Learning how to learn: the key to CQI.

Let's eavesdrop for a moment upon a typical interdisciplinary CQI team meeting. The members are struggling to add value to the quality of their organization's care. Seven members are present: the department heads of surgery, family care, nursing, internal medicine, and pathology; a marketing staff person; and a facilitator from the organization's development group. The group,s task is to improve patient access. scheduling times, waiting periods, and cancellation procedures. They have been grappling with policy recommendations.

In Figure 1, examples of comments we might overhear are listed in the left-hand column. Those listed in the right-hand column reflect dialogues going on in people's minds. (The reader is free to speculate on their correlations).

The members of this group are not intent on making life difficult for one another. This CQI group, and many others, lack two essential ingredients for success: (1) they don't understand that people have different learning styles, and (2) they don't understand how certain behaviors can - and must - these differences into their greatest asset.

The process

of experimental learning

Learning is a search for truth, and our individual definitions are inevitably limited: Remember the blind men exploring the elephant! Because learning is a dynamic circular process[1] (see Figure 2), the information about a problem or an opportunity will be limited unless four perceptions of die truth - each valid, and each incomplete - are accepted. Let's look at a simplified example of the process of experiential learning in action before we apply this model to the complex challenges facing CQI teams: four people, each overemphasizing one of the stages, as they assemble a child's toy.

1. The abstract conceptualizers quickly reach for the instructions. "You've got to study the plans carefully before you can put anything together correctly."

2. The active experimenters take a cursory look at the instructions, then move quickly to put the pieces together: "Why worry about a few leftover pieces? It works, doesn't it?"

3. The concrete experiencers also reach for a few pieces, although more cautiously than the active experimenters, preferring to feel their way through the task. They often become more interested in the shape and color of the pieces than in putting them together.

4. The reflective observers watch the others: "What's the rush?" They carefully study the pictures in the instructions, or intently examine the cover of the completed gift.

The inner smile most people experience at reading this example confirms the validity of the underlying phenomenon. We recognize ourselves and others, and the blinders that come with our humanness. Less clear, but no less true, is the fact that unless all the stages of the process have been fully completed (before the fact of taking new action), we cannot safely conclude that something has been fully learned. Some of the leftover pieces may not prevent the toy from working in the short run. The toy's creators may have built in a safety factor that will only be realized if the plans are followed. Examining the picture provides a visual road map in the mind's eye, but the toy cannot be concretely experienced - no one can play with it - until the hand builds what the eye sees.

The strength of reflective observation is that "seeing is believing," and the strength of active experimentation is that "the proof is in the pudding [doing]." The fact that "figures don't lie" is the strength of abstract conceptualization. And the strength of concrete experience is that "if I hadn't felt it in my own heart," I might never have seen the figures I believe... which just happen to belie yours!

Socialization in our families and schools results in our learning how to learn with a particular bias (in the same manner that it is rare for a person's four brain quadrants to develop equally). As a back-up to our primary way of defining the truth (feeling-seeing-thinking-doing), we draw also upon one of the other adjoining modalities. As a result, a fourfold typology emerges from these stages: Convergers emphasize a combination of abstract conceptualization and active experimentation, while divergers combine concrete experience with reflective observation.

Assimilators stress the role of reflective observation and abstract conceptualization, while executors (Kolb's original terminology was accommodators), combine active experimentation with concrete experience. Understanding these different learning styles can help us explore what is going on with the spoken comments in the left column (and with some of the unspoken dialogue in the right column).

Surgeons,[2] in Kolb's terminology, are typically convergers (combining the strengths of abstract conceptualization and active experimentation). Consequently, they are able to quickly grasp and decisively select from the most up-to-date information a plan of action that can save a life. The demands of their profession (reinforced by their education) have taught them to learn how to learn to do their jobs well. We are grateful for their ability to clearly direct the actions of others in the operating room. When it comes to cutting into the skin human being, there is likely to be a most effective way.

To surgeons and others with convergent learning styles, all that needs to be done to solve a problem is to "tell [others] what to do and [expect] they'll do it!!" When the issue is improving patient access, there are likely to be several good ways to "skin a cat" Cutting through the ambiguity of policymaking is not a precise surgical procedure. Little wonder that convergent surgeons have little patience for their psychiatric or organization-development colleagues who seem so comfortable exploring the vast array of soft possibilities that mark the divergent terrain. Divergers' strength is in concrete experience and reflective observation.

