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How Do We Get Continuously Better, How Do We Prevent Level-Out?

November 08, 2018 - By Atul Gawande, an American surgeon and public health researcher. He has written extensively on medicine and public health for The New Yorker.

COMMENT BY WENDY LAMBOURNE, LEGITIMATE LEADERSHIP, ON THIS VIDEO

One of the differentiators between leaders and managers is that managers don’t care how good or bad people are as long as they produce the results. Leaders, on the other hand, are relentless in their pursuit of excellence in their people as an end in itself. One of the ways of enabling human excellence is through coaching. By that is meant “watching the game” and giving the person whose game is being watched specific and detailed feedback which enables her to improve her game. Legitimate Leadership sees the leader as a coach and has witnessed significant improvements in performance when leaders suspend their own agenda to go out to “watch the game” of their direct reports and give them developmental feedback. Atul Gawande shows how coaching in birth centres in India literally saved lives. His experience irrevocably demonstrates the power of those in leadership positions in organisations coaching their people to realise the best in themselves from an ability point of view.

OUR SUMMARY OF THIS VIDEO: How do professionals get better at what they do? How do they get great?

I think it’s not just how good you are now, I think it’s how good you’re going to be that really matters.

I was visiting a birth center in the north of India. I watched the birth attendants and realized I was witnessing in them an extreme form of this very struggle – namely, how people improve in the face of complexity, or don’t. In this region  the typical birth center has a 1-in-20 death rate for babies, and moms die at a rate 10 times higher than elsewhere.

Now, we’ve known the critical practices that stop the big killers in birth for decades, and the thing about it is that even in this place – in this place especially – the simplest things are not simple. We know for example you should wash hands and put on clean gloves, but here the tap is in another room and they don’t have clean gloves. To reuse their gloves, they wash them in a basin of dilute bleach, but you can see there’s still blood on the gloves from the last delivery.

Everywhere, 10% of babies are born with difficulty breathing. We know what to do. You dry the baby with a clean cloth to stimulate him to breathe. If he does not breathe, you suction out his airways. And if that doesn’t work, you give him breaths with the baby mask. But these are skills that they’ve learned mostly from textbooks, and that baby mask is broken.

It presses on a fundamental question. How do professionals get better at what they do? How do they get great?

And there are two views about this. One is the traditional pedagogical view. That is that you go to school, you study, you practice, you learn, you graduate, and then you go out into the world and you make your way on your own. A professional is someone who is capable of managing her own improvement. That is the approach that virtually all professionals have learned by. And it works.

Consider for example legendary Juilliard violin instructor Dorothy DeLay. She trained an amazing roster of violin virtuosos: Midori, Sarah Chang, Itzhak Perlman. Each of them came to her as young talents, and they worked with her over years. What she worked on most, she said, was inculcating in them habits of thinking and of learning so that they could make their way in the world without her when they were done.

Now, the contrasting view comes out of sports. And they say, “You are never done, everybody needs a coach.” Everyone. The greatest in the world needs a coach.

So I tried to think about this as a surgeon. Pay someone to come into my operating room, observe me and critique me. That seems absurd. Expertise means not needing to be coached.

So which view is right? I learned that coaching came into sports as a very American idea. In 1875, Harvard and Yale played one of the very first American-rules football games. Yale hired a head coach; Harvard did not. The result: over the next three decades, Harvard won just four times. Harvard hired a coach.

And it became the way that sports works. But is it necessary? And does it transfer into other fields?

I decided to ask Itzhak Perlman. He had trained the Dorothy DeLay way and became arguably the greatest violinist of his generation. One of the beautiful things about writing for The New Yorker is I call people up, and they return my phone calls.

And Perlman returned my phone call. So we ended up having an almost two-hour conversation about how he got to where he got in his career.

I asked him, “Why don’t violinists have coaches?” He said, “I don’t know, but I always had a coach.”

“Oh yeah, my wife, Toby.”

They had graduated together from Juilliard, and she had given up her job as a concert violinist to be his coach, sitting in the audience, observing him and giving him feedback.

