By James L. Holly, MD

At an accreditation site visit, in discussing quality, safety and decreasing of errors, the following “poem” was read.  This critique is in response to the original publication which is found iin the left-hand column.  While that material is not poetic, how I would state the contrast is found in the right hand column.

Excellence versus Perfection

A contrast like this to be helpful, should give understanding about the real and “actionable” distinctions between concepts.  In this case, the characterization of “excellence” isn’t really “wrong,” but the description of “perfection” is more a caricature than it is explanation. 

The first column seems to reflect a prejudice against the concept of perfection.  Perhaps the author means “perfectionism,” which might make more sense.  My recommended changes in this contrast which appear in the right hand column, continues to reflect the original prejudice but does so by expressing the potential hazards of having “perfection” as a goal rather than seeing “perfection” as a “sickness.”

SETMA's "target" has always been excellence.  Even our Mission Statement addresses our goal as “leading healthcare delivery through excellence.”   And, why would we choose excellence? We choose it because anything less is compromise and is unworthy of the "calling" which we all have as participants in the delivery of healthcare to our friends, families and neighbors.

Lest the choosing of the goal of excellence be considered arrogant, after all, how can you judge excellence, we adopt the comment of a friend who said, "Excellence is not a stop sign which you pull up to.' Excellence is a direction in which you are going."  Essentially, excellence is the determination to be better than you were before, with the constant goal of continuing to improve. Excellence does not happen by accident. It is intentional and its achievement requires the establishment of goals, objectives, standards, measures, reviews and critiques.

However, excellence will never be achieved simply by design or by resolution; it will only be achieved by character. It is only as excellence is compelled from within, from our heart and soul, that we will have the resolve and the strength to daily and hourly pursue excellence. The drive to excellence which comes from within has many faces. Some of those are found in a competitive spirit, but the good news about excellence is that I is not a zero-sum game, i.e., if you are excellent, it does not prevent others from being excellent as well.  In fact, most often, your drive for excellence will motivate and encourage others to do the same.

Excellence is objective but it is not comparative. It is not like an examination in school where a bell-shaped curve determined who could receive an "A" for "excellence" and who would receive a "C" for "mediocrity." In fact, in life and particularly in the delivery of healthcare, in the short run those who are excellence may not have the best results because they accept the challenge of meeting the health care needs of the neediest.  And, as in other life pursuits, when you achieve your goal, you discover that the goals and objectives have already changed.

The journey of excellence, which will not end at a destination, is defined by our commitment to a standard which is excellent. Only you can sustain that standard. Only you can relentlessly pursue that goal every day, every way, every time. No amount of scrutiny, auditing or regulations can achieve excellence which is not driven by your heart and soul.

Excellence will be the inevitable result of caring for every person you see, every day in the year. Caring is first the result of you seeing everyone as someone of import. For Christmas one year, I gave my wife a porcelain box which has the following hand-painted message on its top: "To the world you are one person, but to one person you are the world." So it is with each person we see each day, they must for the moment we "see" them become "our world," receiving from us our full attention and caring.

But excellence will also be seen as we apply the highest standards to that caring; standards which are defined by "best practices" and "national standards." Whether it is the care of a patient with diabetes, hypertension, heart disease, depression, anxiety, uncontrolled pain, etc., excellence requires the application of the best knowledge in existence and our best effort - every time.

This may be the greatest promise of electronic patient records (EMR). Designed and executed best, the EMR is a tool for excellence. The EMR provides a benchmark of excellence against which you can measure your performance every day with every patient. The EMR provides an objective standard for determining that you have applied "best practices" and "national standards" to every patient. And, when coupled with genuine caring for others; when coupled with that person being the world to you, receiving your full attention, as if they are the most important person to you, the EMR will fulfill its greatest potential.

The commitment to excellence is an individual passion but it becomes a collective, organizational passion as two, then three, then ALL embrace from their heart and soul the same standard. Sustaining excellence is much easier when it is the product of a group's effort. Like the "three-fold cord which is not soon broken," the group sustains the one's commitment to excellence at times of fatigue and discouragement.

The physics of the three-fold cord is that at the point of one cord's weakness another is strong and the reciprocal is also true. A cord which can only support 200 pounds, when intertwined with two equally strong cords, the three can sustain 2,000 pounds. So it is with our effort and commitment of excellence. What we cannot do alone; we can do together.

MIT's Dr. Peter Senge, wrote the following which describes a "learning organization, which is really an organization of excellence:

"Most of us at one time or another have been part of a great ‘team,' a group of people who functioned together in an extraordinary way - who trusted one another, who complemented each other others' strengths and compensated for each others' limitations, who had common goals that were larger than individual goals, and who produced extraordinary results. I have met many people who have experienced this sort of profound teamwork - in sports, or in the performing arts or in business. Many say that they have spent much of their life looking for that experience again. What they experienced was a learning organization. The team that became great didn't start off great - it learned how to produce extraordinary results."

Excellence and greatness are within the grasp of any organization which is made up of individuals who have a shared vision and purpose which creates and sustains the energy and drive toward excellence of the group. Those who most contribute to that sustained effort are those who have achieved "personal mastery," i.e., they drive events rather than being driven by them; they define their future rather than being surprised and disappointed by it; they are agents of change, where the change makes a difference.

