Changing the Culture of an Emergency Department (Part 2 of 2)


In my previous post, I discussed some of the challenges physician leaders face in shaping organizational culture. Today, I'll outline some practical steps physicians can take to begin the process of leading change.

Understand the Culture

In assessing the current culture, a new medical director should seek to understand the strengths, weaknesses and opportunities for improvement. It is important to talk to the staff, leaders and providers to understand the current culture and why its participants act as they do.

Questions to be explore:

  • What values are important?
  • What defines success or failure?
  • Are the goals for the front line the same as those set by administration or leadership?
  • What are the key components of the department culture?
  • What aspects of the culture are positive?
  • What features of the culture must change in order to meet the medical director's expectations and goals?
  • What is missing or needs improvement?

Creating a list can assist in capturing components ripe for change:

Strengths Weaknesses or Missing Components
Excellent clinical medical staff Staff apathy due to consistent turnover and lack of leadership
Inexperienced nursing staff; may be easily led by strong leaders Lack of a shared vision for the department
New leadership is motivated and eager to make a difference Physician apathy due to lack of support structures
  Patients not satisfied with care due to long waits and delays

Create a Design for a New Culture

Using the information from a comprehensive assessment of the emergency department, a new medical director should create an outline of the culture of the future.

In the example from my earlier post, these were the new values outlined:

  • Patient care will be the priority.
  • Patients will be seen soon after entry and moved through the department quickly.
  • Staff will interact positively with each other and patients.
  • Success will be measured and celebrated based on metrics.
  • Resources will be saved, because patients will spend less time in the department.
  • Patient satisfaction and outcomes will improve.
  • The new culture will be built by staff and providers practicing on the front lines.
  • The medical director took a step back and reviewed the positives that had occurred during the day, citing the door-to-provider time and the number of patients seen. She asked the team to think about what could be changed and bring ideas to her the next day.

It is important that the new medical director understand a "tipping point" approach to leadership. Shifting the culture of an entire department is not possible all at once. It is important to start with people who have disproportionate influence in the organization. Getting commitment from key leaders, both formal and informal, will help others commit to the shift and begin to shine a spotlight on accomplishments.

Keys to Designing a New Culture

1. Have regular meetings between department leaders.

Outside of multidisciplinary meetings, it is important to meet with the department leaders regularly. Alignment of mutually agreed upon goals is imperative. Meet with the department leaders to discuss your assessment and ask for joint redesign of the culture, committing to work together as a team of leaders.

Then, scheduling weekly discussions regarding progress and accountability is important to move the culture forward.

With nursing leadership, agree to disagree in private and support each other publically. Agree to be a team. Discuss barriers to achieving improved metrics.

2. Attend one another's meetings.

For example, the medical director can ask to attend portions of the charge nurse, staff and unit council meetings. Attending nursing meetings can assist in developing relationships and allow for a better understanding of the role of the nursing leadership team.

3. Celebrate success together.

Recognize both the nursing leadership and medical teams. Always treat the nursing leadership team and staff as partners.

4. Gain buy-in with hospital leadership.

Ask to present to large, multidisciplinary groups on the success of the changes in the department. Meet with administration together with nursing leadership to demonstrate collaborative efforts. When improvements are sustained, provide a multidisciplinary presentation to the board of directors.

5. Model the culture you desire.

Even during the toughest times, leaders must model ideal behaviors and focus on the positive.

In the beginning, when the culture has not yet improved, it is easy to become frustrated. The leadership's reactions are observed by all and often emulated. As a new leader, modeling ideal behavior will help others begin to mirror those behaviors.

For example, the medical director in our case study had just worked a 12-hour shift. The day was busy, and she was tired. At the 7 p.m. huddle, the nursing staff and PAs who worked that evening could only complain about the new processes and did not provide constructive ideas.

What she wanted to do was tell them how she really felt, and ask them to step up to the plate and lead the process instead of complain about it.

Repeated behaviors have cultural impact because they are contagious. People unconsciously imitate what they see others do. Even small changes in behavior picked up by more than one individual can ripple through an organization as others see their value and begin to act accordingly.

Small wins are important; share praise when they occur to encourage ED staff. People should be celebrated for behaviors that model the new culture. Those who do not embrace the new culture should be scheduled for meetings with leadership to discuss opportunities for improvement.

6. Identify methods to politely stop negativity.

Simple methods can be designed where staff recognize negative behaviors in one another and suggest change. One is "The Quarter Jar," where people are asked to deposit a quarter any time they are observed being negative.

Alternatively, agree upon words or phrases to signal when someone is not putting their best foot forward. In the case above, staff would remind colleagues to "tie your shoe" if the person started talking negatively in front of a patient. Use this type of strategy consistently to remind everyone of the new culture and encourage compliance.