Doctors attitudes to a culture of safety: lessons for organizational change

Introduction

The notion that hospitals and medical practices should learn from failures, both their own and others', has obvious appeal. Yet, healthcare organizations that systematically and effectively learn from the failures that occur in the care delivery process, especially from small mistakes and problems rather than from consequential adverse events, are rare. The NHS has been slow to learn in comparison with other industries. There have been unprecedented improvements in the safety of air travel, oil exploration and nuclear power which have all occurred because of a cultural change following major disasters. In contrast, hospitals deal with life and death everyday but have been slow to adopt the ideals of the quality improvement movement, which suggests a form of cognitive dissonance when they are so deeply involved with the business of caring.

A central argument in this field is that hospitals don't learn from failure because of two related organizational issues. Firstly, at the frontlines of patient care in hospitals the interpersonal climate often inhibits speaking up with questions, concerns, and challenges that might have contributed to catching and correcting human error before patients are harmed. ¹ Moreover, the culture of medicine generally discourages admission of error, thereby greatly diminishing a given hospital's potential to learn from mistakes, both consequential or not. Secondly, features of the work design and culture of most hospitals make workarounds and quick fixes the dominant response to failures, ² rather than root cause analysis and systematic problem solving, which contribute to organizational improvement and innovation. ³ Much of the literature also suggests that both causes of and solutions to these organizational learning failures ultimately lie in leadership.

The research topic for this project is ‘Best and Safest Care’ which is a patient safety and quality improvement plan and a top priority for a large hospital trust in the south of England. There is concern however about its implementation. Annual staff surveys in the hospital trust in question, rank it in the bottom quartile for putting safety first when benchmarked against other trusts nationally. Complaints and clinical incidents regularly provide examples of where care and treatment could and should have been better, and there is consistent failure to address such issues. Poor communication, bullying, active covering up, inadequate leadership, ineffective team working, racism, lack of respect, intolerance, selfishness and a culture of fear conspire to poison attitudes and behaviours, and result in an unsafe and toxic environment that everyone ‘sees’ but no-one talks about. Worse still, in the field of management, the true nature of these forces is too often regarded as not capable of being openly discussed and is, therefore, rarely addressed.

“We are very good at training clinicians to look after individual patients but fail completely to train them to understand and to look after the system of care”

The dissonance between the espoused ideals of the strategy and its concrete reality are the subject of this project. The aim is to explore issues around whether there is a receptive organizational context for change. Specifically the project will explore the culture of Doctors and how they fit into the strategy. The rationale for studying the trust's interpretation of patient safety improvement is that Best and Safest Care is a crucial, critical strategy, but there is concern that via a top down driven mandate, there is failure to influence the ones who most need to respond to a cultural change and implement the strategy into effective, meaningful operational practice.

What is Culture?

A great deal of the literature on patient safety explores the pervasive barriers embedded in healthcare's organizational systems that make shared or organizational learning from failure difficult. If only it was as easy as the NPSA's guidance suggests;

‘Organizational culture refers to the patterns of beliefs, values and learned ways of coping with experience that have developed during the course of an organization's history, and which tend to be manifested in its material arrangements and in the behaviour of its members'

Organizational cultures are difficult to assess because their shared beliefs, values, and assumptions are not always explicit. There is increasing international interest in managing organizational culture as a lever for health improvement. In the United States, health policy is directly embracing culture change as a key element of health system redesign ^5,6 and many other countries are also focusing on cultural renewal as a potential lever for performance improvement. ⁷

Approximately one third of NHS organizations in England are currently using a culture assessment tool to support their clinical governance activity, and almost all the instruments used focus heavily on the assessment of safety cultures rather than more broadly on perspectives of quality and performance.

Johnson & Scholes' Cultural web ⁸ represents culture as an interlinked set of organizational subsystems in which the paradigm drives the visible manifestations of culture (Figure 1). It has been used in the NHS as well as by organizations as diverse as Shell, KPMG, Castrol, the UK Labour Party and as part of high profile education programmes at Manchester Business School, Cranfield School of Management and Lancaster University Management School. OPEN IN VIEWER

The advantages of this model are that it is relatively straightforward to use, has a long history of use in the business world with empirical results to back it up, it is comprehensive and holistic, and forces one to consider aspects of culture that one may not normally contemplate, such as the differences between the designed and the emergent culture. It is also easy enough for employees to comprehend it by themselves and perform their own analysis.

Ultimately, as Machiavelli suggests, it doesn't necessarily matter which particular tool you use just so long as you demonstrate that you have taken a long hard look at the issue; ⁹

“the clue to successful statecraft lies in recognising the force of circumstances, accepting what necessity dictates and harmonising one's behaviour with the times”

Method

The focus will be on strategy, change and culture in order to best answer the research question. This project will use the Cultural Web to study aspects around ‘Best and Safest Care’. It will provide information regarding:

The strategic context of the organization

Process

This project will use focus groups of junior doctors in order to produce primary qualitative data.

