think it is a matter of finding the balance between pushing for the development of something that is relatively concrete while explicitly setting the expectation that we may not have gotten it right. We need the commitment from every member of the team to continue to move forward while putting our concerns, questions and confusion on the table for all to review and act on.

Power: I think about planning in three parts: where have we been?, where are we now?, and where to do we want to go? This begins by listening and trying to really understand the work that has gone before, giving very strong signals that it is respected and valued. So, I listen a lot. I go to the place where the people are and I listen again. When I'm three generations of contacts in—people available referring to the next referring to the next—I usually find that I understand the space and have sufficient knowledge about how people have been working and how well that has worked for them. I usually do not try to become a content expert. Transitioning from ‘where we are now?’ through ‘what we are confident and comfortable in doing?’ towards a more radical ‘what could this look like if we stretched ourselves to better our best?’ is interesting as well. This transitioning allows you to draw on some of your prework about best-in-class examples or places. The aim is: put a disrupter into the collective mindset to get different thinking. Learning what that might do to people has been another significant part of my own learning. Some people love the disruptive provocation and will run with you until they can run no more. Others feel very uncomfortable and I have learned to recognise that discomfort and acknowledge my understanding of their reaction as key to keeping them with me.

Planning includes being able to describe a compelling vision. It is often helpful to have several different ways of describing a vision, so it is appealing to those delivering day-to-day care, those working in the system, and those who are more policy-oriented, such as those in the Department of Health. I bring them into the same room together, helping them all focus on the shared goal. I try to help each person to see the situation from the perspective of others. Together we create a shared vision of what ‘good’ might be. We work like a village more than as individuals in silos. This connecting role can be quite a challenge, though not all improvement challenges are equally complex. I realised that often we don't give people an estimate of the anticipated degree of the difficulty of the change, nor do we engage them in conversation about it. I have learned to get a sense of the complexity, how it might be simplified, and how we can get the skills and people necessary for the challenge. This step is just so critical.

Twum-Danso: In Ghana, the approach we used was new, so we began our planning with staffing. We wanted enough time for recruiting, training and coaching the new staff so they understood what we were trying to achieve—both content and culture. Our improvement approach involved behaviour change, and many job applicants were not aware of the cultural changes involved in these ways of working. If the new project officers weren't ready to work on their own after our training, we did joint site visits with them for 3–12 weeks—whatever was necessary—for us to feel confident that each person understood the work content and had the right attitude to facilitate change. We had to plan protected site visit time for the change facilitators. In the Ghanaian context, we can do very little coaching by telecom technology because the telecom infrastructure is weak and/or too expensive. Because so much of it involves behaviour change, the facilitating change agent has to be compelling and reliable. If you commit to visit monthly, then you should do that. If you don't, people will lose faith and trust in you. You will be like others who have disappointed them previously.

Further, we had to make allowances for the 3–4 h travel over bad roads in rural areas to get to particular clinics. We used Excel spread sheets to calculate complex factors: number of site visits possible in a day or week in a particular region, proper mix of ‘weekends in the region’ versus ‘returns to the office,’ and considerations of the burden(s) of travel! Because we didn't want to disappoint our quality improvement (QI) teams, we had to carefully plan logistics to meet the expectations set. We had to plan the logistics of getting rural auto travel in Ghana: vehicle(s), driver(s), fuel, funding—all in the right places at the right times. Something as simple as having available funds could be such a hurdle! The amount of money was not the issue. The challenges were in the administrative bottlenecks related to moving money. Sometimes, those controlling money or its movement were not as time-sensitive to the needs in the field as the project officers were. Sometimes there were delays in communication, bank wire transfers, contracts, and so on. I was amazed! Sometimes vehicles in for repair didn't come back in a timely way, or the costs of needed repairs exceeded the costs of renting an alternative vehicle for the next year and we needed to make those decisions in a timely way. These administrative issues and amount of logistic detail were not my area of expertise. Nevertheless, I had to pay attention and get involved with them or we would have had staff sitting in the office unable to do the fieldwork that we knew was so critical to change management.

Last, and maybe most importantly, we were working in partnership with bigger institutions that were not as directly involved with the project. Based on their good understanding of the project and our understanding of their plans and time requirements, we had to match our time plans with theirs to avoid disappointments and achieve necessary project elements. We did this in joint meetings which also required careful attention to logistics to avoid driving 2–3 h for a meeting where critical people weren't present. My time ‘planning’ meant time trying to keep things moving forward. I could literally spend 4 h a day on the phone with team members in Accra and in Boston. It was all coordination. So my main ‘planning’ job was really coordination and anticipating enough ‘oil’ to keep the wheels turning.

Kabcenell: I start planning with a standard work template and begin ‘pattern matching.’ I pull plans from similar past projects, thinking deeply how this may be different and similar, and what implications that might have. I develop a time line with milestones, trying to imagine what they may be, even if I don't have precise details. Then I try to make that a shared timeline that everyone is working from. This is not always easy because many don't think in timelines. With a draft, I then get as many people on the project as possible involved in the planning. One trick I use involves getting those involved together and asking them to imagine a time 4 or 5 years after the project. I invite them to tell the story about how the project went and what happened. Sometimes it gets kind of silly and whimsical, but rarely is it pessimistic. It is too soon to be pessimistic. This actually helps us with the milestones a little bit. If I have gotten the aims and strategy right, we then start to think about the actual results we want at each milestone. This really helps us all understand the size of the change and the kinds of obstacles we are going to have. I always plan for obstacles. In fact, at several planning stages, we do a quick failure-mode analysis: “Here's a good plan, how could this go wrong?” People might get upset because it sounds pessimistic, but it has helped us a great deal many, many times. I work to communicate about the plans as much, but as simply as possible, always starting the discussion by reminding people of the aim. Frequently I ask, “We are expected to be at this point at this time, how are we going to get there?” Lastly, I have to be as humble as possible about the plan. Often, I will say “this is probably wrong, like a budget at Christmas—these are all the things that people try to put some control into their world. We might fail or be wrong, but let's use this as a starting guideline so we have a chance to get it done.” So adopting humility goes a long way and people seem to understand that it would be okay to come off our plans, but if we have them, we can get started.

Learning from leaders

These four leaders were chosen because others who worked with them regarded them so highly. We all learned in these conversations. Their thoughtful words invite our own reflection on ‘the work before the work’, when improvement interventions happen in our own settings. More learning will happen when—and if—we ‘hear each other into speech’ about the same themes in our local communities.


  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.