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Organizational Culture and Change Management

TeamSTEPPS Master Trainer Workshop

Master Trainers 1. Know the team strategies and tools

2. Role model, teach, coach, team strategies and tools

3. Implement action plans to use the team strategies and tools to solve clinical problems

4. Manage culture change as you implement action plans

Objectives: Managing Culture Change

1. Explain the concept of safety culture (what are you trying to change?)

2. Use an explicit strategy to manage culture change

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Explain the concept of safety culture

• Definition

• 4 Categories of Culture

• 3 Levels of Culture

• 4 Components of Culture

• Role of Organizational Culture

• Role of Leadership in Organizational Culture

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Objective 1.

What is a Safety Culture?

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•LEARNED,1 enduring, shared, beliefs and behaviors that reflect an organization’s willingness to learn from errors2

•Patient safety has a high relative importance to other organizational goals (i.e. productivity)3

•Four beliefs present in a safe, informed culture4

1. Our processes are designed to prevent failure

2. We are committed to detect and learn from error

3. We have a just culture that disciplines based on risk

4. People who work in teams make fewer errors

Four Categories of Culture1

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Macroculture

Organizational Culture

Subcultures within Positions

Microculture withineach Clinic

http://clinics.nebraskamed.com/Clinics/Eagle-Run.aspx

https://nufoundation.org/image/journal/article?img_id=2741083&t=1384988167442

http://previews.123rf.com/images/alexraths/alexraths1308/alexraths130800093/21709019-

Nurse-taking-blood-sample-from-patient-at-the-doctors-office-Stock-Photo.jpg

14 clinics each have their own

culture

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Three Levels of Organizational Culture1

“…values reflect desired behavior but are not reflected in observed behavior.” (Schein, 2010, pp. 24, 27)

Behaviors

Beliefs & Values

Underlying Assumptions

Observed Communication Behavior: 29% agree, “Staff feel free to question decisions or actions of those with more authority.”

Belief: Belief about Communication:60% agree, “Staff will speak up if they see something that will negatively affect patient care.”

Assumption: Safety is a system property but I will be attached if I speak up. Staff and providers should work together as a team to achieve results (patient safety and clinical outcomes)

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Four Components of Safety Culture5

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HRO

LEARNING

FLEXIBLE

JUST

REPORTING

1. Reporting Culture2. Just Culture3. Flexible (Teamwork)

Culture4. Learning Culture

• Effective reporting and just cultures create atmosphere of trust5

• Sensemaking6 of patient safety events and high reliability result from an explicit plan to engineer behaviors from each component of safety culture

INFORMED and SAFE

T

R

U

S

T

S

E

N

S

E

M

A

K

I

N

G

Reason’s Components4 HSOPS Dimension or Outcome Measure

Reporting Culture - a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses

•Frequency of Events Reported (U)

•Number of Events Reported (O)

Just Culture - management will support and reward reporting; discipline occurs based on risk-taking

•Nonpunitive Response to Error (U)

O=Outcome Measure, U=Unit, H=Hospital

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Crosswalk Reason’s Components

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Reason’s Components4 HSOPS Dimension or Outcome Measure

Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers

•Teamwork w/in Units (U)

•Staffing (U)

•Communication Openness (U)

•Teamwork ax Units (H)

•Hospital Handoffs (H)

Learning Culture -organization will analyze reported information and then implement appropriate change

•Hospital Mgt Support (H)

•Manager Actions (U)

•Feedback & Communication (U)

•Organizational Learning (U)

•Overall Perceptions (U)

•Patient Safety Grade (O)10

Crosswalk Reason’s Components

The Role of Organizational Culture

Safety Culture7

• A cross cutting contextual factor

• Moderates effectiveness of patient safety interventions

• Associated with adverse events and patient satisfaction

Organizational Culture1

• Allows us to make sense of environment

• Reflects common language… is heard and observed

• Leaders create/teach culture− Share information

− Reward, provide feedback

− Hold people accountable

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“…it is the unique function of leadership to perceive the functional and dysfunctional elements and to manage cultural evolution and change.”

Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.

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Leaders Engineer Culture1

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The Bottom Line…

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Improving safety culture increases likelihood of success of all other patient safety interventions

Use an explicit strategy to manage culture change1. Kotter’s Eight Steps of

Change10

2. Comprehensive Unit Based Safety Program (CUSP)11

3. Diffusion of Innovations12

Objective 2.

Why Does Change Fail?

Why isn’t the US on the metric system?

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http://static.ddmcdn.com/gif/us-metric-system-1.jpg

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Why Does Change Fail?

