Identify Culture

• Communication

• Behavior

• Rituals

• Tolerance

From Dr. Scott Ellner, St Francis Hospital & Medical Center, presented June 27, 2013

Improving Culture:Not as easy as it appears

• Culture: How is it relevant to better care?• What is current state • TRIZ: a way to get the front line engaged• Teamwork and Communication “Ins and Outs”• How can you apply some of these tools?

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: www.jointcommision.org.

© 2012 Pascal Metrics Proprietary & Confidential

CCU OR

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PEDS

DIALY

SIS

PHAR

MIC

USI

CU OB0

20406080

100

28333641454549495152556262737580

98Teamwork 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 fromBlinded Client Data

What are you seeing aroundculture issues?

Poll Everywhere

Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve.

Unpredictable

(Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)

Three Core ElementsOur System

1. Structure2. Process 3. Patterns of Behaviour

Fritjot Capra

At present, prevailing strategies [in healthcare] rely largely on outmoded theories of control and standardisation of work. More modern and much more effective, theories seek to harness the imagination and participation of the workforce in reinventing the

system

Don Berwick, Former CEO, Institute for Healthcare Improvement

Self-Organization

Self-organization is a process whereby local interactions give rise to patterns of organizing.

ADAPTIVE – RESILIENT – UNCERTAIN(and difficult to manage)

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

InterdependenciesOverarching term for relationships, connections, and interactions among parts of a complex system.

Pre-Intervention Post-Intervention

Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration

Sense Making

So now what?How do we lead in a complex system…

Acknowledge Unpredictability• Allow design to be tailored to local contexts• Emphasize discovery in each intervention setting

Recognize Self-Organization• Develop “good enough” • Facilitate sense-making

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

So now what?How do we lead in a complex system…

Facilitate Interdependencies• Reinforce existing relationships when effective or foster new

ones• Encourage sense-making

Encourage Experimentation• Encourage participants to ask questions, admit ignorance and

deal with paradox• Seek out different points of view

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

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

Ron Heifetz

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

TECHNICAL

CULTURE/ADAPTIVE

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 Leadership2009

Distinguishing technical problems and adaptive challenges

ExampleReducing Urinary Tract Infections on my unit

Items Adaptive or Technical

Clinical guidelines Technical

How does it fit with local organizational guidelines?

Technical

Communicating the guidelines to staff

Technical

Seeking input on how to implement guidelines

Adaptive

Identify change ideas Adaptive

Testing change ideas Technical/Adaptive

Measuring impact Technical

Staff to “care” about UTIs Adaptive

Leading this initiative: The WHY?

Adaptive

22

“the most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.”

Ron Heifetz

Culture eats strategy for lunch!

“The source of energy at work is not in control, it is in connection to

purpose.”Don Berwick

Compliance Commitment

A minimum performance standard that everyone must achieve

A collective goal that everyone can aspire to

Uses hierarchy, systems and standard procedures for coordination and control

Based on shared goals, values, and sense of purpose for coordination and control

Threat of penalties, sanctions, shame creates momentum for delivery

Commitment to a common purpose creates energy for delivery

Christina Costello,Babson Entrepreneur Experience Lab

“I have a dream”

“I have some new clinical guidelines

for you….”

Framing

• Connect with people’s hearts and minds• Turning opportunity into action• Hooks to pull people in• Springboards for mobilizing support• Need to be authentic and connect with

reality

TRIZ

DESIGNING A PERFECTLY ADVERSE SYSTEM

THE WORST POSSIBLE RESULTS FROM YOUR

WORK

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Why do we use TRIZ?

• Creative destruction

• Challenge the status quo & sacred cows

• Gives permission to discuss taboo subjects

• Builds trust

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:

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/residents when they are here?

Pick one you like!

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.

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.

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

Teamwork and Communication “Ins and Outs”

Allison Muniak, M.A.ScHuman Factors Specialist

BC Patient Safety and Quality Council

The Culture Toolkit

What is Human Factors?

designing for human use

a body of information about human abilities, human limitations, and other human characteristics that are relevant to design

Chapanis, A. (1995, p. 11). Human Factors in Systems Engineering. Toronto: John Wiley.

the application of human factors information to the design of tools, machines, systems, tasks, jobs, and environments for safe, comfortable and effective human use

Chapanis, A. (1995, p. 11). Human Factors in Systems Engineering. Toronto: John Wiley.

We cannot change the human condition,

but we can change the conditions under which humans work

James Reason

(BMJ 2000;320:768)

Teamwork

Memory

Perception

Fatigue

Attention

Improving Culture

Team-Building Games

Power Distance Index

Observations

Peer coaching teams

Debriefing

TELEPHONE GAME

Rules:• Speaker cannot repeat the message• No one can ask questions• Do not write anything down

How did it go?

