Part 1: Why culture matters.
Part 2: What culture do you have? What culture do you need?
Part 3: Transforming your culture.
Today, we'll cover the nuts and bolts of leading culture change. Let's kick things off with a little case study.
What It Takes
My colleague Bonnie Carl, RN, MBA uses the following story to illustrate the challenges of culture change.
For a long time, a certain county hospital emergency department (ED) had been underperforming on measures of quality and patient satisfaction.
Complacency was an issue. Team members felt secure in their jobs, despite their lackluster performance.
The ED also had a poor reputation among local nurses. This led to recruiting difficulties, chronic understaffing, and reliance on travelers.
Worst of all, the team displayed little empathy for patients. None of the departmental leaders seemed to expect much in the way of customer service, and no feedback, discipline, or training was provided in this area.
Finally, a new chief nursing officer (CNO) came on board and decided to make a change.
She enacted new policies and procedures detailing how staff would treat patients and one another. She let everyone know they had better get on board, or she would assist them with finding a new place to work.
The change was a painful one. Many nurses left the department, creating new vacancies and aggravating the staffing shortage. But the CNO persevered. Eventually, she staffed the entire department with competent, collaborative nurses. Within a few years, she had a waiting list of nurses seeking positions.
This story illustrates a crucial point: culture change isn't for wimps. It takes time, determination, and courage. And it takes leadership.
This CNO succeeded because she had a long-term vision. She realized that good nurses gravitate toward environments where everyone is held to high standard. She saw culture as a potential recruitment tool, and she was right.
This YouTube video, "Leadership lessons from the dancing guy," provides an excellent blueprint for culture change.
So how do we translate these lessons from the music festival to the hospital?
First, there must be a leader. Ideally, culture change is driven by a strong, passionate leadership team that includes the medical director, nursing director, CNO, and chief medical officer.
In some cases, demand for change comes from the grassroots. The champions in this case may be frontline providers and nurses. While these "unofficial" leaders can be very effective, it's crucial that they work with their institutional leaders to ensure alignment and sustainability.
Even the most passionate leader can't change the culture alone. The leader's first job is to create believers. And followers.
This takes finesse. If you charge forward waving your sword, people will run. Instead, show people how they might benefit from the proposed changes. Some ways to do this:
- Use patient-specific examples. One hospital took action after a seemingly small service failure led to tragedy. You can also use positive examples. Have your team reflect on a case where everyone came together for the patient.
- Make work meaningful. Ask your team members to describe their last great day at work. Usually this means they made a great connection with a patient or colleague.
As for the dancing guy, your first few followers are crucial to your success. Once you have a few people dancing beside you, others gradually join in. Eventually, you'll reach a critical mass where everyone takes notice and rushes aboard the bandwagon.
Your Strongest Potential Allies
When gathering your followers, pay special attention to the naysayers. Getting your most visible holdouts on board sends a powerful message to the rest of your team.
One of my anesthesia colleagues told me a naysayer story that I love. His team wanted to implement a "time out" before invasive procedures. The chair of surgery disliked the idea. "It's a waste of time," he'd grumble. "Only bad doctors operate on the wrong side!"
A few days later, the surgery chair stood by silently while the anesthesia team demonstrated the time out procedure with a patient. Afterward, as fate would have it, the chair stepped forward to begin the operation — and moved to the wrong side of the patient. The team quickly noticed and corrected his mistake.
The chair was deeply moved. He had almost operated on the wrong body part, and he suddenly realized that "wrong side" operations could happen to anyone. As a result, He went from an opponent of the initiative to its strongest champion.
A Roadmap for Change
Once you've gathered a critical mass of followers (and your followers shouldn’t just be doctors and nurses, they should be anyone who touches a patient — techs, phlebotomists, registration, housekeeping, etc.), it's time to get others involved in the change process.
As I mentioned in my previous post, your entire team should be involved in defining your vision, values, and ideal culture. When possible, use patient and personal stories to stimulate thinking and elicit responses.
