Abstract
We believe, as Donabedian taught us, that “the secret of quality is love.” It is possible to lead with love and discover abundance among teams who feel safe, cared for, and aligned toward common purpose and their own professional growth. We offer five practical tips for leaders’ consideration: (1) focus on the people; (2) develop a culture of professional diastole; (3) foster relational trust by reducing the vulnerability of others; (4) make sure the right people are in the right seats on the bus; and (5) administer policies with kindness and common sense. The return on this investment is non-linear and difficult to tally on a spreadsheet, yet it delivers the results that matter most. In the end, we are human, and this is human work. What better time than now to make love the center of what we do.
KEY WORDS: leadership, culture, professionalism, improvement, diastole, trust, love
I remember the first time I read Mullan’s interview with Donabedian near the time of his death1. When I read the line, “the secret of quality is love,” I paused. The pronouncement struck me with moral force. It seemed suddenly self-evident.
My early forays into improvement tended toward the technical. I was invigorated by the work of understanding variation and running experiments at the “threshold of knowledge2” toward a clear goal. I was also guilty of pursuing well-formed ideas without sufficiently engaging the people most directly affected by the problem. I learned the wisdom of the adage winning hearts and minds: the heart always comes first; only then will the mind be open to new ways of thinking.
Love is the secret sauce. The necessary connections in health care are not levers or signals, but people, each of whom must decide—Should I speak up? Do I trust you? Our best hope for coherence is to use the operating system we have evolved to live together in community: love.
In our own experience as patients, we intuit when the person who shows up is there to complete a task, or if they truly care about us in that moment. We can tell if they see us as a fellow human being, one who is suffering and worthy of the highest quality of their attention.
We understand when a co-worker is negotiating a transaction and when they care about what we think and why we feel that way. We know when our leaders’ primary concern is not our value as human beings but our dollar value to the system. And what a difference when, instead, leaders make us feel that we matter! We yearn for our institutions to acknowledge our meaning beyond the workplace.
Love matters. In an environment of limited resources (everywhere we know), leading with love can make the difference between a team that is declining and one that is growing and discovering new opportunities despite adversity.
In organizational terms, love is the sum of the communications, policies, and actions that together create the atmosphere of safety in the workplace. The goal is for every person in the organization to feel deeply cared for and able to grow and succeed in their work. How can this be done? We offer five practical tips.
FOCUS ON THE PEOPLE
Let kindness be the first principle. Practice “respect for people” by listening deeply, communicating the why and substance of changes early and often, and ensuring each person is given opportunities to contribute to their fullest potential. Develop an understanding of each person’s aspirations and abilities, then use that knowledge to create pathways for their growth. Greet team members warmly by their first name. Learn and follow up on key details of their lives, dreams, and loved ones. I set aside several hours each month to meet with new team members, offering each my cell phone number and an open invitation to follow up with me if desired. I also meet with every medicine resident every year, making sure to touch on their well-being, their aspirations for the future, and how I can help.
DEVELOP A CULTURE OF “PROFESSIONAL DIASTOLE”3
This means setting the intention, then hard-wiring opportunities for renewal. For example, my Epic password is a variation on the word “kindness.” During a typical day, I type this core value dozens of times, reminding myself why I chose this profession and how I can best contribute to our culture. Another example: create space for human connection. Dedicate time at the top of meetings to share something each person is grateful for, share a patient’s story that speaks to why we do what we do, or read a poem. The check-in can be kept brief; at other times it can be allowed to breathe. During the COVID-19 pandemic, I at times allowed the check-in to become the entire meeting. When love is understood to be the most important work of leadership, human connection can take priority over process and action items. Creating a culture of professional diastole takes time and persistence, but its yield is a team able to stay open and creative through challenge.
FOSTER RELATIONAL TRUST BY REDUCING THE VULNERABILITY OF OTHERS4
This is a corollary to Deming’s principle that we must “drive out fear.” Mindfully examine each of the subtle ways you project power. For example, I ask everyone to address me by my first name. When someone enters my office, they find a comfortable sitting space decorated with pictures of my family, our favorite outdoor spots, and a painting from Liberia of a great tree that reminds me of the “one trunk, many branches” ethos I had the privilege of learning while serving there. I strive to meet people in their space, where they are in control.
MAKE SURE THE RIGHT PEOPLE ARE IN THE RIGHT SEATS ON THE BUS
Hire for kindness, teamwork, and growth mindset5, as well as for excellence and experience. This takes intention and practice, with time set aside for members of the hiring team to compare notes and align their approach. Encourage learning, with gaps between intentions and results celebrated as opportunities for improvement. If someone’s intention was to do the right thing for the right reasons and they are willing to learn, then leaders should focus on growth, not censure. If, however, someone is unwilling or unable to change, then leaders should do what is needed to transition this person from the team. Developing people as we have described is even more important at the leadership level. The person at the top of the organization must personally champion this approach for it to be successful.
ADMINISTER POLICIES WITH KINDNESS AND COMMON SENSE
Rules of the road and standard procedures are important safeguards and foundational to improvement. But inevitably there are situations that the rules do not adequately cover. In these cases, it may seem easier to enforce the letter of the law. Yet taking the time to listen and consider whether the rule should be waived or amended can demonstrate that people really are the bottom line. Standards are in service to people and their shared purpose—not the other way around. Even if the “process outcome” is the same (the rule stands), the “relationship outcome” will be better when the person at the receiving end feels heard and treated with respect. Each of these moments of predictable friction between standards and circumstances is an opportunity to invest in the culture of caring. Leaders who navigate these waters with love will amplify the message of safety. A few brave souls will risk being vulnerable and give more of themselves at work. When only good things happen, others will follow.
Conclusion
Donabedian’s pronouncement that love is the secret of quality demands change. It is possible to lead with love and discover abundance among teams who feel safe, cared for, and aligned toward common purpose and their own professional growth. We offer five practical tips for leaders’ consideration: (1) focus on the people; (2) develop a culture of professional diastole; (3) foster relational trust by reducing the vulnerability of others; (4) make sure the right people are in the right seats on the bus; and (5) administer policies with kindness and common sense. The return on this investment is non-linear and difficult to tally on a spreadsheet, yet it delivers the results that matter most. In the end, we are human, and this is human work. What better time than now to make love the center of what we do.
Acknowledgements
We are grateful to Drs. Christine Sinsky, Fred Hafferty, Paul Barach, and Neil Baker for their review of earlier versions of this paper.
Declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Prior Presentations
None.
Publisher’s Note
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References
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