Which is the Better Motivator for Performance – Fear or Confidence?

  |  , The Science Behind Learning  |  Which is the Better Motivator for Performance – Fear or Confidence?

A March 19 study in JAMA Internal Medicine reported that a Harvard-led study found that patient mortality rates drop when The Joint Commission (TJC) is physically in the hospital. This is kind of a Deus Ex Machina claim; their mere presence saves lives. But let’s explore this issue because it’s important.

Specifically, the study of 1,984 patients admitted to hospitals between 2008-2012 found that patients admitted during an unannounced Joint Commission survey had lower 30-day mortality rates than those patients admitted three weeks before or after the unannounced survey. The JAMA study’s authors said the most probable reason for the decrease in mortality during survey weeks is the “heightened scrutiny during visits” and the physical presence of surveyors, similar to how the Hawthorne effect contributes to better hand hygiene compliance.

Why is this study important? At first glance, it looks like it touts The Joint Commission as the long arm of the law and that hospital staff fall in line and take the best care of patients when being off their game could get them in trouble. In other words, the fear inspired by Joint Commission surveyors brings out the best in hospital staff.

Really? So what are we to do with this finding? Are we to extend greater superpowers to The Joint Commission to instil more fear, more continuously in hospital staff so that patients are safer? To do so would require a constant TJC presence in hospitals. How is that possible? More surveyors? More frequent unannounced surveyors, or 24/7 drone surveying? Deputized hospital staff to serve as whistleblowers? More real-time access to quality and safety data by TJC to monitor when things may be going wrong and swoop in with tasers?

The abiding question is whether fear is a sustainable motivator for performance. This study would suggest that fear works. But if you’re like me, when I’m in a state of fear, I seek the comfort of authority, I don’t trust my own judgment, I don’t use my peripheral vision, and I get frustrated by the sense of oppression. So, the REAL question from this study isn’t how we get more Joint Commission in healthcare; it’s how do we liberate healthcare from The Joint Commission to perform well without fear.

An antonym of fear is confidence. Today’s physicians and healthcare professionals have every reason to be afraid and every reason to lack confidence. Every decision made for patients is scrutinized by payers, regulators, and risk underwriters, with harsh consequences. Professional judgment is being codified into guidelines and standards of care because rogue physicians may go “off book” when caring for patients. Metrics are imposed on physicians that are supposed to represent “quality”, and performance against them is publicly reported, not to mention financial penalties levied on those whose numbers don’t measure up. In other words, doctor, we don’t trust you.

But just because you are confident doesn’t mean you’re correct. Just as being correct isn’t of great value if you don’t act on it with confidence. The answer would seem to be that physicians and staff being Confident AND Correct is the best way to ensure performance. In an industry that is utterly dependent on knowledge, being Confident and Correct when making care decisions is the best alternative to an oppressive Draconian system of regulatory oversight and fear-based motivation.

Prolific advances over the last 25 years in the brain science of how people learn and remember now make it possible to embed knowledge in people and commit it to long-term memory, at scale, without relying on extraordinary teachers available 24/7 or an oversight process that scares people into learning and remembering. I am not suggesting that physicians are infallible or that they know more than they do. In fact, in our work using Amplifire in healthcare so far, most physicians are confident and incorrect about 25-35% of what they need to know, and that needs to be and can be corrected.

Correcting misinformation is ultimately what The Joint Commission’s job is. But the JAMA article’s suggestion that beefing up The Joint Commission’s presence in hospitals to keep staff motivated to do the right things right more often is neither scalable nor sustainable. Offering hospitals and physicians a scalable way to stay current and continuously fend off misinformation so that physicians are both confident and correct is the best pathway to improving healthcare performance.

In the 1991 film called Defending Your Life, Albert Brooks plays a recently deceased man who is in a celestial weigh station where people defend the quality of their lives on earth as a way to make the case that they are worthy of advancing to the next level of existence in the universe. Brooks’ defense attorney Rip Torn explains to Brooks that, “the point of this whole thing is to keep getting smarter, to keep growing, to use as much of your brain as possible. Fear is like a giant fog, it just sits on your brain and blocks everything—real feelings, true happiness, real joy, they can’t get through that fog. But if you lift it, buddy, you’re in for the ride of your life.”