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  • Writer's pictureStephen Harden

Why Most Training Doesn't Help Quality Improvement for Healthcare

Updated: Aug 7, 2020

Last week in my blog about quality improvement entitled, “Make Sounds Come Out of Their Mouths” I made what I thought was a very simple offer at the end of the email:


"Want a copy of the best book on coaching I have ever read?

I’ll send a free copy of the best and most useful book I have ever read on coaching skills to the first three folks that try this technique and send me an email about their experience."


Simple, right?

The offer clearly states that if you try the quality improvement technique I explained in the blog, and send me an email describing your experience, I will send you a free copy of the best coaching book I have ever read.

Want to know how many people followed the instructions correctly (out of the thousands of subscribers to the blog)?


That’s right, exactly one. One person out of thousands read it correctly and followed the instructions to the letter. (And she was the first to get a copy of the book- Coaching for Improved Work Performance.)

Fifteen readers, misreading or misunderstanding the instructions, just sent me an email saying “Send me a copy of the book.”

Thousands more either didn’t read it at all or chose not to respond.

The thought struck me that this whole event is a perfect example of what happens to many of us when we devise and implement a new patient safety policy or quality improvement process. We codify the policy/process in writing, disseminate it to physicians and staff via email or other written format, and then are disappointed with the levels of understanding and compliance we get.

We find ourselves saying, “I told them what to do. Why aren’t they doing it?”

In short, we've acted as if we believe that "Telling is Training."

In a sense, that’s exactly what happened to me. I devised a policy (e.g. try a communication technique, tell me about your experience with it, and get a free book), put the policy in writing, disseminated the policy via email, and got very low compliance.

The lesson here?

Telling is Not Training.

Training requires four steps...

  1. Provide information;

  2. Demonstrate how to apply the information;

  3. Provide the learner an opportunity to practice;

  4. Provide feedback to the learner on how well their practice met the standard of performance.

As leaders, if we haven’t done all four of these, we haven’t really provided the training or education necessary to enable our staff to comply with the new policy or process we’ve just implemented. This is not how to accomplish quality improvement in nursing.

Using the technique of “Make Sounds Come Out of Their Mouths” can really help in the training process and turbocharge quality improvement for nurses, especially with Step #3: Provide an opportunity to practice.

Here are some examples of this that newsletter readers sent me last month...

The first example is from R.S., a nurse and Director of Patient Safety in Wisconsin...

“I showed them the quarterly report with the core measures related to surgical patients. They both said that they don’t pay attention to these reports. One of the nurses said ‘I don’t believe the report because I know that I am doing everything I can for my patients.’ I was disappointed because I thought the policy and my colorful reports made it clear to all what our current performance is and where we expect to go.

Then your words floated into my head - ‘...the communication problem is often not with the listener, it’s with the speaker’. So I turned to one of the RNs and asked, “When I say "white" what comes to your mind?” She said, “black”!

I got it then and spent the next 30 minutes asking questions to make sounds come out of their mouths. Based on their responses I am changing my process.”

This example comes from K.K., the Chief Learning Officer at a hospital in New York...

“We tried the technique while coaching a physician (faculty) on giving feedback to a resident about poor performance. The usual approach is lecturing the resident and then asking, ‘Do you know what you did wrong? Do you know how to correct it?’ The resident nods her head and there is no acknowledgment if the resident actually understands and owns the problem and solution.

This time, the physician asked the resident to tell in her own words what she did wrong and what she must do to correct it. At first, she just said, “Well, you said that I...’

The physician then said, ‘No, tell me in your own words...’

It was really impactful.”

M.K., an administrator in Georgia was having difficulty trying to get others to understand the policy on an issue essential to their work in quality improvement for healthcare. She had this to say...

“So, to create better dialogue, and cement the message I asked:

• Have you had a family member or friend who needed this but didn’t have one?

• How do you think promoting this would help our work here?

• What would you suggest I do to get the ball rolling?

• If we don’t do this, what impact would it have?

The sounds came out of their mouths...! We’re starting a big push on this!”

Bottom line? If you are not getting compliance with quality improvement initiatives that you want, remember that Telling is Not Training, and ask yourself which of the four steps of the training process haven’t been done. Where it makes sense, use the technique of Make Sounds Come Out of Their Mouths to help you accomplish those steps.

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