What tactics did you use to

remember?

Please mix me 2 gm of Ancef in 100 ml bag of normal saline which you need to run down to

Dr. Bossy in OR 4 to catch the orthocase starting at 10 am.

Rules:• The person who hears the message

repeats back what they heard• They may also ask a clarifying question• The speaker can repeat the message or

clarify discrepancies

*Each person can only repeat-back once for this exercise

How did it go?

How was your memory during Round 2?

Mrs. Johnston needs to have her antipsychotics reduced as I think it is too much for her. Can you be sure to raise this in the care meeting today but make sure to tell them that she used to be on half the dose she is on now and functioned much better.

Critical Language

A phrase that is commonly understood to imply “stop the line – there is a safety concern”

Example: I need clarity

GP: I’m concerned about how sick your mother is. Her breathing is getting worse. How are you doing looking after her?

Daughter: It’s just me looking after her and it’s getting tougher and tougher doing this all by myself.

GP: It sounds like this is becoming more of a problem and I’m getting uncomfortable with having this load on you at home.

Daughter: I’m just about at the end of my rope, I don’t think that I can look after her anymore.

GP: I think that we will have to stop what we are doing and get you some help caring for her.

Daughter: I found her on the floor this morning and hurt my back getting her back into bed by myself.

GP: This is becoming a safety issue for both you and your mom. We can get some home care to help with her medication and personal care and give you a break until she gets better.

Power Distance Index

“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

www.Clearlycultural.com

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

http://www.reply-mc.com/2011/12/27/unraveling-social-interaction-part-4/

Can hierarchy cause plane crashes?

“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.”

Malcome Gladwell, Outliers – The Story of Success

Canada

Power Distance Index

Canada

• Canadian culture is marked by interdependence and value placed on egalitarianism.

• Lack of overt status and/or class distinctions in society.

• Hierarchy in Canadian 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 = 39

What do you see in a high power distance index?

• Senior-level people get no information• Senior leaders perceive that everything is going

well • Junior-level people do not bring ideas forward.

It’s hard to innovate under these conditions.

Geert Hofstedehttp://geert-hofstede.com

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

Situational Leaders

Let’s Talk Culture!

How can you create experimentation?

“best failure” ritualWho is brave enough to share your biggest bomb from last week?Focus on what you’ve learned most from a mistake

Coaching

Coaching

Communication Approaches • Command

• Team Obligation Statement

• Team Suggestion

• Query

• Preference

• Hint

Slide courtesy of Ron Collins, 2014

Example

A patient has been prepped and draped, and as the surgeon reaches for the scalpel to begin a right total hip arthroplasty, the circulating nurse notes that the X-Ray on the screen is of a left hip!

This nurse must now assume the role of situational leader; her role is to raise the situational awareness of the entire operating team.

The question is this: “What does she say?”

Slide courtesy of Ron Collins, 2014

Slide courtesy of Ron Collins, 2014

Communication Approaches

• Command

• Team Obligation Statement

• Team Suggestion

• Query

• Preference

• Hint

Slide courtesy of Ron Collins, 2014

Hint

Hint

• Is intended to be very general. A hint does not have any personal reflection or engagement in it; it is not a personal statement! Think “insinuation, innuendo, pointer, whisper….”

For example: “It would be nice to get through the day without making any mistakes.”

Preference

Preference

• A weakly stated request that recognizes that several options exist. The person stating the preference does take personal ownership of their idea or request, but it lacks a really strong stance.

For example: “I wish I was in another OR right now!”

Query

Query

• A query is a question to draw other’s attention to a situation without being very direct. The person asking the question is weakly attempting to raise the situational awareness of the rest of the team by calling into question the validity or accuracy of an emerging situation.

For example: “Is that the correct X-Ray?”

Team Suggestion

Team Suggestion

• Elevates the personal statement of one member of the team to engage the situational awareness of the rest of the team. It may be couched as a personal statement, but it clearly raises the comment to the level of the team; look for ‘we’! The suggestion is not a command and does not suggest an obligation to act: it is only raising awareness.

For example: “Can we check the X-Ray please?”

Team Obligation Statement

Team Obligation Statement

• A team obligation statement is a strong call to mobilize the situational awareness of the team. It involves a ‘we’ but includes a ‘must’ or a ‘should’ as well.

For example: “Before we go any further, we need to verify which side this patient has consented to.”

Command

Command

• A command is the highest form of one member of a team raising the situational awareness of the team. It is an imperative to either act or to not act due to impending harm.

For example: “Stop! We are about to make a mistake that will harm this patient

Slide courtesy of Ron Collins, 2014

BCPSQC Menu of Support

Contact

Marlies van Dijk

mvandijk@bcpsqc.ca

Allison Muniak

amuniak@bcpsqc.ca