The 4 disciplines of execution

'I know what I need to do. I just don’t know how to do it'

We know that we want to bring strong leadership to our workplace. We have put thought into the strategies that we think will succeed. But how do we move forward? What principles do we need to put in place to ensure success?

I recently came across a discussion about a book called ‘The 4 Disciplines of Execution’. A book that builds on extensive case studies to describe 4 disciplines (abbreviated 4DX) that help organisations implement high level strategies. I believe there might be something in this for medical leaders who want to bring positivity, strength, purpose and direction to their own leadership. 

So what is the 4DX framework, and how can we adapt it to our goals?

Discipline #1: Focus on the Wildly Important
The more you try to do, the less you actually accomplish. Execution should be aimed at a small number of ‘wildly important’ goals. This simplicity will help focus energy (yours and your departments) to bring real results. As David Brooks wrote in ‘The Art of Focus’: ‘If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else’.

Pick a few challenges or new approaches that - when successful - will really turn around the way your team work together and provide care. Don’t be afraid to be ambitious, make them ideas that will produce profound, tangible rewards for your team.

Discipline #2: Act on the lead measures
Once you’ve chosen your wildly important goal, you need to measure your success. There are 2 types of metrics for this: lag measures and lead measures. Lag measures describe the thing you’re ultimately trying to improve. For example, you might choose to do some work on supporting your staff. You know that staff who are better supported will be both happier in the workplace and contribute to better patient care, for a whole range of reasons. The relevant lag measure for supported staff is improved feedback at their 6/12 monthly review; or improved patient outcomes if you look even further afar.

As the 4DX authors explain, the problem with lag measures is that they come too late to change your behaviour. Lead measures, however ‘watch the new behaviours that will drive success on the lag measures’. In the case of supporting our staff better, you might choose lead measures such as:

  • number of weekly teaching sessions that occur
  • monthly review of training log book or touch-base meetings staff have with their supervisor, consultant or head of department, just to see how they are doing, and if they need any additional assistance
  • number of update meetings or communications by head of department to keep team appraised of what is happening within the service
  • number of opportunities sought and taken to provide ad hoc positive feedback to members of the team

Of course there are many more activities that are involved in creating an engaged workforce, and these are just a few examples. As you improve the numerical quantity of your lead measures, your lag measures will improve as well. In other words, lead measures turn your attention to improving the behaviours you directly control in the near future, which in turn will ensure the success of your long-term goals.

Discipline #3: Keep a compelling scoreboard
The 4DX authors explain: ‘People play differently when they’re keeping score’. This means that it’s important to have a public scoreboard to drive your team’s engagement toward your wildly important goal. This not only creates a sense of competition, but once the team notices their success in the lead measure, they become invested in perpetuating the performance.

Turning to our example, you might keep a physical document that tabulates all the registrars and RMOs by month and the number of meetings that have taken place. Other lead measures are more personal, so the Director might alone keep a calendar on the wall and check off when she or he carries out a weekly communication with the team in some form or other. Finally, individuals may keep a note on their daily journal or have a recurring ‘To do’ item on their phone that reminds them to seek out individuals within their team to reward with some specific positive feedback.

For other wildly important goals, you might create a public scoreboard for the whole team: e.g. if you decide to do a piece of work focusing on reducing complication rates of some description, it’s important that you have a running score somewhere, so the team knows how it’s going.

Discipline #4: Create a cadence of accountability
To maintain focus on lead measures, this is the final step to put in place. ‘A rhythm of regular an frequent meetings of any team that owns a wildly important goal’. During these meetings, the contributors confront their scoreboard, commit to actions to further the cause and reflect on what happened to the numbers since the last meeting, reviewing their previous actions.

For individuals assessing their own scoreboard, this means a ‘weekly review and reflection’. Where the goals are owned by larger teams, it should include all who are committed to the cause, and be systematic in it’s approach. This might take place at a weekly or monthly team meeting, depending on which lead measures need review.

The 4DX framework is based on the fact that execution is fundamentally more difficult than strategising. For all of us. After reviewing hundreds of case studies, the inventors nailed it down to a few simple disciplines that can help. For most medical leaders, the idea of keeping and reviewing a scoreboard isn’t intuitive. And even if our goals aren’t wide ranging or desperately complex, the 4DX disciplines can help achieve success by aligning our practice with a method that is known to work. 

If you think this is important, join the positive leadership movement and talk about these issues. Share/like on social media, so others know you believe in it and the word spreads. Be the change you want to see in our health care systems.