Pathologists and other basic researchers in academic medicine have learned to emphasize dispassionate reflective observations and abstract conceptualization. As assimilators, their truths come from using inductive reasoning to create theoretical models that work, i.e., fit the data. A tissue sample needs to be paralyzed on a sterile piece of glass to be subject to the cold analysis of a microscope. Without this kind of laboratory data, root causes may go undiagnosed, and the same mistakes or same illnesses can result.

Assimilators also have, an important point. There are situations where "We've got to get more data to know what the real problems are with patient access. Simply staying open longer hours, a solution we may have tried before, may result in our making the same mistakes if patients are afraid to come to the clinic at night, because they are scared of our dark parking lot."

"Hard data [may be] better than navel gazing," as assimilators often feel about their divergent colleagues. But "paralysis by analysis" is an equally valid concern that executors feel about their assimilator colleagues. For their marketing colleagues (and family practitioners) are strong in active experimentation and concrete experience. The proof is in the pudding and while the academic theories [created by assimilators] are useful, what's really important [to the executor] is that our solution works. It's practical.

What's practical to a marketing person is satisfied customers. Satisfied customers will actively choose to repeat the experience that left them feeling good. They will return to the clinic. Similarly, patients who will actively experiment with their own wellness and who take responsibility to help themselves feel better, are the bottom line for family practitioners. Family practitioners are more likely to accept the power of a placebo effect (because it works), whether or not abstract scientific evidence exists to verify how or why.

"Different strokes for different folks" is very much a truism when it comes to the process of experiential learning. However, to re-emphasize a point made earlier, unless all the stages of the learning process have been fully completed, unless all the strokes work in harmony, we cannot be confident that a CQI effort has added its full value.

With respect to CQI in health care, Berwick has put the challenge this way: "Our mind sets [learning styles] work against us." When "linear thinking predominates [the strength of convergers], the risk is that we become insensitive to remote effects. Win-lose assumptions predominate."[3] If we allow this situation to continue, our active experiments to achieve continuous quality improvement will flow from sterile theories devoid of human experience, of feeling. Because learning is a dynamic circular process, our experiments risk becoming self-fulfilling prophecies.

Differences count

So what can we do about the reality of life that facts (truths) never speak for themselves but only through the eyes of the beholder? The first thing we must do is not see this as a problem to be solved, a condition to be eliminated. CQI teams composed of individuals with homogeneous learning styles will not achieve their purpose. A CQI team made up solely of active experimenters, typically weak in concrete experience, may well fail to observe the human consequences of their actions.

Differences in learning styles and the fact that learning is a dynamic, circular process confront us instead with a dilemma. Dilemmas require a delicate balancing act, a continuous fine-tuning to ensure that all four voices are heard, that all stages of the process of learning are completed. It would be easy to put this responsibility upon the shoulders of those who lead CQI teams. Certainly, it would help if these individuals were aware of the experiential learning loop and skilled in the behaviors needed to turn this diversity into the group's greatest learning asset. However, even the group's leader is likely to suffer from a limited learning style.

CQI efforts would be better served if the entire group were given the opportunity to learn how to improve the quality of their experiential learning process - their reason for existence. The training and development of CQI teams must include an appreciation of the value-adding potential of different learning styles and an awareness of behaviors having win-win versus win-lose consequences.[4]

Learning how to learn:

theory versus practice

Repeated short-circuiting of the dynamic, circular, experiential learning process can permanently reduce the quality of CQI efforts. A study of the implications of Kolb's model on the success of R & D project teams (highly analogous in form and function to CQI teams), offers some invaluable advice.[5] A CQI team's success depends on their ability "to pull themselves around the four-stage experiential learning model instead of across it".[6] In other words, a CQI team,s interpersonal process, the tools by which individually limited truths are forged into a consensual holistic truth, must ensure that the group's effort goes "around in circles."

A few simple and learnable behavioral tools can empower a group to pull itself around the full circle of experiential learning. Nonjudgmental, open-ended questions are a CQI team's truth-mining tools. And, given the old adage of form follows function, different questions are appropriate at the four different stages of the learning process.