Focus Groups

Focus groups are special discussions exploring a specific set of issues. They are distinguished from both individual and group interviews by the use of interaction to generate data. Focus groups are good for exploring people's experiences, opinions and concerns. It also allows us to tap into the tacit knowledge that quantitative methods would struggle to unearth. Ultimately focus groups are ideal for examining how knowledge, ideas, story telling, understandings and dynamics operate in a given cultural context. ¹⁰

Random sampling was used to encourage diversity. All summaries and transcripts were read by EN and MM (independent research assistants), who identified any issues describing management styles by iterative examination. We discussed themes as they emerged and explored them using the cultural web as an interpretive framework where appropriate.

Questionnaires

Focus groups can also be combined with quantitative methods such as questionnaire surveys. This use of mixed methods is complementary and expands the amount of data available for analysis. We used a web based questionnaire (Survey Monkey) and invited all junior doctors in the trust (850) to participate. Questions were based on the emergent themes from the focus groups. To enhance the reliability and validity of the questionnaire it included some relevant, validated questions from the Manchester Safety Framework, which is a facilitative educational tool. ¹¹ It aims at providing insight into an organization's safety culture and how it can be improved among teams.

Results

Table 1 (above) contains key themes which emerged from the focus groups about the current organizational culture at the hospital, supported by a trust wide questionnaire (with a return /completion rate of 66%). Alongside are the elements which make up the future organizational paradigm of Best and Safest Care.

Discussion

What does the cultural web therefore say about the organization as a whole? The results demonstrate that the trust has a large body of committed, autonomous professionals who have strong identity and who are primarily present for the best interests of the patient. The medical profession is theoretically more in line with patient needs and there is little corresponding truck with strategic initiatives because the necessity, the drivers and the likelihood of success do not come into their sphere.

Mapping the Differences between the Current and Idealized Cultures

Cultural strengths highlighted by analysis of the current culture:

Doctors are hard working professionals with a strong tradition who work well in teams. There is already a structure in place to monitor their professional development and training. There is a strong element of socialisation due to the long hours, job complexity and emotional commitment. Their core value is the patient in front of them.

Doctors tend to work for a different value – that of the individual patient, rather than the abstract, perceived irrelevant goals and strategies of senior management or of the organization. Whilst however, this is believed to be true, the fact that there has been such a surge of interest in Clinical Leadership from junior doctors means that within the next generation, there is a bubbling frustration with the way that the health service is run and organized. Not all Doctors are leaders, and not all will be interested in adopting strategic goals but it may only require a committed few to ‘lead’ others in the right direction to bring about convincing change. This perhaps is the focus that management needs to include: get some committed junior doctors who are interested in patient safety and let them undertake some high profile projects with the full support of management. This will allow both role modelling and spread the message that doctors and managers are on the same side and working towards the same end.

Cultures are notoriously difficult to change because they cannot be controlled in the way that work can be organized because a culture is not something that an organization completely owns or develops in a certain way. Different functions within the same organization, for example a team of junior doctors, have a very different culture from a team of accountants. In a large hospital, there are several overlapping cultures. Some aspects of culture can act as a barrier to change. Junior doctors for instance, wish to preserve their distinct identity, which is traditionally separate from the ‘dark side’ of management (an oft repeated term), focus on their main value (the patient in front of them) and maintain their firm's position in the medical hierarchy (which is a separate, contrarily non-corporate part of the wider organization). However, things are not all disparate, the 3500 year old medical tradition is dedicated to patient care, so by being able to understand which features of the culture help to support change and which hinder it, then management will be in a better position to influence improvements in the direction of ‘Best and Safest Care’.

Conclusions

Cultural change is not something that can be achieved at the flick of a switch. Cultures develop through social interactions in fields of practice. Everyone becomes aware of what types of thinking and behaviours are broadly acceptable. Change cannot happen without some form of disruption. Managers and clinical leaders must therefore recognize their role in preparing people for the disruption of change and consider the many ways in which progress towards an improvement, even one that brings many benefits, impacts on individual lives and improves the experience of care. This project has demonstrated that this is not occurring in the trust in question. Despite a strong vision, it has not been communicated adequately (if at all), the sub-culture of the medical profession has not been acknowledged and the design choices have not taken junior doctors into consideration. This seems both surprising and frustrating in the context of a significant change management programme.

Rethinking the project using an understanding of the cultural context provides better design choices:

Change Path: safety and quality focussed through an incremental transformation.

Change Target: modifying the values and behaviour of staff – the desired result of changes is to increase personal accountability, directness, openness and trust.

Change Roles: High profile clinical leadership – spread the message; Chief of Patient Safety; Chief Nurse; Medical Director and CQUIN lead. Can't be led by an outsider.

Change Style: Different styles for different levels of the organization. Involve workers collaboratively in design or to implement in a participative fashion ‘how would it work here?’

Change Start point: Top-down initially – directive, top trust priority as it relates to FT application, safety ratings, CQUIN and key performance indicators. But also needs to be bottom up to encourage investment – pilot sites and pockets of good practice are required.

Change interventions:

‐ policies and procedures updates (of relatively minimal value),

The secret of care for the patient is to care for the patient. The challenge for management is to extend this as care for the service, or the wider organization. ¹⁴ No amount of regulation, process improvement or reimbursement can change this fundamental fact. It's about the people, not the policy.