Perspectives on Organizational Culture in Healthcare

Over the past 30 years, the term organizational culture has gained prominence and have stimulated plenty of interest. Theories have been developed, definitions abound and debates have spurred. Today we still talk about how (and if) one can change organizational culture.  

And “whether managers think that the culture is too soft or too complicated to bother about or whether there is no unique corporate culture does not reduce the significance of culture” (Alvesson, 2002).

“Culture isn’t everything” says a title that caught my eye. The article mentions that even though it's difficult, culture is something that can be enforced. One of two perspectives on organizational culture developed by Smircich (1983) - "culture as a variable"- implies that culture is something the organization "HAS". In essence, it implies that organizational culture needs to be viewed as a tool for enhancing organizational effectiveness. Hence, the existence of "strong culture organizations" that are highly effective (Google, Southwest Airlines, Nordstrom, Westjet).

What is Your Story?

Today concludes Patient and Family Centered Care Week (#PFCC2015). It was a week full of great events, webinars and presentations interlacing storytelling about how we care with how we learn from patients. Meetings started with people sharing patient stories, and everyone seemed to beat faster to the heart of our ultimate purpose: to care for our patients.

My story? As an operating room nurse, I cared for people in vulnerable moments. Surgeries are highly stressful for all patients, and one of my main goal was not only to care, but advocate for the patient while he/ she was unable to do so. You might say "we all advocate for our patients". But how do we do it? For me, it is a no-brainer: patient IS and always WILL come first. In the operating room environment, that can be challenging at times. It is a work environment with a strong culture and even bigger egos. If you are a novice nurse, that can be very intimidating - how would you speak up to a surgeon, demand the whole surgical team to stop and listen to a "Safe Surgical Checklist", or even refuse to proceed if your think the patient is unsafe? For me, it was always there, at the back of my mind: just like you would not accept any act of unsafe care on a loved one, you don't accept it for any patient.

Sometimes, it takes a small act of rebellion to stand up and talk for your patient. And as any act of rebellion, it stems from a strong desire to respect your own values. It is timely that we remember to stand up for our patients and for the families and share these stories. And this - this is my story.

#WhatsYourStory ?

Coalitions in Healthcare: The Super Power of Pathways

"…then a nurse was telling me how they encountered a problem and how they fixed it…and I said 'No! Don’t do that way!'"* 

These are the words of Paul Levy, former CEO of Beth Israel Deaconess Medical Centre in Boston. His leadership style during the restructuring of BIDMC is studied in organizational behavior courses in postgraduate schools to illustrate decision-making and change management skills. But why would he be against local, grass-root level implementation of changes?

Don't Just Stand There: Finding Creativity in Meetings

 There is a saying that goes: 'If you want to kill an idea, bring it to a meeting'. Or, 'if you are lonely, call a meeting'. Meetings in hierarchical healthcare organizations seem to follow a dull and counter-intuitive format: a waste of printed copies of 'meeting minutes', asking people to vote on the previous meeting agenda they most likely do not remember and the un-healthy snacks provided. Too many meetings are poorly organized, are bad for the morale and bad for productivity. Plus, they cost money.

Caregiver Becomes Patient: 3 Arguments for QI

I consider myself lucky. Until lately, I did not need any surgeries or extensive medical care. But this suddenly changed and I had my first experience as a patient. I joked that I wanted to actually see first hand how the healthcare system works…but my smile was tentative and my apprehension surpassed my curiosity. Now, after being at the receiving end of medical care, I would like to ask my healthcare colleagues: 

Are you able - and willing - to better your care for the patient?

Your Input Matters: Improving Opinion Surveys

If you work in an organization - any organization - you probably received periodical emails with links to opinion surveys. The email message would say something like "your opinion is valued" or "your input matters" and kindly asks you to take few minutes of your day to complete a survey. So what do you do? Click on the survey link? Postpone to action on it? Or simply ignore- or even delete the email?

Learning to Change

How do you feel about learning? 

Do you remember your school years as an exciting time, or do you just recall exam anxiety? 

Whatever the answer, it is OK. 

A recent presentation on adult learning on #rebeljam15 started with "Have an open mind". As adult learners, we might be conditioned by past behaviours but we can also approach learning in a novel, productive way (if we choose to). That is because the learning science also followed an incredible evolution and has become accessible, fun and rewarding, and more than ever- necessary.

There is no question about why we need to be life long learners (LLL). Here are some of the many benefits of LLL:

Questions on Quality: Sail or Sink?

Quality in healthcare: we talk about it, debate about definitions, wonder if we can and if we do measure it. For some of us, it’s an intricate concept that feels like it could make your head explode. For others, it’s common sense: to give the best care, to the right patient, at the right time. 

If it is true that all good things (i.e. Danish-sounding ice-cream) come in small packages…can we at least hope that quality in healthcare comes in cargo loads? Or are we bound to provide healthcare on islands of excellence in a sea of mediocrity?

I will not use this space to expand on the "quality" etymology or on matters of semantics. Instead, I would like to focus on 3 areas related to quality that I came across in discussions and readings this week:

Healthcare Worker's Search for Meaning

"The last of human freedoms- the ability to choose one's attitude in a given set of circumstances" 
Viktor Frankl

When you are a healthcare worker there is one thing you never want to hear: a fatal error leads to patient death. Sadly, today was one of those days. This terrible event is mentally and physically painful to grasp and reminds us all of our inherent and human ability to fail. The pain of the family is extremely raw and the society’s response is intensely broadcasted, and for good reason. Today though, just for once, I will talk about the pain of the provider, the one entrusted with your safety.