Some teams find it helpful to complete this groundwork at a retreat. Participants will generally be more relaxed and open outside the hospital.
Once your team has crafted a vision statement, ensure that they live by it. Use it to open meetings and huddles. Display it on signs, posters, and newsletters. Refer to it when making decisions.
Once you have a vision, your next job is to set priorities.
Culture change is a bit like eating a metaphorical elephant. The only feasible way to do it is to take one bite at a time.
A good rule of thumb is to tackle no more than two priorities at once. Use your data to determine which potential projects will have the biggest impact, but it is also important to have early wins.
Go for the low hanging fruit: put together a holiday party or a journal club. Perhaps set up a provider of the month award or develop "caught in the act of caring cards" to acknowledge coworkers who have done something very special. Maybe a commitment to say good morning, afternoon, and evening to coworkers as you come on a shift. To change a culture you need people to feel good about themselves and the work they do, and they need to feel good about the people with whom they work.
As you launch your first initiatives, be sure to involve your champions. Giving them opportunities to lead will reinforce their sense of pride and ownership, in addition to making your life easier.
Finally, use your influence. Team members should treat everyone who touches the patient (housekeeping, radiology, lab, etc.) according to your vision and values. Over time, you'll see your culture spread across the hospital.
Going the Distance
Once change is in motion, there's often a stormy period while your team struggles to adapt to new expectations. When faced with resistance, it's important to refocus everyone on the values and vision you designed together.
During this time, the leader and first followers need to set a consistent positive tone. Model the behavior you expect from others, even when that courtesy isn't returned. You are under the microscope, so find ways to manage your frustrations outside of work.
In order to effect change, you must hold people accountable. Use leadership rounds to check that expectations are being met and provide coaching as needed. Be consistent in addressing noncompliance, and encourage team members to hold one another accountable. You may need to provide occasional "career transition assistance" to outliers who won't get on board.
One of the easiest ways to transform your culture is through hiring. If you can recruit people who already share your values, you'll gain a follower and potential champion. And if you set your expectations of the applicant at the time of the interview, they know how to behave and how they will be evaluated. This also lets them know that this is a special place where people take pride in their work and expectations are high.
Culture in Action
As we discussed in my last post, culture is exemplified by action. Here are some of the ways that great healthcare workplaces make work fun and meaningful.
Learning together. This can take many forms, from journal clubs, grand rounds, and joint meetings to multidisciplinary case review. Education can also be impromptu. I always get a warm feeling when I see nurses and physicians round together or teach one another at the bedside.
Collegiality. In healthy organizations, teamwork trumps self-interest. Teammates work together to cover vacations and absences. When a difficult case arises, everyone pitches in to the best of their ability.
Focus on providers. Sure, caring for others is our job. But it's an important job. Take time to celebrate successes and praise strong efforts. Smile at one another, thank colleagues for the great care they have provided. Ask your staff what causes them the most grief and work on ways to fix those problems.
Have fun. When people have opportunities to socialize outside the hospital, it changes the way they work together. Parties, volunteering, sports teams, and retreats are great ways to create positive memories and strengthen relationships.
So how do you know when your culture has changed? In some ways, that work is never done. But here's one clue you've made progress.
Back when I was a medical director, my ED had an issue with noise. I was one of the "shushers" who went through the halls reminding people to keep it down.
Then one day, I was talking in the hall a little too enthusiastically. A nurse came by and shushed me. I was thrilled. I apologized and thanked her profusely.
Over the next few weeks I was shushed a few more times. I no longer had to go on long shush patrols, because teammates patrolled one another. The noise level dropped noticeably. We had reached a point where maintaining a calm, quiet atmosphere was just part of what we did.
It's no small thing to transform a culture. But in the crucible of change, remember that this work is mission critical. By staying the course, you're creating an environment where patients receive great care, and providers find joy and meaning in their work. What cause could be more noble?