This is a nice story about an ambitious, determined self-starter, who ingeniously constructed his own first “team” from the raw material of mailing labels. But what does excellence look like when embodied in a larger clinical setting, like an agency? What might be the recipe for actually building this way of relating from the inside out?
The Role of Leadership
“Cultures of excellence don’t just happen—leadership is essential,” says Cynthia Maeschalck, a Vancouver-based training consultant specializing in improving clinical performance. “Leaders need to take charge and make sure practices that encourage excellence are standard throughout the agency.” It’s now well-known that having clinicians consistently get client feedback and measure their outcomes improves the quality of therapy. Measurement and feedback are vital for any clinical culture of excellence, because of the human tendency to underplay our shortcomings and overplay our successes.
“But most people still don’t want to measure outcomes,” continues Maeschalck, “because it’s laborious—just because it’s a good idea and improves results doesn’t make it more appealing. Somebody has to take the lead and have the passion to insist on and maintain high standards, so that excellence becomes a habit.” However, the leader can’t merely act as an enforcer, ordering staff members to use the measurement tools they’re given; he or she needs to “make it come alive for people,” help them understand and believe in these tools.
Leadership may be the first principle in creating a culture of excellence, but success remains unlikely unless a culture of trust is established at the same time. This is because the most important building blocks of excellence are failure and the willingness to admit it. Failure and error, if not accompanied by shame, can provide compelling motivation to learn. However, people won’t admit to error—making a mistake—if they fear it’ll be held against them or that they’ll be viewed as incompetent.
It’s an open secret in the world of great achievement—from art to literature to sports to business to science—that the road to success inevitably passes through the dark terrain of failure. Psychotherapy studies similarly reveal that effective therapists report making more mistakes and being more self-critical than their less effective counterparts. Other evidence documents that healthcare professionals who acknowledge errors and disclose mistakes are less likely to be sued. Additionally, research conducted by Stanford psychologist Carol Dweck and colleagues points out that purposefully striving to be mistake-free is characteristic of an approach to life and learning that leads not only to poorer overall performance, but also to seeking out fewer, less challenging tasks.
“Error-centric” thinking—looking for what isn’t quite right, where there’s a shortcoming, where improvements can be made—is characteristic of work environments that are committed to enhancing therapeutic performance, according to experts on the subject. In fact, leaders of excellence cultures sometimes seem as focused on failure as the rest of us are on success. “I purposefully recruit staff that are flawed, have tripped up, made mistakes—and recovered,” says Belinda Wells, the managing director of the 16-member, United Kingdom–based treatment agency known simply as The Counseling Team. “Don’t get me wrong,” she adds, “They’re top performers. It would be hell if they weren’t, since the standards are so high.” But, she says, “I avoid those who, being young or having little real-life experience, are always trying to ‘do the right thing,’ so to speak.” In cultures of excellence, such people can feel deeply threatened; their investment in seeing themselves as smart, competent, and capable at all times clashes with the very behaviors that promote high levels of achievement—recognizing and being unashamed to share failure, and using it as a springboard for improvement.
Unfortunately, many managerial and regulatory policies undermine the willingness of professionals to reveal their own failings to colleagues. An example is the recent passage of Oregon State Statute HB 2059, which mandates all healthcare professionals to report on one another for any “conduct unbecoming a licensee.” Under such a censorious shadow, with potentially serious legal penalties hanging over their heads, it isn’t likely that a doctor, nurse, or psychotherapist will go to colleagues to admit making a mistake. Rather than encouraging the admission and exploration of errors, this kind of policy shuts down conversation. In fact, leaders of local professional organizations are already reporting that the statute is having a chilling effect on professional collaboration.
The third element in building a culture of excellence is creating a common ethic about performance and measurement. Whether working as a private practitioner, in a group practice, or an agency, a key feature of cultures of excellence is being able to easily share and compare results. Among top-performing therapists and agencies, measurement is as commonplace as the more established benchmarks, such as efficiency and return on investment.
Many therapists experience misgivings about measuring their impact—how can the subjective quality of the therapist–client relationship possibly be reflected by crude metrics? Yet, at agencies committed to excellence, measurement is central to the way staff members think about what they do. Far from being a source of discouragement, numbers that assess the outcome at every visit focus attention on the session-to-session progress. No matter how refractory the depression, how paralyzing the anxiety, tracking outcomes can help to reveal some—possibly small, but concrete—improvement. By contrast, if there’s no progress, or the scores deteriorate, the therapist is learning that changes in the service are necessary—useful information that can be shared and discussed with colleagues.
As noted earlier, when therapists track progress, dropouts decrease and overall outcomes improve—a great motivator for any clinician. “We are and have been from the outset obsessed with measurement,” says the Counseling Team’s Belinda Wells. “I expect staff to measure and to be interested in the results.” The impact of such a “measurement obsession” has been astonishing. “One day, the consultant whose scales we were using to measure our results called me. After exchanging the usual pleasantries, he asked, ‘What exactly is your team doing up there in Kent?’ And when I said, ‘What on earth are you referring to?’ he replied, ‘Your team is exceptional: first, the quality and comprehensiveness of the data you send for analysis, and second, the astonishing rate of recovery among the people your group treats.’ It was a pivotal moment.” Wells paused. “But it’s not the numbers, really. It’s about being curious,” she notes. “Trying to figure out what’s not working and how we can do better.”