On Revolutions, Rebels and Reshaping Healthcare

In a world of constant change, transforming healthcare is a topic that receives considerable attention. We talk about how we can improve, what solutions to adopt and how to implement change. Then we find ourselves trying to sustain the changes and we go back again to the drawing board: a continuous PDSA cycle within an infinity Enso circle.  This is the fight: against the status quo, to protect our ethical principles as healthcare providers. Our passion guides us like a flag into a war. But is a revolution necessary? Who are the rebels and what do they do?

Leveraging Social Media for Quality (and Self) Improvement

 

TIL (Today I learned)* something new from my nephew. He studies software engineering and is one of those young people really plugged into the digital world, always clicking away on his electronic devices. While I was digressing about my twitter activity, he suggests me to try reddit, a popular social media platform. I heard about it, but never tried it, so am now feeling a bit overwhelmed...just another “internet thing” I have to try now, when I am barely a "joiner" on the social media ladder! Still, what do I have to lose? Perhaps I could use this new tool on my QI journey?

So here I am on reddit. I find out that "This is a place friendly to thought, relationships, arguments, and to those that wish to challenge those genres." The stats are impressing:

Take me to the forest: Changing hospital culture

We recently had a staff meeting where a guest speaker prepared a presentation about communication. At one point in the presentation, the speaker encouraged the audience to play the telephone game, in an attempt to illustrate how messages are distorted while they are passed from one person to another. This innocent game, where one person whispers the message to the next person and then through a line of people until the last person loudly announces the message to everyone, took an odd turn. And rather than making me think about communication, it brought back a difficult question on hospital culture: How can we change the insidious culture of “name, shame and blame” that still exists? Why can we not see the forest, and focus solely on the trees?

The Challenges of Change Agents

 

I don’t know about others, but when I think of my own improvement attempts on my unit, I usually recall challenges, resistance, hitting walls. Yes, I was told it will be difficult, and once you realize that you are not alone in your passion, it is even harder to get back to the daily whirlwind. It is discouraging, and some days are worse than others. And then I am thinking: for sure others have the same challenges, but does it make a difference if you would be in a formal position of authority rather than front-line staff? Would you be able to influence and leverage more for your ideas?

Say Yes to Engagement!

 

Love is in the air...but not as much in hospitals. Let's talk about it, it is called engagement. And by engagement I mean nurses' work engagement, or more generally, healthcare provider engagement. It is a topic that surprisingly is still poorly actioned on, although research suggests it is an important issue in health services.

It is estimated that as many as 25% of nurses suffer from burnout (this is an estimate in a population of European nurses), and the prevalence of burnout among both doctors and nurses is on the increase (2006 study). Over the last few years, there has been a shift in focus, from "burnout literature" to an alternative movement of "positive psychology". This focus gives more attention to human strengths and optimal functioning rather than to their deficits, so rather than focusing on burnout, the idea is to find ways of increasing the positive consequences for people at work.

Recent research also support the findings of Maslach and Leiter, who identified six areas of organizational life that are crucial in the development of burnout:

"The Four Frank Principles"

I have to write this down as it is still fresh on my mind: I greatly enjoyed Prof. Art Frank's keynote speech at the 2015 Imagine Project! What an inspiring and truthful depiction of the challenges in health care, brilliantly set into words by such an accomplished scholar! In his speech, Prof. Frank enumerated 4 principles that I will call "The Four Frank Principles":

1. Responsible response. Take one idea per month and track the progress! (Yes! Who needs 13 organizational goals, each with 6 sub-goals?!). This is how many hospital institutions became huge success stories. Look up the Cincinnati Children's Hospital, Virginia Mason Medical Centre, Jonkoping County in Sweden, Kaiser Permanente. They all 'gold-plated the bolt'.

2. Small and specific demands. Please, do not talk about 'transformational change'...a small change in attitude can have great effects (for example respect patient's time and dignity; establish open charting etc.). Change starts with small steps. And as Hugh MacLeod, the CEO of the Canadian Patient Safety Institute, exclaims: Stop calling healthcare a system!

On Measuring Performance and the Bell Curve

I have recently had an interesting conversation with one of our surgeons about clinical performance and how to improve on it. The talk inevitably led to a discussion on the validity of the bell curve, and how surgical performance can be improved once you are in the top performing zone. As you probably know, the bell curve has been used for years as a model on how people perform. As the image below shows, this model is easy to understand and stipulates that human performance fits a normal distribution, with most performers being average and occupying in the middle, while poor performers and high performance as outliers. 

However, in 2012, a research study involving over 600K participants

New Year: Let's Talk About Resolutions!

It's that time of the year again: you can barely find a parking spot at the gym or a corner to spread your yoga mat in a studio, the produce section at the grocery store is suddenly the busiest place in town, and everyone has a (sometimes manic) glitter of determination in their eyes. If you are one of the people who make New Year resolutions (nothing wrong with that!),  research actually says that you have an 8% chance to stick to it. Yes. Eight Per Cent. Sorry to be a downer, but I am also quite unhappy with the fact that in healthcare up to 70% of change initiatives fail! And for the amount of opportunities for improvement, this is discouraging.

Why do we fail to change? Just like in self-improvement, workplace improvement fails from the very same reasons: competing priorities, the daily whirlwind of activity that makes it difficult to keep on our plan, and choosing far too many goals to reach. But beware! There is that 8% of people who succeed, just like those 25% of change initiatives that prove there is hope! I am clinging on to this rope of hope (ha!) and wonder what can we do to succeed?