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Culture Change: Not as easy as it sounds

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Culture Change: Not as easy as it sounds

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We know culture plays a key role in any organization. What role does it play in healthcare? Not speaking up and being safe is a significant issue for safe patient care. This presentation outlines why.

We know culture plays a key role in any organization. What role does it play in healthcare? Not speaking up and being safe is a significant issue for safe patient care. This presentation outlines why.


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Culture Change: Not as easy as it sounds

  1. 1. Identify Culture • Communication • Behavior • Rituals • Tolerance From Dr. Scott Ellner, St Francis Hospital & Medical Center, presented June 27, 2013
  2. 2. Culture eats strategy for lunch!
  3. 3. Improving Culture: Not as easy as it sounds • Culture: How is it relevant to better care? • What is current state • TRIZ: a way to get the front line engaged • Power distance index
  4. 4. Why culture? • Silence Kills Study • 90% of JAHCO never events linked to communication • 17 years to implement best practice • Reviews of academic literature conclude correlation between culture & outcomes 1. Disease-Specific Care Certification – National Patient Safety Goals. Oak Brook Terrace (IL): The Joint Commission; 2008. Available from:
  5. 5. © 2012 Pascal Metrics Proprietary & Confidential 28333641454549495152556262 737580 98 0 20 40 60 80 100 CCU REHAB OR EMERG 5WEST 6WEST PEDS GERI DIALYSIS PERIOP PHARM 3WEST ICU NICU SICU PEDS OB Teamwork Climate Scores Across Facility HCAHPS 9250 Medication Errors per Month 2.06.1 Days between C Diff Infections 12140 Days between Stage 3 Pressure Ulcers 5218 Illustrative Data: Extracted from Blinded Client Data
  6. 6. How positive is your culture? Poll Everywhere Morale and Culture
  7. 7. “the most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.” Ron Heifetz 7
  9. 9. Kind of Challenge Problem Definition Solution Locus of Work Technical Clear Clear Authority Technical and adaptive Clear Requires Learning Authority and stakeholders Adaptive Requires Learning Requires Learning Stakeholders Ron Heifetz, The Practice of Adaptive Leadership 2009 Distinguishing technical problems and adaptive challenges
  10. 10. Example Implementing an Electronic Health Record Items Adaptive or Technical Co-designing the fields Technical & Adaptive Engaging staff and clinicians Adaptive Building the frame and programming Technical Communicating along the way on progress Adaptive Implementing tools to support quality of care Adaptive Evidence and guidelines from other AHR initiatives Technical Leading this initiative: The WHY? (framing) Adaptive
  11. 11. Adaptive in leadership style • Ask more questions rather than issuing more directives • Build extra time into meeting agendas so that the adaptive challenges do not get either bypassed in favor of more immediate concerns or treated with short-term technical fixes • Expand the circle of individuals who need to be consulted in exploring possible solutions to the problem • Stay close to those who oppose your ideas; spend time with them, ask for their input on your initiative, listen closely to their reality (especially when it differs from yours), and take their temperature. Ron Heifetz, Practical Tools and Tips for Adaptive Leadership
  12. 12. John Kotter, Accelerate
  13. 13. Source: Gary Hamel
  14. 14. Source:@Alfacarlo
  15. 15. When you are dealing with an adaptive challenge that requires creativity, you have to tolerate the pains of processes that increase the odd that new ideas will lead to new adaptive capacity. Ron Heifetz
  17. 17. Lipmanowicz, McCandless 20 PALETTEOFLIBERATINGSTRUCTURES Designer:LesleyJacobs
  18. 18. Why do we use TRIZ? • Creative destruction • Challenge the status quo & sacred cows • Gives permission to discuss taboo subjects • Builds trust
  19. 19. TRIZ – First Step Be creative! Make yourself laugh! This is SERIOUS FUN….. Reflect in your small group, make a list of “to do’s” in answer to:
  20. 20. How will we make the best ideas fail? How will we stifle creativity in our staff? How can we be sure that our staff morale is rock bottom? How do we ensure that our we harm patients when they are here? Pick one you like!
  21. 21. TRIZ – Second Step Go down the list and ask: Is there anything on this list that we currently practice, even remotely? Is there an element of truth in here? Cross out the ones that you are not doing EVER.
  22. 22. TRIZ – Third Step Look at your list…what items do you want to commit to avoiding? Pick your top two. What will you do to avoid those items? Do you need leadership or organizational help? What needs to stop or change? Be as concrete as you can.
  23. 23. The Culture Toolkit
  24. 24. Power Distance Index
  25. 25. “Power distance is the extent to which less powerful members of organizations and institutions accept and expect that power is distributed unequally.” A high power distance score accepts a hierarchical order in which everyone has a place that needs no further justification. 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’s Power Distance Index
  26. 26. High Power Distance Index Cultures • Authority and demonstrate rank. • Subordinates expect clear guidance from above. • Subordinates are expected to take the blame for things going wrong (Collateral damage). • The relationship between boss and subordinate is rarely close or personal. • Class divisions within society are accepted. Slide courtesy of Ron Collins, 2014
  27. 27.
  28. 28. Can hierarchy cause plane crashes?
  29. 29. Boeing and Airbus design modern, complex airplanes to be flown by two equals. Malcome Gladwell, Outliers – The Story of Success
  30. 30. Power Distance Index
  31. 31. • American culture is marked by interdependence and value placed on egalitarianism. • Lack of overt status and/or class distinctions in society. • Hierarchy in organisations is established for convenience. • Superiors are always accessible and managers rely on individual employees and teams for their expertise. • Managers and staff members consult one another and share information freely. • With respect to communication, value a straightforward exchange of information. Power Distance Index Score = 40
  32. 32. What do you see in a high power distance index? • Senior-level people get limited information • Senior leaders perceive that everything is going well • Junior-level people do not bring ideas forward. • Staff ask for permission every step along the way. It’s hard to innovate under these conditions. Geert Hofstede
  33. 33. Questions to ask yourself? • Are you aware of how others react to you? • Do they start or stop talking when you enter the room? • Do you feel you can not talk to higher levels in the organization without permission. • Does your organization encourage the use of titles and position.
  34. 34. “Top down is a serious disease but it can be treated” Celine Schillinger @celineschill Source of image:
  35. 35. Questions?
  36. 36. Marlies van Dijk Provincial Implementation Lead, Innovation Quality and Healthcare Improvement Alberta Health Services @tweetvandijk
  37. 37. References • cultural-dimensions/power-distance-index/ • Culture-Book_6x8_2013_web-FINAL.pdf • • •