1. In the divergent phase of the learning cycle, the group's focus needs to be on getting everyone to reflect out loud what they have seen or experienced. In the CQI meeting we've been following, the comment was made (probably by a diverger sensitive to feelings): "You should see the look on patients, faces after an hour in the waiting room." It is the nursing staff and scheduling desk who most often notice the patients' frustrations. Unless someone asks: "What do patients, faces look like after an hour in the waiting room?" the group's problem solving could easily be incomplete.

2. In the assimilation phase, the group will need to be sure they understand "what additional data, if any, are needed to keep from making the same mistakes" before it can select the best alternative. Staying open longer hours, in and of itself, as a solution to an access problem may prove to be incomplete. As Berwick reminds us, we must also make certain we have the data to allow us to minimize the risk of becoming insensitive to remote events. Staying open longer hours may require policies that protect the security of clinic personnel who may be returning home late at night. Without this data, the executors risk applying a Band-Aid solution that will not stick over the long term. Without complete data, facts and feelings, convergers are hampered in their ability to sort data and weigh alternatives.

3.It is appropriate and necessary in the convergent phase for the group to ask (pull from) the member who would tell them what to do" exactly what that means, who should do what. Sooner or later everyone will have to voice their bottom line opinion of "what needs to be done to improve." Unless the CQI group converges their commitment on specific policy recommendations, no new experiments can be actively implemented and no new concrete experiences will be felt. If nothing changes, nothing changes.

4. Finally in the execution phase (the step before exposing others to a new, and hopefully improved, concrete experience), the group will need to be sure it understands the concrete (as contrasted with academic) indications that their solution works. The executor who points out that "what's really important is that our solution works" is reflecting an important truth. Questions to be addressed during this phase include: "How will we know our solution worked? What are the dimensions of practicality?"

And even if a good solution seems at hand, the group would still be wise to stay with the divergent voice that says, "I can't put my finger on it, but I have a feeling we're missing something." It can be hard to hear that voice when what we've got looks good enough to most everyone, and a lot of energy has gone into piecing it together. The truly creative breakthrough often-times does not emerge until we believe we are finished - unless we are prepared to go round the circle once more.

An inventory of generic trigger questions, each appropriate to a different stage of the learning process, can be developed and hung up for all to see. Such a checklist can help ensure that the group's learning process is being driven by all four voices. The very existence of the protocol can help people to monitor their impatience. They can see that their turn will come. They will be pulled into flow when their unique perspective on the truth is essential to moving the group forward.

As a side benefit, each may find the limits of their own learning style stretching and changing over time. They are learning how to learn, growing to appreciate the relevance of questions that, at first, seemed foreign to them. Developing these and related interpersonal skills needed to improve the process of learning how to learn is a practical requirement for any successful CQI team.

The second challenge, of equal importance, to learning - and healing is itself a process of learning to grow from being ill to being well - and to learning how to learn is reducing fear. To address this somewhat more theoretical issue (albeit of the utmost practical significance), we need to return to our eavesdropping example and focus our attention on the right-hand column.

An environment must be created in a CQI team that encourages people to verbalize their thoughts and feelings. These private thoughts often contain nuggets of truth. Two examples will be sufficient. Someone in the group is thinking, If we didn't waste so much time in these meetings, we'd have fewer cancellations." (Convergent learners are likely to react this way first.) It is possible that the group has allowed itself to become too diffuse and is operating with too little focus. From a learning-stage point of view, divergence may have too large a voice.

On the other hand, if this person voices frustration, one possibility is that the unspoken thought We certainly wouldn't want patients to interfere with your golf game, might also pop out. What on the surface looked like a logistics issue of time availability has now grown to include the possibility that some people are perceived to care more about their golf scores than about their patients. Once a wound is lanced, many surprises pop out. Exploring hidden issues does not cause a cancer. The point is, that unless someone speaks up, the group is lacking information needed to diagnose and improve the quality of its own learning process. Its ability to learn how to learn will suffer.

Let's look at a second example. Somebody wonders if CQI is the "flavor of the month." While disconcerting to those fully on board, this notion is essential information to get on the table. Flushing out the truth activates the need for yet another experiential learning loop, another CQI effort. This unspoken concern could be hurting the success of this CQI group because one member is dragging his or her heels.

