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By Roger Coleman and Pamela Weisse
Coleman Associates

One of the brighter spots in the bleak picture of the national and state response to Hurricane Katrina was the commander of the deployed National Guard troops. If he asked of his reports to get something done and the response was along the lines of: “Yeah, OK, I think we’ll be able to do that by Friday,” the commander would say: “Here’s the problem: You’re looking at the calendar, I’m looking at my watch. Do it now!”

One of the toughest things for healthcare-conditioned workers to learn — and that includes all of us — is to act with immediacy, to neither delay nor procrastinate. You want to look only at your watch. But to get to that performance point, you need to understand that time is as precious as water in a desert community. There is too little to lose, and so it is egregiously wrong to waste it in any amount, in any way. But a sense of urgency is not the only thing that is needed.

In his book “Better: A Surgeon’s Notes on Performance,” surgeon and author Atul Gawande explores how there is often a large gap between good intentions and actual performance results. He mentions diligence as a necessary component of stellar performance:

“People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as ‘the constant and earnest effort to accomplish what is undertaken.’ There is a flavor of simplistic relentlessness to it. [It is] the prerequisite of great accomplishment. Diligence is, according to Gawande, not a small thing. It is “both central to performance and fiendishly hard.”

Similarly, we would define diligence as “the relentless and all-encompassing attention to a thousand details that add up to a very dramatic achievement.” In healthcare today, there is a cavalier attitude toward diligence — whether one is speaking of clinicians, managers, or support staff.

You can see the lack of diligence at huddles at a Coleman Associates Patient Visit Redesign™ or Patient Centered Scheduling™ Learning Session. Often teams can’t organize thoughts or plans of action. Their plans lack focus, details, and depth.

And you can so readily observe the lack of diligence in so many clinics, where patients’ needs are not attended to speedily, and broken processes go unfixed, year after year after year:

• Dirty, malodorous patient restrooms (no wonder staff have separate restrooms!)
• Patients wanting to be seen the same day they call, and not being able to get an appointment for weeks or even months.
• Patients who have to call repeatedly to get a prescription refilled, or a form completed, or information about a recently performed lab or diagnostic test, who finally walk in to the clinic, knowing that's the only way they'll get a response.
• Long lines of patients with appointments, waiting to be registered so they can be seen.
• Rude or — just as bad — indifferent treatment by staff, whether in person or on the phone.
• Packed waiting rooms, day after day, and the attitude of staff is, oh, well — this is just the way it is, there’s no fixing it.

Here’s what we know about diligence: It is a facet of character, not a mere work habit. We don’t find that people lack diligence in their Patient Centered Scheduling™ or Patient Visit Redesign™ work, but that they are incredibly diligent in their work with patients, or in their management of staff. You’re either diligent in all your work, or none of your work.

So, when you’ve been trained in either PCS or PVR and you push to be diligent in your work, and your coworkers push back because “we have more important work to do in our clinics,” don't be fooled. No where is the drive to do better more important than in health care, where people’s well-being is at stake.

To couple diligence with urgency is to create a powerful force for change. No detail is too small to be noteworthy — or to big to tackle. Dead plant in the waiting room? Get rid of it. It is your job — go ahead and take care of it as soon as you notice it! Long patient wait times? Phone messages piled up, awaiting action? Stacks of lab reports waiting to be reviewed? Rude or indifferent behavior towards patients or coworkers? Don’t accept these problems as things that can’t be changed — hundreds of clinics have done so. Don’t let another day go by — take action, tackle your problems and fix them. (There are many articles on this website which can help — see the section How to Start, read the article Broken Windows in the Techniques section, and read some of the Success Stories).

Gawande writes, “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people — and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve.” We must do a better job than we are doing.

When you apply diligence and urgency in the work you do every day, no standard other than “exquisite” is acceptable. No excuse for mediocre performance should be tolerated.

Gawande acknowledges: “…we in medicine are only humans ourselves. We are distractible, weak, and given to our own concerns.” Even so, by having chosen to work in medicine, he states, we accept the responsibility to do the right thing by our patients. And having accepted that responsibility, we are obligated to do our work well.