leadership and culture
DESCRIPTION
Leading in the complex environment of healthcare is tricky. Changing culture can be made more practical. This presentation was delivered to members of Northern Health's leadership team by Marlies van Dijk, Director of Clinical Improvement for the BC Patient Safety & Quality Council, on October 1, 2014.TRANSCRIPT
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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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© 2012 Pascal Metrics Proprietary & Confidential
CCU OR
5 W
EST
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
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What are you seeing aroundculture 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 ElementsOur System
1. Structure2. Process 3. 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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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
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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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TECHNICAL
CULTURE/ADAPTIVE
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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
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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
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22
“the most common cause of failure in leadership is produced by treating adaptive challenges as if they were technical problems.”
Ron Heifetz
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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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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
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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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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
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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.ScHuman 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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Teamwork
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Memory
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Perception
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Fatigue
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Attention
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Improving Culture
Team-Building Games
Power Distance Index
Observations
Peer coaching teams
Debriefing
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TELEPHONE GAME
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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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http://www.reply-mc.com/2011/12/27/unraveling-social-interaction-part-4/
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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 Hofstedehttp://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” ritualWho 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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Coaching
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Coaching
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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
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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
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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
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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
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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
Allison Muniak