Identify Culture

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Identify Culture Communication Behavior Rituals Tolerance From Dr. Scott Ellner, St Francis Hospital & Medical Center, presented June 27, 2013

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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?

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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.

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HCAHPS 92 50 Medication Errors per Month 2.0 6.1 Days between C Diff Infections 121 40 Days between Stage 3 Pressure Ulcers 52 18 Illustrative Data: Extracted from Blinded Client Data

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What are you seeing around culture issues? Poll Everywhere

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Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve. Unpredictable (Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)

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Three Core Elements Our System Structure Process Patterns of Behaviour Fritjot Capra

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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

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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)

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Interdependencies Overarching 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

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Sense Making

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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)

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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)

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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

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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

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Ron Heifetz, The Practice of Adaptive Leadership 2009 Distinguishing technical problems and adaptive challenges

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Example Reducing Urinary Tract Infections on my unit

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“the most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.” Ron Heifetz 22

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Culture eats strategy for lunch!

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“The source of energy at work is not in control, it is in connection to purpose.” Don Berwick

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Christina Costello, Babson Entrepreneur Experience Lab

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“I have a dream” “I have some new clinical guidelines for you….”

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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

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Lipmanowicz, McCandless 34 PALETTE OF LIBERATING STRUCTURES Designer: Lesley Jacobs

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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

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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:

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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!

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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.

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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.

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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

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Teamwork and Communication “Ins and Outs” Allison Muniak, M.A.Sc Human Factors Specialist BC Patient Safety and Quality Council

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The Culture Toolkit

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What is Human Factors?

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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.

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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.

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We cannot change the human condition, but we can change the conditions under which humans work James Reason (BMJ 2000;320:768)

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Improving Culture Team-Building Games Power Distance Index Observations Peer coaching teams Debriefing

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

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How did it go?

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What tactics did you use to remember?

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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.

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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

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How did it go?

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How was your memory during Round 2?

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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.

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Critical Language A phrase that is commonly understood to imply “stop the line – there is a safety concern” Example: I need clarity

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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.

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Power Distance Index

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“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

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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

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Can hierarchy cause plane crashes?

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“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

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Canada Power Distance Index

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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

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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 Hofstede http://geert-hofstede.com

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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

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Situational Leaders

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Let’s Talk Culture! How can you create experimentation?

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

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Communication Approaches Command Team Obligation Statement Team Suggestion Query Preference Hint Slide courtesy of Ron Collins, 2014

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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

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Slide courtesy of Ron Collins, 2014

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Communication Approaches Command Team Obligation Statement Team Suggestion Query Preference Hint Slide courtesy of Ron Collins, 2014

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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.”

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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!”

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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?”

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Team Suggestion

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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?”

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Team Obligation Statement

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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.”

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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

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Slide courtesy of Ron Collins, 2014

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BCPSQC Menu of Support

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Contact Marlies van Dijk mvandijk@bcpsqc.ca Allison Muniak amuniak@bcpsqc.ca