Notas del editor

  • Culture is about
    Traditions (first picture)
    Attitudes (second picture)
    Which manifest as behaviours (third picture)
    Which turn into ways of being that are tolerated and accepted as “normal” (fourth picture)
  • Its folklore (stories that are important), its rituals (how new employees are welcomed into the company), its group norms (dress code), and its meeting protocols. All these cultural ingredients influence the organization’s adaptability.
  • The teamwork climate domain of the SAQ survey has proved to be an effective predictor of various adverse events and patient satisfaction at the unit level

    We have data from >40 hospitals demonstrating this remarkable relationship

    These diagnostic insights point to specific training opportunities that our TEM program systematically address

    A very important correlations with HCAHPS which in the age of the ACO, has dramatic impact
  • Poll Everwhere questions
  • Adaptive challenges can only be addressed through changes in people’s priorities, beliefs, habits and loyalties
  • Technical versus Non-technical/Adaptive/Culture – give a definition of “Culture” and “Non-technical skills”
    The culture side is the base of the iceberg
  • Adaptive challenges can only be addressed in changes in peoples priorities beliefs habits and loyalties. Going beyond authoratative expertise to mobilize discovery and shedding entrenched ways, tolerating losses and generating the new capacity to thrive.
  • Can you think of a project or initiative – where the strategy was clearly articulated and process improvement undertaken but noone talked about mind sets?

    I have a perfect example: the surgical checklist. I have this hypothesis that if a good culture exists then the checklist is easy to implement – if it does not then it is virtually impossible. Or can you change culture using tools?
  • 15 min
  • 5 min
  • 15 min
  • The reason why we are presenting this is in the hopes that there will be something you can take back and apply in your units. Try it… make it your own.

    Could you see yourselves using these types of tools?

    What’s inside?
    1 What is culture?
    8 How do we improve culture?
    10 Ideas for changing culture
    11 Tools
    19 Tools Summary
    42 Process Changes
    48 Process Changes Summary
    50 Generate Ideas Locally
    52 Tips for Success
    57 Acknowledgements
  • This dimension expresses the degree to which the less powerful members of a society accept and expect that power is distributed unequally. The fundamental issue here is how a society handles inequalities among people. People in societies exhibiting a large degree of power distance accept a hierarchical order in which everybody has a place and which needs no further justification. In societies with low power distance, people strive to equalise the distribution of power and demand justification for inequalities of power.
    Hofstede’s Power distance Index measures the extent to which the less powerful members of organizations and institutions (like the family) accept and expect that power is distributed unequally. This represents inequality (more versus less), but defined from below, not from above. It suggests that a society’s level of inequality is endorsed by the followers as much as by the leaders.
    For example, Germany has a 35 on the cultural scale of Hofstede’s analysis. Compared to Arab countries where the power distance is very high (80) and Austria where it very low (11), Germany is somewhat in the middle.
  • On residential unit the healthcare aid – residential care
    Do healthcare aids feel comfortable speaking up in front of nurses. Do they feel empowered to challenge nurses?

    Korean Airlines
    Ferry off the coast of South Korea

    “Senior-level people get no information, and believe that they have nothing to improve upon, and junior-level people do not bring ideas forward. It’s hard to innovate under these conditions.”
  • “Korean Air had more plane crashes than almost any other airline in the world for a period at the end of the 1990s. When we think of airline crashes, we think, ‘Oh, they must have had old planes.’ They must have had badly trained pilots. No. What they were struggling with was a cultural legacy, that Korean culture is hierarchical. You are obliged to be deferential toward your elders and superiors in a way that would be unimaginable in the U.S.

    But Boeing and Airbus design modern, complex airplanes to be flown by two equals. That works beautifully in low-power-distance cultures [like the U.S., where hierarchies aren't as relevant]. But in cultures that have high power distance, it’s very difficult.”

    What we are learning from aviation is that
    Home care, residential, acute care, or surgery – there are
  • Highest power distance index is in Malaysia and Philippians
  • Sugar coating
  • Using the word doctor – Doug, our chair says that using the ‘doctor’ puts his patients at risk. It creates a barrier.

    I never refer to physicians by doctor –