Share examples from your setting

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ENGAGE

EDUCATE/TRAIN

EVALUATE

EXECUTE

EXPAND

ENDURE

Peter Pronovost

1. Kotter’s Eight Steps of Change10

Multiple Strategies for Change

CUSP

• Get people’s attention (with stories and data)! – MOS results, harmful events, issues with waste

of time/resources, patient satisfaction, core Measures

• Sell the need for change…and the consequences of not changing to administrators, clinic leaders and managers, clinic providers and staff

• Immerse clinic staff in information about the change

• Empower people to solve problems associated with the change

1. Create a Sense of Urgency10

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• Include proven leaders who can drive the change process

– Formal power with high credibility

– Informal opinion leaders

– Interprofessional

– Set expectations for follow through

• Need management and leadership skills

– Management skills control the process and details

– Leadership skills drive the change with a vision

2. Build the Guiding (Change) Team10

…TeamSTEPPS initiative should have a designated executive/leadership sponsor

• Work with leaders to define and communicate your vision for change…

• Defining a culture of safety aligned with expectations, core values, shared beliefs

• Informing the clinic of these values and evaluating the culture

• Leading the process of:

• Translating values into expected behaviors

• Establishing trust and accountability

• Share how this change is consistent with mission and core values

3. Develop the Change Vision and Strategy10

• Includes education and training

• Encourage discussion, dissent, disagreement, debate … keep people talking

• Tell people what you know―and what you don’t know

• Value resisters (NO NO)

– They clarify the problem and identify other problems that need to be solved first

– Their tough questions can strengthen and improve the change

– They may be right―it is a dumb idea!

4. Communicate for Understanding & Buy-In10

…communicate, communicate, communicate…

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It is important to improve teamwork in our organization because: • 1/4 of our nursing staff believe that shift changes

are problematic for patients• 2/3 of our clinical staff do not feel psychologically

safe speaking up to those with more authority when patient safety is at stake

• Only ½ of the staff in the ED agree that there is good cooperation among hospital departments that need to work together.

• RCA identified poor communication during a handoff of a patient from floor to radiology that led to a fall

• Lack of using check-back in a code situation may have contributed to a patient death

4. Communicate Using Talking Points (Data & Stories)

• Train employees so they have the desired skills and attitudes

• Identify personnel with the vision and skills to COACH others

• Manage high-level resisters…how does professor manage NO NO?

5. Empower Others to Act10

An organization cannot be improved from the top only

http://www.kotterinternational.com/our-principles/our-iceberg-is-melting

• Provide positive feedback (shirts, pins)

– Further builds morale and motivation

– Results from debriefs

• Provide feedback to plan next goal

• Create greater difficulty for resisters to block further change

• Provide leadership with evidence of success

6. Produce Short-Term Wins10

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• Evaluate your training sessions and learn from the evaluations (form on website) http://www.unmc.edu/patient-safety/teamstepps/toolkit.html

• Reaffirm the vision

• Celebrate successes and accomplishments

• Orient new employees to the tools

• Include in annual training to reinforce behaviors (Overview on website) http://www.unmc.edu/patient-safety/teamstepps/teamstepps-training/index.html

• Communicate, communicate, communicate

• Stay connected to TeamSTEPPS communities (your 14 clinics, UNMC, National Implementation)

7. Don’t Let Up10

• Hard wire the change– Job descriptions

– Performance evaluations– Policies/procedures

• Use language and tools in clinical and nonclinical settings– Managers use the tools

– Leaders call for briefs, huddles, and debriefs

– All monitor the situation to establish situation awareness

– All seek and offer task assistance

– All structure communication with SBAR, Call-out, Check-back and I PASS the BATON

– All structure email communication, document reviews, requests for maintenance with SBAR

8. Create a New Culture

Strategies and Tools to Enhance Performance

and Patient Safety

TeamSTEPPS…Innovation to Address Need

2. Comprehensive Unit Based Safety Program (CUSP)11

Innovation: An idea or practice that is perceived as new

Diffusion process: Innovation is communicated through channels over time among members of a social system12

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Getting a new idea adopted, even when it has obvious advantages, is difficult. Many innovations require a lengthy period of many years from the time when they become available to the time when they are widely adopted. 12

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TeamSTEPPS as an Innovation

Rogers EM. Diffusion of Innovations (5th ed.). New York, NY: Simon & Schuster; 2003. pp. 1, 281.

General Attributes

•Relative advantage

•Compatibility

•Complexity

•Trialability

•Observability

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Attributes of Innovations12

TeamSTEPPS

•Train-the-Trainer

•Fundamentals

•Essentials

•Coaching

•Culture Assessment

•Implementation/ Action Planning

Rogers EM. Diffusion of Innovations (5th ed.). New York, NY: Simon & Schuster; 2003.

