First things first
This is one of many truly superb ideas from the book If Disney Ran Your Hospital by Fred Lee, who has had senior positions both at Disney and in an American hospital. The ladder of priorities astutely recognises how often staff are placed in seemingly impossible dilemmas between apparently equally important objectives, or organisational values. A brilliantly simple and practical concept, invaluable for ward staff. As Lee says, “If [an employee] does the one thing, he could be in trouble for not doing the other, no matter which he chooses.”
Just like a mission statement, this idea helps focus the team’s energy and clarifies your purpose.
The Disney ladder of priorities is:
3. Show (how guests experience an aspect of a theme park, eg what is looks or ‘shows’ like)
The ladder of priorities makes explicit, official and therefore ‘approved’, the order in which staff should address competing demands. For Disney:
“You are always right when satisfying a guest.” If you come late or miss a meeting because you’re trying to serve a guest, you’re exonerated. If you decide to buy something from the gift shop to placate an upset guest, you are not going to be reprimanded for spending too much. A value statement like this clearly empowers people to say Yes to a guest’s request instead of passing the decision up the line to a supervisor. And it’s on the wall backstage for all employees to read day in and day out.
According to the scientific method, for a theory or model to be considered “elegant” it must have clarity, simplicity, and completeness. Disney’s ladder of priorities has all three. First, each of the concepts is discrete and clear. The words chosen are unambiguous and there is no fuzzy overlap in meaning between them. Secondly, the prioritizing eliminates confusion about expectations when equally good alternatives confront the chooser. Thirdly, it is complete, because it defies the observer to find any conflict of interest that is not settled by the words and priorities chosen on the ladder.
…..our patients judge their stay by courtesy, and employees are managed according to efficiency,
If Disney ran your hospital, you would make courtesy more important than efficiency.
The sorts of everyday dilemmas faced by ward staff include things like:
- When to start getting heavy with very agitated patients
- Spending time with one patient ‘at the expense of’ others
- Paperwork vs patient contact
- The risk of conversations with patients ‘opening a can of worms’
- Confidentiality issues with friends and family
- Risk management eg home leave
- Often we aren’t consciously aware what our priorities are, or they might conflict between the MDT or with those of the patients. Getting together as a ward (including MDT members and patients representatives) to establish a ladder is both a cathartic and therapeutic activity. It also gets everyone on the same track, helps with organisation and could possibly decrease conflict amongst staff and patients.
- Wards at our Trust have created vision statements. All staff and patients can get involved with the words and images.
- The ward has identified a ladder of what is to be achieved and is displayed for all to see.
- “All wards need to have a Ladder of Priorities as a focus as staff get so bogged down with competing demands.”
- “The ladder of priority exercise can be used as a guide when interviewing new staff.”
A little note from Marion Janner (founder of Star Wards)
Reading the Disney book made me continuously think about my recent inpatient experience with a night nurse. I’d just been admitted because I could no longer contain my suicidality myself. It was about my 4th admission to St Ann’s and (as I lovingly describe whenever I get the chance), the staff are wonderful and I’m full of appreciation and admiration for them. Quick bit of ward background – they very astutely get us to sign a form soon after we arrive, which commits us to, among other things, foregoing sex, drugs and excessive rock and roll and to speaking to a member of staff if we have urges to self-harm. Quick bit of me background: . I’ve got plenty of mental health ‘form’ and I’m completely open about my self-destructiveness. In other words, my risk level is very ‘out there’.
So, at 2AM when I felt desperate to self-harm, I remembered that I’d committed myself to talking to a nurse instead of immediately resorting to self-mutilation. And I duly but highly reluctantly took myself through the darkened ward to speak to someone. The nurse was on the computer and told me I’d have to wait. No explanation, no apology, no time limit. This was in complete contrast to every other occasion when I (always with trepidation for interrupting and imposing on very over-worked staff) went to the office and staff always, always paused whatever they were doing, if only to apologise and agree a time within the next hour when we could speak. Perfect.
Anyway, unfortunately this nurse let down the team! And me!! I’ve got Borderline Personality Disorder and we’re not known for being able to cope well with experiences that feel like rejection. So I cut and I was stuck on special obs which I really hate. (Please see Idea #9 Engagement.) And which is a big waste of everyone’s time and the hospital’s money.
I thought a lot about what would it have taken for this nurse to prioritise speaking with me over the paperwork at 2AM, even for a minute to delay. And then I discovered Disney’s Ladder of Priorities.
Creating a Ladder of Priorities
To recap: Disney’s ‘ladder of priorities’ are:
The three domains which must be covered by all quality accounts – patient safety, patient experience and clinical effectiveness – have informed our suggestion for a mental health ward ladder of priorities:
But as with all the Imagine That ideas, and indeed all of Star Wards’ ideas and resources, this is simply a starting point for ward discussion, and the process of considering what your ward’s priorities are has an inherent value.