Collaborative Care

Collective genius as a tool for engagement and improvement

patient satisfaction

When bedside caregivers are engaged in their work, patient outcomes are improved, the patient experience is enhanced, and staff satisfaction is high. Most nursing managers and leaders I have worked with over the past 20 years believe that staff engagement is important. However, these leaders are at a loss as to how to gather the thoughts of their staff in a manner that is efficient and not burdensome, yet allows for each individual staff member to contribute his or her input with equal weight.

One possible technique is what some in the process improvement field have coined “collective genius.” This tool enables you to gather qualitative data and create a quantitative analysis in the form of a pareto diagram for the purpose of improvement. You can lead a collective genius exercise during a staff meeting, a shared governance council meeting, or other opportunities where there are 15 to 20 minutes of protected time.

You’ll need the following: one large flip chart with paper to post on the wall where everyone can see it, one fine point marker per participant, a stack of 15 sticky notes of the same color for each participant, and another stack of sticky notes of a different color. The collective genius technique consists of 5 steps, followed by a call to action.

The first step is to create a robust question to be answered by the staff. The question is integral to the success of the collective genius technique and should link directly to a challenge you are currently experiencing. For example, if your Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is low for the pain management domain, the question you pose to your staff might be: What are your barriers to providing effective pain management to all patients, every touch, every time?

Ensure each participant understands the purpose and importance of the exercise. The outcome of the exercise will drive change on your unit. You must be sure the cultural environment on your unit is one where staff members feel safe to be open and honest. I have facilitated the collective genius technique more than 100 times, and each time, it is invigorating to staff to be asked about their barriers and to know they were heard.

The second step is to ask each person to write one barrier per sticky note. This part of the exercise should take no more that 2 minutes and is usually completed in less time.


After the notes have been completed, call on one staff member to read aloud one barrier from the sticky notes in front of him or her. Then ask the group if anyone else has recorded the same or similar barrier. Collect the other sticky notes reflecting the same or similar barrier and construct a column on the flip chart paper hanging on the wall. Continue this process, calling on a different staff member to read aloud a different barrier, then ask the group for their same or similar barrier and build another column.

By the time you have completed this exercise, you should expect to have five to seven columns with same or similar barriers. You also may have several single barriers where no additional staff has documented the barrier.

The third step is to verify with the group that the barriers are grouped similarly into like categories. Work with the group to decide on a name for each column that defines the overall issue. For example, if one of the categories has barriers regarding nursing staff knowledge deficit, the category could be titled Staff Knowledge.

The fourth step is to arrange the columns into a pareto diagram, so that the category with the most barriers is first, followed by the other categories in descending order. This is a visual way of displaying the collective genius of the group. All will see what issue is a barrier to the greatest number of your staff members. For example, barriers to pain management might be workflow, staff education and attitudes, ordering, and communication with the patient.

The fifth step is to ask the team to select the barrier they would like to remove. It’s important to select a barrier you and your staff own and have control of, even if it’s not the biggest barrier. It is also important to experience a “quick win” when conducting a collective genius exercise so that the staff can quickly see tangible improvements addressing their concerns.

One of the top two barriers under your control is staff education and attitudes. For example, staff might decide to work on education about analgesic conversions and attitudes to remove that barrier to effective pain management.

Call to action

Ultimately, the collective genius activity becomes a call to action. You’ll need to engage a small team of about six individuals, ideally including key participants related to the issue. For example, in the case of pain management, you might want to include a pharmacist, anesthesiologist, physician, bedside nurse, and patient. This team will be most effective if facilitated by a seasoned process improvement facilitator. The barrier is explored in further detail, and the front-line staff is engaged in selecting one or two solutions that will result in removing the barrier.

Getting results

At Inova Fair Oaks Hospital, the collective genius technique and activity of the follow-up team helped us discover that because nurses weren’t familiar with analgesic conversion tables, they weren’t confident in recommending changes to the physician when the patient’s pain wasn’t being managed well. We also determined that not all physicians were familiar with the tables and that nurse and physician attitudes towards the patient with chronic pain were a challenge.
Representatives from nursing and pharmacy developed a nursing screening tool that triggers a standard pharmacist intervention within 24 hours of admission for any patient who is determined to be suffering with a chronic pain management challenge. The nursing staff was educated regarding analgesic conversions and attitudes and beliefs regarding the chronic pain patient. The anesthesiologist led the effort to educate and coach all physicians regarding safe and effective analgesic conversions. These interventions have produced significant improvement in the pain management domain of the HCAHPS survey.

Shirley Cahill is a Senior Strategic Process Improvement Consultant in Cabin John, Maryland.

Selected references

Deming WE. The New Economics for Industry, Government, Education. 2nd ed. Cambridge, MA: The MIT Press; 2000.

Imai M. Kaizen: The Key to Japan’s Competitive Success. New York, NY: The Kaizen Institute; 1986.

Sitzman K, Watson J. Caring Science, Mindful Practice: Implementing Watson’s Human Caring Theory. New York, NY: Springer Publishing Company; 2014.

Virkstis K. The national prescription for staff engagement. The Advisory Board Company. April 10, 2014. advisory.com/research/nursing-executive-center/studies/2014/national-prescription-for-nurse-engagement. Accessed November 3, 2014.

Starak Y. What is the 80/20 rule and why it will change your life. Entrepreneurs-Journey.com.
entrepreneurs-journey.com/397/80-20-rule-pareto-principle/. Accessed November 3, 2014.

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