“Itzhak, in that middle section, you know you sounded a little bit mechanical. What can you do differently next time?” It was crucial to everything he became, he said.

It turns out there are numerous problems in making it on your own. You don’t recognize the issues that are standing in your way or if you do, you don’t necessarily know how to fix them. And the result is that somewhere along the way, you stop improving.

I thought about that, and I realized that was exactly what had happened to me as a surgeon. I’d entered practice in 2003, and for the first several years, it was just this steady, upward improvement in my learning curve. I watched my complication rates drop from one year to the next. And after about five years, they leveled out. And a few more years after that, I realized I wasn’t getting any better. And I thought: “Is this as good as I’m going to get?”

So I thought a little more and I said, “OK, I’ll try a coach.” So I asked a former professor of mine who had retired, Bob Osteen, and he agreed to come to my operating room and observe me. I remember the first case. It went beautifully. I didn’t think there would be anything much he’d have to say when we were done. Instead, he had a whole page dense with notes. “Just small things,” he said.

But it’s the small things that matter. “Did you notice that the light had swung out of the wound during the case? You spent about half an hour just operating off the light from reflected surfaces.”

“Another thing I noticed,” he said, “Your elbow goes up in the air every once in a while. That means you’re not in full control. A surgeon’s elbows should be down at their sides resting comfortably. So that means if you feel your elbow going in the air, you should get a different instrument, or just move your feet.”

It was a whole other level of awareness. There was something fundamentally profound about this. He was describing what great coaches do – they are your external eyes and ears, providing a more accurate picture of your reality. They’re recognizing the fundamentals. They’re breaking your actions down and then helping you build them back up again.

After two months of coaching, I felt myself getting better again. And after a year, I saw my complications drop down even further. It was painful. I didn’t like being observed, and at times I didn’t want to have to work on things. I also felt there were periods where I would get worse before I got better. But it made me realize that the coaches were onto something profoundly important.

In my other work, I lead a health systems innovation center called Ariadne Labs, where we work on problems in the delivery of health care, including global childbirth. As part of it, we had worked with the World Health Organization to devise a safe childbirth checklist.  It breaks down the fundamentals, the critical actions a team needs to go through when a woman comes into labor, when she’s ready to push, when the baby is out, and then when the mom and baby are ready to go home.

We knew that just handing out a checklist wasn’t going to change very much. And even just teaching it in the classroom wasn’t necessarily going to be enough to get people to make the changes that you needed to bring it alive.

I thought on my experience and said, “What if we tried coaching? What if we tried coaching at a massive scale?”

We found some incredible partners, including the government of India, and we ran a trial in 120 birth centers in Uttar Pradesh, India’s largest state.

In half of the centers basically we just observed, but the other half got visits from coaches. We trained an army of doctors and nurses to observe the care and also the managers, and then help them build on their strengths and address their weaknesses. One of the skills for example they had to work on with people – it turned out to be fundamentally important – was communication. Getting the nurses to practice speaking up when the baby mask is broken or the gloves are not in stock or someone’s not washing their hands. And then getting others, including the managers, to practice listening. This small army of coaches ended up coaching 400 nurses and other birth attendants, and 100 physicians and managers. We tracked the results across 160,000 births.

The results: in the control group (these who did not get coaching), they delivered on only one-third of 18 basic practices that we were measuring. And most important, over the course of the years of study we saw no improvement over time. The other group got four months of coaching and then it tapered off over eight months, and we saw them increase to greater than two-thirds of the practices being delivered. It works. We could see the improvement in quality, across a whole range of centers that suggested that coaching could be a whole line of way that we bring value to what we do.

We were clearly at the beginning of it, though, because there was still a distance to go. You have to put all of the checklist together to achieve the substantial reductions in mortality. But we began seeing the first places that were getting there.

I saw a team transformed because of coaching. And I saw at least one life saved because of it. We followed up with that mother a few months later. Mom and baby were doing great. The baby’s name is Anshika. It means “beautiful.” And she is what’s possible when we really understand how people get better at what they do.

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