Altering a dysfunctional emergency department (ED) culture is possibly the toughest task a medical director might face. Changing entrenched organizational behavior is a difficult undertaking — and not something taught in medical school.To begin the process of changing a culture, it is important to win the trust, hearts and minds of the people who work in that environment. This can take both creativity and persuasion.
For the ED staff and providers, the ingrained culture is largely invisible. It's like water to a fish or air to a bird: it's simply the environment they exist in. Behaviors can be acceptable — even if they are dysfunctional or do not have the appropriate primary focus — because they are considered the norm.
In order to change a culture, it is important to first understand the culture and why those working in it embrace it.
A Holistic View of Change
Culture does not change because we desire change. Culture changes when the organization is transformed — through its purpose, its focus on patients and its results.
If we note Peter Drucker's definition of innovation — "Change that creates a new dimension of performance" — it is performance that changes the culture, not the inverse.
Peeling away the shell of an organization reveals a culture, a set of values, practices and traditions that define who we are as a group. In great organizations, the competence, commitment, innovation and respect with which people carry out their work are unmistakable.
I once worked with a physician leader who was appointed medical director of a struggling ED.
For the previous two years, the department leadership had been filled with temporary leaders and experienced frequent turnover. The ED director was new and was not well established with the nursing staff but was a seasoned professional. However, she had different goals than the incoming medical director. The ED nurse manager lacked experience in the role as a leader.
In the past two years, 60 percent of the nursing staff had left. These positions were filled through an agency, mainly with new graduates.
Quality suffered, and the nursing staff struggled to meet the basic requirements for patient care. Many were unresponsive to the never-ending flood of patients through the ED door and exhibited no sense of urgency to provide care to them. Patients were experiencing long delays in receiving treatment.
The physicians had given up hope that the situation could be turned around. Outstanding clinicians felt as if they were in a position of risk due to inexperienced staff.
So was the situation hopeless? Not at all. In my next post, we'll look at some of the practical steps medical directors can take to understand the current culture and begin the challenging process of leading change.