Suppose, however, that this is not an isolated cynic, a lone ranger, but reflects a more deeply felt lack of credibility by others. Skepticism can be healthy if it is voiced. Left to fester, it turns to apathy and passive aggressiveness. Just as "you can dictate notes into a medical record, but you can't dictate to people" people cannot be pushed to put their heart and soul into CQI. They need to be pulled into the process, to be attracted by people who lead by example, who eliminate the obstacles to people freely giving of themselves.

It has been my experience that there is one CQI team that most organizations fail to create: it is the one responsible for continuous quality improvement of all CQI teams by reducing fear and reinforcing behaviors that can turn individuality into an organization's greatest asset. Continuous quality improvement of the process of continuous quality improvement is the responsibility of top-level health care executives.[8]

The bottom line

In discussing the centrality of learning to the success of any CQI effort, Berwick reminds us of some painful and, heretofore, ignored truths.[9] To be truly "engaged in learning as a way of being ... involves risk ... vulnerability ... joy in the journey (... not mere fascination with results ....)" Experiential learning is a lifelong process; indeed, it is the process of life itself. Learning better how to learn, to correct the mistakes of our pasts - the inevitable consequences of our humannes - and to create better futures, is the business of living.

As a result, experiential learning and CQI are synonymous and are "not a matter of modification, but of rebirth" and this fundamental truth carries "the threat of extinction...and that's scary." Old ways won't do. They must the, and their loss must be grieved. While all organizations can benefit from CQI, health care organizations have no choice but to embrace the process of experiential learning. When your business is life and death, learning how to learn is not an option. It is the key to CQI.

References

[1.] Kolb, D., Rubin, I., and Osland, Organizational Behavior: An Experiential Approach, Fifth Edition. New Jersey: Prentice Hall, 1991, pp. 49-71. [1a.] Kolb, D., Rubin, I., and Osland, The Organizational Behavior Reader, Fifth Edition. New Jersey: Prentice Hall, 1991, pp. 145-173. [1b.] Kolb, D. Experiential Learning. New Jersey: Prentice Hall, 1984. [2.] Plovnick, M., "Primary Care Career Choices and Medical Student Learning Styles", Journal of Medical Education, Vol. 50, September 1975, pp. 849-855. [2a.] Fry, B. and Kolb, D., Experiential Learning Theory and Learning Experiences in Liberal Arts Education", New Directions for Experiential learning, Vol. 6, 1979, pp. 79-91. [3.] Berwick, D., "Seeking Systemness." Healtbcare Forum Journal, March/April 1992, p. 26. [4.] Rubin, I. and Inguagiato, R., "Changing Work Cultures", Training and Development, July 1991, pp. 57-60. [4a.] Rubin, I. and Inguagiato, R., "BQA: A Transforming Experience." Physician Executive, 16(5)30-33, September/October 1990. [5.] Carlsson, B. et al, "R & D Organizations As Learning Systems." Sloan Management Review, Spring, [6.] Carlsson, B. et al, ibid, p. 41. [7a.] Rubin, I. and Fernandez, C.R., My Pulse is Not What It Used To Be. The Leadership Challenges in Health Care. Hawaii: The Temenos Foundation, 1991. [7a.] Rubin, I., Jack and Jill's Crowning Achievement," Medical Group Management Journal, September/October 1991. [8.] Rubin, I., "Total Quality Management: Care Dealers vs. Car Dealers" Physician Executive, 18(5)15-20, September/October 1992. [9.] Berwick, D., op cit, pp. 27-28.

Key Concepts. CQI/TQM/Quality/Learning how to Learn/Experiential Learning/ Learning Styles

All CQI/TQM efforts share a common purpose. to learn something that can correct past mistakes and/or to create better futures. Because learning is a dynamic circular process, the information about a problem or an opportunity will be limited unless four perceptions of the truth - each valid,,and each incomplete are accepted. These four types of learning styles or ways of perceiving are: abstract conceptualizers, active experimenters, concrete experiencers, and reflective observers. Unless all the stages of the learning process have been fully completed, unless all the strokes work in harmony, we cannot be confident that a CQI effort has added its full value. A CQI team's interpersonal process, the tools by which individually limited truths are forged into a consensual holistic truth, must ensure that the group,s effort goes "around in circles."