culture change: not as easy as it sounds
TRANSCRIPT
Culture Change: Not as Easy As It Sounds
Christina Krause I @ck4q JCC Showcase 2016
Culture in Your Organization/Practice
• Handout: Culture - Current
• Exercise:
Take 5 minutes to read through the list of
descriptors, and circle the top 10 current characteristics you see within your system.
Helen Bevan, 2009
TECHNICAL
CULTURE/ ADAPTIVE
“the most common cause of failure in leadership is produced by treating
adaptive challenges as if they were technical problems.”
Ron Heifetz, Practical Tools and Tips for Adaptive Leadership
The Facts
• Failures more often originate from non-technical rather than technical aspects of performance.
• On closer examination, a recent study found that communication was a causal factor in 43% of errors made in surgery.
Yule et al, 2006
Non-Technical Skills
Medical Education 2012: 46: 838–849
Power Distance Index
“Power distance is the extent to which the less powerful members of organizations and institutions accept and expect that
power is distributed unequally.”
Geert Hofstede (www.Clearlycultural.com)
Power Distance Index
The higher the power distance in a culture, the less likely those in subordinate roles will
question the actions or directions of individuals in authority.
Geert Hofstede (www.Clearlycultural.com)
Concept of Psychological Safety
• Belief that you will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes
• Critical element of an effective learning system
• Associated leadership behaviours:
– Actively invite input
– Accessible
– Acknowledge limits of their own knowledge
– “Go first”, particularly in displays of fallibility
Lower the psychological costs of voice and raise the psychological costs of silence
A. Edmondson, 1999; Sexton, 1999
Cultural Humility
A life-long process of self-reflection and self critique to understand
personal biases and to develop and maintain mutually respectful
partnerships based on mutual trust.
Levels Within a Culture
• Concrete manifestations of culture
• e.g., incentive structures, traditions Artefacts
• Operate at a more conscious level
• Standards and goals to which individuals attribute intrinsic worth
Values
• Operate at a more unconscious level
• “taken for granted” beliefs that structure individual thinking and behaviors
Assumptions
Davies, Nutley and Mannion, 2000
Why is this important?
• Artefactual elements of culture are more visible and may be more readily changed
• Deep-seated beliefs and values may prove to be more resistant to external influences
Davies, Nutley and Mannion, 2000
Another view:
Quality of …
Level One: doing
(processes)
Level Two: thinking/
decision making
Level Three: information that
influences thinking
Level Four: information that influences
behavior
Level Five: relationships (information flow)
Level Six: perceptions and feelings (culture)
Level Seven: individuals mind-sets (personal beliefs and values)
“Engine” of quality
D. Balestracci. Data Sanity. 2009
“Fuel” of quality
Quality of …
To add to the complexity …
• Diversity of cultures between: – professional groups
– “geographic areas” (e.g., ICU, OR, pediatrics)
– Levels of the organization (e.g., executive vs front-line)
– Gender, ethnicity, generation
• Rivalry and competition between groups (health care’s “tribes”)
• Different “sub-cultures” may be more or less open to change
• Outside cultural influences exists; can be at odds with internal culture
• Organizational culture can conflict with values and beliefs of organizational members
Davies, Nutley and Mannion, 2000
© 2012 Pascal Metrics Proprietary & Confidential
What does the literature say?
Culture • Observation of non-
technical skills • Staff perceptions of
culture measured by survey or interview
• Root cause analysis of never events or malpractice claims
Patient Outcomes • morbidity • mortality • length of stay • readmission rates • patient safety incidents
or adverse events • patient-reported health
outcomes
Provider Experience • Sick leave • Morale • Turnover
Associated with
Source: B. Sexton, Canada’s Forum on quality Improvement and Patient Safety, 2009. www.patientsafetyinstitute.ca
No BSI 21%
No BSI = 5 months or more with no
Blood Stream Infection
No BSI 31% No BSI 44%
24
Michigan Keystone Initiative:
Teamwork Climate Across ICUs Predicts Infection
25
Awareness Iceberg
4% known to
top leaders
9% known to
middle managers
74% known to
supervisors
100% known to
the front line &
patients/families
Adapted from study conducted by Sidney Yoshida,
initially presented at the International Quality Symposium
LS unleash action on the front line
Let’s go back to the individual … (Level Seven)
Some points to consider: – Every member of an organization brings to work processes shaped by the
unique experiences of their first 20 years of life
– Regardless of the efforts made a Levels 4 – 6 (the “fuel”), each person is “perfectly designed, because of his or her personal values and resulting belief system, to exhibit the behavior he or she is exhibiting”
→ Unconscious, automatic, and unintentional
Beliefs are changeable by significant emotional events: – Personal (e.g., death, illness, birth, marriage, loss of job)
– Societal (e.g., 9/11, Great Depression, WW II, etc)
– Sudden realization through feedback that some behaviors are detrimental to a successful personal life or one’s organizational success
D. Balestracci. Data Sanity. 2009
Belief Systems
• Need to keep a focus on organizational results to drive cultural change through changing underlying belief systems – both organizational and individual
• “Belief windows” drive change (think of a car windshield)
Individual belief windows (1000’s of individual beliefs)
+ Organizational or sub-culture’s belief window (1000’s collective beliefs)
= Organizational Culture
Measuring Culture
• One person’s attitude is an opinion, the attitudes of everyone taken together = an assessment of the climate of a team, unit or organization
• Correlation between staff happiness and satisfaction at work with organizational performance
• Culture survey tools can be used to: – Diagnose organizational strengths and weaknesses
– Evaluate the effects of organizational changes
– Improve communication with staff
– Provide context for absenteeism and staff turnover
– Develop targeted interventions
Sexton & Thomas, 2004
OR Coordination in BC
Benchmarks
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Job Satisfaction TeamworkClimate
Safety Climate LocalManagement
SeniorManagement
StressRecognition
WorkingConditions
Top 25%
50-75%
25-50%
Bottom 25%
59
51 54
43
24
63
32
Source: B. Sexton, Canada’s Forum on quality Improvement and Patient Safety, 2009. www.patientsafetyinstitute.ca
© 2012 Pascal Metrics Proprietary & Confidential
Can you influence it?
Interventions
• Checklist • Team training • Leadership
Walkrounds • Handovers • Briefings or huddles • Multi-faceted patient
safety education programs
Patient Outcomes • Morbidity &
mortality • Adverse events
Provider Experience • Morale
Culture • Observed
behaviours • Staff perceptions
Associated with
Culture in Your Organization/Practice
• Handout: Culture - Desired
• Exercise:
Take 5 minutes to read through the list of
descriptors, and circle the top 10 desired characteristics you see within your system.
Source: H. Bevan, 2009
Is there overlap?
Acknowledge Build Keep
Top 10 Current Top 10 Desired
Source: H. Bevan, 2009
Source: H. Bevan, 2009
Is there overlap?
Cost Focus
Results oriented
Customer focus
Silos
Inconsistent
Operational focus
Being of service to others
Openness
Visionary
Well organized
Respect for People
Courage to do what’s right
Continuous improvement
Focus on coaching and mentoring
Acknowledge Build Keep
Top 10 Current Top 10 Desired
Visionary
Values
driven
Making a
difference