In his work, The Fifth Discipline, Senge identifies the characteristics of a person who has achieved personal mastery:

1. They have a special sense of purpose that lies behind their vision and goals. For such a person, a vision is a calling rather than simply a good idea.
2. They see current reality as an ally, not an enemy. They have learned how to perceive and work with forces of change rather than resist those forces.
3. They are deeply inquisitive, committed to continually seeing reality more and more accurately.
4. They feel connected to others and to life itself.
5. Yet, they sacrifice none of their uniqueness.
6. They feel as if they are part of a larger creative process, which they can influence but cannot unilaterally control.
7. They live in a continual learning mode.
8. They never ARRIVE!
9. (They) are acutely aware of their ignorance, their incompetence, and their growth areas.
10. And they are deeply self-confident!

Number nine and ten seem contradictory, don't they? Yet, it is true that those who have achieved a degree of personal mastery are “self-confident” while being aware of "their ignorance" - what they don't know - "their incompetence" - what they are not good at doing - "their growth areas" - where they have room for improvement and where they need to improve.

The relentless pursuit of excellence will make us become our own harshest critic. Perhaps we could all adopt Churchill's habit. In 1939, he told his private secretary, Jock Colfield, "Every day I try myself by court-martial to see if I have done anything effective that day, not just pawing the ground but something really effective."

A year of excellence will be achieved one day at a time. If every day, we set our minds and hearts to do something really effective and we do that for 365 days in a row, our history will be a credit to ourselves and to our colleagues. Today is the beginning; we shall see how we fare.

Excellence in Medicine

Excellence in medicine is not practiced by the person who knows the most, or even by the person who is the brightest. Excellent medicine is practiced by the person who relentlessly pays attention to details and who consistently completes the mundane, routine tasks which cumulatively result in excellence.  In this regard, it is much easier to keep up when you stay up, than it is to catch up when you start behind. Recently, I have coined a new phase which has become my excellence-in-healthcare- management mantra: “I want it done right and I want it done right now.” That's what I now require of myself.

Lessons from a Tree

Let me tell you a story about a tree. It was an ugly tree actually, which is remarkable as I have rarely seen what I judge to be an ugly tree. It stood to the right side as you faced toward our house. It had been there for many years and grass had been allowed to grow up under and around the tree. Various items had been discarded and thrown under the tree, allowing it to become an eyesore in the neighborhood. I know this tree well because it was on the north side of the first house my wife and I bought in San Antonio.

It was a beautiful house in a very nice neighborhood. I worked every weekend I was off during my internship and residency in order to supplement my residency salary of $500 a month in order to provide this home for my wife and two children. I would leave San Antonio on Friday afternoon and drive to Bryan, Texas where I worked in the ER until Monday AM. I then drove back to Beaumont at 4:00 AM to start at the hospital by 7:00 AM.

After living in this house for a couple of weeks, "in my spare time," I decided to get rid of this junk heap and this ugly tree. I discarded all of the junk, mowed the grass and began cutting the tree down. Realizing that cutting out the roots was the only way to "get rid" of the tree permanently, I dug down to the tap root. I cut off the root four feet under the ground. I then planted a flower garden on the spot.

All of our neighbors began stopping by and commenting about what a beautiful spot that eyesore had become. One of my medical school professors lived across the street and he and his wife often commented about how this effort had improved the neighborhood.

It was only a couple of years after that before we moved to Beaumont. We reluctantly sold that house. I had put a sculptured patio of my own design at the back of our large back yard, put lighting in the beautiful Spanish oaks, planted dozens of roses and made other improvements. We still talk about the "Green House" with pleasant memories. It was almost twelve years before we returned for a visit to San Antonio. The first thing we did was drive by Spanish Oaks, the street on which our house stood. As we drove by, I was shocked. There stood the tree I had cut down, only now it was at least 7 feet taller than it had been when I cut it down.

I learned a life principle from this tree. We can beautify our lives and make them look pretty by removing the obvious clutter but if we don't root out the problems, they will re-grow until they are bigger and "badder" than they were in the beginning. Our lives require constant attention in order to be the best we can be. Excellence requires relentlessness in its pursuit. Procrastination, compromise, laxity, slothfulness will all destroy our best intentions.

Application to Medicine

As I review my work flow and other responsibilities, I realize how easy it is to "fall behind." And, then when we are behind, we become despondent, or forlorn, giving up on any idea of "doing it right." It is not unlike the person who finds themselves morbidly obese with all of the health problems associated. They did not set out to become obese. It just happened. When it started they thought, "Well, I'll stop next week," but two years and 60 pounds later, when "next week" has never come, they rationalize, "this isn't so bad." Before long, 60 pounds has turned into 200 and there is no reason to stop.

It takes no imagination, using our weight-gain metaphor to see what happens when a person gets themselves in hand and loses 70 pounds, only to lose their focus and like this tree reach a larger size when their attention and energy are focused on something else.

Relentlessness

Remember:  excellence in medicine is not practiced by the person who knows the most or even by the person who is the brightest. Excellent medicine is practiced by the person who relentlessly pays attention to details and who consistently completes the mundane, routine tasks which cumulatively result in excellence.

Interestingly, like our tree, when a health-care provider is "doing it right," it becomes easier to continue doing it right. As a person stays current with reviewing lab, x-rays, telephone messages, correspondence, procedure reports, orders, information and referral requests and a myriad other routine, ordinary and mundane tasks, staying current becomes easier and easier. Conversely, when lab review stacks up; when x-rays accumulate unread; when telephone messages go unanswered; when correspondence, procedures and information requests are not dealt with, like the morbidly obese person who "gives up," it is easy to rationalize that:

• I just don't have the time
• I am too busy
• I have more important things to do
• I am so tired
• This is overwhelming, etc.

Excellence is the goal; excellence is possible.  Excellence should be our ultimate goal.