You don’t have to look far to see the NHS is facing huge difficulties. With the government demanding the NHS makes £20 billion worth of “efficiency savings” and health bosses seeking new ways to make these cuts without repeating the mistakes made at Mid Staffordshire’s hospital. By taking their eyes off quality and focussing on the money, the resulting poor standards of care may have contributed to the deaths of at least 400 patients. How does a hospital get to this point without seeing it coming? How does a hospital make financial cuts, but not at the cost of quality? How does a hospital maintain morale in difficult times?

Cuts cannot be completely to blame in Mid Staffordshire. The death rates were far higher there than at a number of other hospitals which were faced with similar financial challenges. People need opportunities to review their performance and reflect on the difficulties. Without an effective feedback process, hospitals have no real way of evaluating the performance of their employees at an individual level. When your performance management approach includes the opportunity to review what is happening, employers can become part of the solution to the challenges they face.

The scientific grounds for behaviour based performance management tools are now well established, and these have been proven to be highly accurate. However, we are regularly met with resistance and disdain regarding these methods of assessing and managing performance. Granted, nobody enjoys having their performance scrutinised and their competence questioned, but the mistrust, denial and scepticism directed at these well-established techniques is equivalent to burying one’s head in the sand, and does nothing to solve the underlying issues. We don’t just see this at an individual level, but up to the highest level within NHS organisations.

Just by making small changes to how we do things can deliver a significantly better outcome. If a whole profession adopts these changes, a huge cultural shift can be achieved that can lead to vastly improved outcomes for the organisation.

However, getting people to change is easier said than done. The factors that have the greatest influence on behaviour are what happen to the individual as a result of their behaviour. Behaviour which is reinforced tends to be repeated (i.e. strengthened); behaviour which is not reinforced tends to die out or be extinguished (i.e. weakened). Psychologist BF Skinner first coined this law of human behaviour as operant conditioning in 1930 – roughly meaning changing of behaviour by the use of reinforcement which is given after the desired response.

Whilst Skinner’s findings were based on rewarding rats with sugar solution, the implications of his research were huge, subsequently revolutionising the way learning was perceived. This methodology is still applied today, and is highly relevant to feedback processes in the learning organisation. If no attention is paid to the consequences of an individual doctor’s behaviour, why would a doctor perceive the need to change – after all, he/she didn’t get up in the morning to harm patients. Yet, time and time again we observe behaviours that are unacceptable – is the service important enough to do anything about it or do we all just turn the other way? Without a reinforcer, how will an employee know that their behaviour is appropriate, and whether or not they should repeat it?

People are different, and not surprisingly different consequences have varying levels of potency - whether a consequence is positive or negative is very much in the eyes of the beholder. A key ingredient in the potency of a consequence is its immediacy and certainty: the more it can be connected to the behaviour in question, the greater the likelihood of the behaviour changing. An immediate and certain consequence will change behaviour far more than a future and uncertain consequence. Therefore, those of you who are hoping the current system of annual medical appraisal and 5-yearly revalidation proposals will drive quality improvement optimally might be waiting a long time! The organisation and the profession must get behind this to bring about sustained cultural change.

We like to think that most people do not come to work with the objective of under-performing, yet if we do nothing, how can they know there is a potential problem brewing, let alone do anything to correct it? From our brief survey of under-performing doctors, a lack of self-insight is a recurring characteristic, which often results from a lack of adequate feedback. Another behavioural trait associated with doctors in difficulty was arrogance, a behaviour that is often a mask for insecurity, low self esteem, poor relationship skills and lack of insight. Without constructive feedback given in a skilled manner, these behavioural traits can produce the conditions where colleagues who are in a position to provide developmental support merely avoid the individual. Thus, any problems are either ignored or go undetected.

Developing a high feedback culture is incredibly important if high performance is desired. Sadly, for the most part, the NHS is a no-feedback culture. According to surgical trainees, they consider no feedback is excellent feedback: you will only be told if you are doing something wrong. However, if there are other members of the NHS who are not being provided with feedback on their poor performance, are they under the impression that they are performing as well as those surgical trainees? I have lost count of the number of clinicians who tell me how difficult it is to give feedback to a colleague and how doing so often results of them being at the receiving end of a ‘verbal attack’.

Doing nothing has a massive impact on performance. In a culture where if any feedback is provided, it is negative, a lack of feedback will actually lead the poor performer to be effectively reinforced for what they do, in the same way that the high performing surgical trainee’s behaviour is reinforced if nothing negative is said. Put another way, If the only form of feedback you provide is punishing poor performance and you stop using this feedback, the poor performers will start to believe that they are, in fact, high performers. When a profession does not differentiate its high performers from its poor performers, it deems poor performance as acceptable and often inadvertently punishes the high performers. A lack of feedback will lead high performers to doubt their performance, and low performers to exaggerate theirs. When this happens, the profession as a whole loses credibility, risks its reputation and ultimately puts patients’ lives at risk

For many, this issue remains in the ‘too difficult box’, yet the solutions are there if you choose to apply them. Doing nothing will not only prevent development, but may also lead to a degradation in the quality of care provided.