• How to Go Naked

    May 25, 2012

    By James L. Reinertsen, MDJames Reinertsen

    Transparency can help leaders generate the motivation needed to implement difficult changes.

    Many leaders have asked for specifics on how to be more transparent. With your consent, here are some examples of how good leaders can "go naked."

    Start Undressing at the Top

    Reluctance to talk openly about quality performance usually begins in the boardroom. Too many boards hear mostly good news and, therefore, tend to think quality is far better than it is. As a result, when a serious problem surfaces, the board is surprised. So the first step in transparency is to ensure that board reports clearly display the good, the bad, and the ugly in ways that your board can understand-without phrases that explain away suboptimal performance.

    Suggestion: Review your past three board quality reports for comforting language such as, "These rates are within the expected range for a hospital of our size and complexity." Then excise these comforting words, substituting phrases such as, "If our performance were at the level of the world's best hospitals, the number of patients who experience these defects would be XX, instead of XX." That will start a different conversation at the board!

    Don't Hide Behind Your Lawyer

    Many hospital lawyers require that safety data discussions occur behind a thick veil in the apparent belief that they are protecting the institution from legal risks. But as one health system lawyer told me, "Patients don't learn they got hurt by seeing their name on a PowerPoint® slide. They don't sue us because of our data. They sue us because of broken relationships. How can we get on with the job of making care better if we can't talk openly about what goes wrong?"

    I think she nailed it. As leaders, your primary job is the mission of the organization. If you think you must choose between fulfilling the mission and protecting the institution, your choice is clear. Besides, it's not an either/or. Many hospitals have made dramatic improvements in both safety and risk management claims-by talking more candidly about safety data.

    Keep It Simple

    Some of the most powerful leadership practices are very simple, involving paper, pencil, and masking tape. Bill Rupp, CEO of Mayo Clinic Florida, asks unit managers to post simple charts of key performance data, such as compliance with infection control bundles, on unit walls visible to all who walk by. More important, he is especially keen on posting the data before it has improved-not after the managers are finally proud of it. He has repeatedly found that performance-especially suboptimal performance-improves rapidly when it's out there for everyone to see.

    Suggestion: Ask your managers to post quality and safety data, such as "days since last serious safety event," in public spaces, along with a simple explanation about what you're trying to accomplish and why.

    Shape Up

    Some leaders worry that if they go naked with quality data, their patients will go to competitors who tout their successes but hide their problems. But patients don't seem to make choices about care based on publicly reported data, even when the data are terrible.a Your staff do pay attention, however. And when they see data they don't like, they tend to shape up. Or as Tapscott and Ticoll phrase it, "If you're going to be naked, it's good to be buff."b

    James L. Reinertsen, MD, is CEO, The Reinertsen Group, and a senior fellow, Institute for Healthcare Improvement (jim@reinertsengroup.com).


    a. Jha, A., et al, "Care in U.S. Hospitals-The Hospital Quality Alliance Program," N Engl J Med, Jul. 21, 2005, vol. 353, pp. 265-274.
    b. Tapscott D. and Ticoll, D., The Naked Corporation: How the Age of Transparency Will Revolutionize Business, New York City: Free Press, 2003.