Teamstepps.ahrq.gov

Characteristics of Innovative Organizations/Individuals

Organizations12,13

Management supportive

Resources available

Implementation practices “hard wired”

Champions

Fit between innovation & values

Effective innovation improves culture/climate

Individuals12

Greater contact with change agents

Actively seek information

Greater knowledge of innovation

Greater social participation

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TEAMSTEPPS 05.2Mod 7 06.1 Page 31

Summary—Pulling it All Together

Organization Innovation Process

Agenda Setting:

Identify need for innovation (performance

gap as a trigger)

Matching:

Find an innovation to

meet need and bridge

performance gap

Redefining/ Restructuring:

Re-invent innovation to

match context, restructure

organization to fit innovation

Clarifying:

Make roles and tasks

associated with innovation

clear

Routinizing:

Innovation is hard-wired into organization’s

policies/ procedures

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ImplementationInitiation Dec

isio

n

Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.

TEAMSTEPPS 05.2Mod 7 06.1 Page 32

Summary—Pulling it All Together

Individual Innovation Process

Knowledge: Recall

information, knowledge &

skill for effective adoption

Persuasion:

Like the innovation,

discuss with others, form

positive perception

Decision:

Intent to seek additional

information and to try innovation

Implementation:

Acquire additional

information and use innovation

on regular basis

Confirmation:

Recognize benefits of using

innovation, integrate into

routine, promote to others

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Preparation Action MaintenancePre-Contemplation and Contemplation

Prochaska et al. In search of how people change. American Psychologist. 47:1102-1114.Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.

Change Management: Putting it All Together

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8 Stages (Kotter) Change Model (Pronovost)

Organizational Stages (Rogers)

Individual Stages (Rogers)

Create Sense of Urgency

Engage Agenda Setting Knowledge –Persuasion

Build Guiding Team Engage Agenda Setting –Matching

Knowledge –Persuasion

Develop Change Vision & Strategy

Engage – Educate Matching – Redefining Knowledge –Persuasion – Decision

Communicate for Understanding

Educate Clarifying Persuasion – Decision

Empower OthersCOACH

Execute Clarifying Decision

Short-Term Wins Execute – Evaluate Clarifying - Routinizing Implement

Don’t Let Up Evaluate – Expand Clarifying - Routinizing Implement

Create a New Culture

Expand – Endure Routinizing Confirmation

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Putting it All Together: The Checklist

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Clearly define the changeManagement is supportiveImplementation ChampionEmployees recognize change is a priorityResources are availablePolicy/Procedure changedJob descriptions/performance appraisals changedChange is evaluatedResults of evaluation guide improvement

Download Checklist for Implementing Change from http://www.unmc.edu/patient-safety/teamstepps_toolkit.htm

• Changes in values come at the end of the transformation process

• New behaviors adopted by the laggards after success has been proven by the early adopters

• Feedback and reinforcement are crucial to using the behaviors—adopting

• Sometimes the only way to change culture is to change key people

• Individuals in leadership positions need to walk the walk and talk the talk

Culture Change Comes Last, Not First!10

…Reculturing takes time and it really never ends

Role of Leaders in Transformational Change

• Create a compelling positive vision• Concretely define the goal as a performance

problem…not “changing culture”• Ensure new behaviors are formally taught in

groups• Ensure new behaviors are reinforced

– Provide opportunities for practice, coaching, feedback

– Be a positive role model• Create structures consistent with new way of

thinking/working/behaving

36Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco:John Wiley & Sons; 2010.

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• Safety culture is the learned, shared beliefs and behaviors that reflect organization’s willingness to learn and whether safety is a priority

• There are multiple strategies to use an innovation such as TeamSTEPPS to change your culture; they all have common elements…– Urgency/Engagement/Agenda Setting…the reason to

change

– Develop the right team to guide the change; make sure they have the time and resources to do the work

– Match a specific problem to a solution and communicate the vision! (targeted or transformational change)

– Empower, clarify, make it routine…don’t give up!

– Expect barriers and manage them!

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Summary

1. Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.

2. Wiegmann. A synthesis of safety culture and safety climate research; 2002.http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf

3. Zohar D, Livne Y, Tenne-Gazit O, Admi H, Donchin Y. Healthcare climate: a framework for measuring and improving patient safety. CritCare Med. 2007;35:1312-7.

4. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

5. Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

6. Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575.

7. Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Int Med. 2013;158:369-374.

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References

References8. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring

relationships between hospital patient safety culture and adverse events. J Patient Saf 2010;6: 226-232.

9. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients’ assessments of hospital care. J Patient Saf 2012;8: 131-139.

10. Kotter JP. Our Iceberg is Melting. New York: St. Martin’s Press; 2006.

11. Pronovost et al. Creating high reliability in health care organizations. Health Services Research. 2006; 1(4, Part II): 1599-1617.

12. Rogers EM. Diffusion of Innovations (5th ed.). New York, NY: Simon & Schuster; 2003.

13. Helfrich et al, (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Med Care Res Rev 64(3), p.282.

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