An emergency department’s journey toward cultural change: a case study
Demetri Karogiannis, John Cabral, Devin Harris, MD, Doreen Perschon, MA, Laura Calhoun, MD
Peter Drucker famously said “Culture eats strategy for breakfast.” In health care, the way things are done, rather than what is done, can make the difference between an engaged workforce and an apathetic one. This case study looks at how the Kelowna General Hospital’s emergency department staff changed their way of doing their usual work and improved their engagement and, subsequently, their quality of care. The article highlights methods leaders can use to uncover previously underground barriers that are affecting engagement. We review the differences between technical problems and adaptive challenges and add to other research that suggests command-and-control leadership is rarely effective in complex systems such as health care.
KEY WORDS: complexity, health care, leadership, workplace culture, engagement, adaptive challenge
Culture can be defined simply as “how we do things around here.” The ED leaders discovered that, although everyone knew what they had to do, the how was not always obvious to the care team. Staffing levels, break coverage, lack of understanding of roles, responsibilities, accountabilities, performance feedback, and a lack of communication between roles at times led to dysfunction in the processes of patient flow. Specialty consults, hospital services’ response times, patient volume management, inpatient admission, and discharge planning were all challenges that impacted the ED culture at KGH.
Changing culture requires a vastly different process than other problems, in that culture is intertwined with interpersonal relationships, group dynamics, traditions, and power imbalances. Culture issues are adaptive challenges as opposed to technical problems.1
In this paper, we review how the leaders of the KGH ED moved from thinking they had a simple technical problem, which would require an expert to tell them how to solve it (best practice), toward understanding that they had an adaptive challenge, which was much more complex. We elucidate how the leaders were able to let go of control strategies and allow a process of adaptation to occur with the beneficial side effect of increasing engagement of staff. Despite an increase in patient demand and having to support the surrounding community during flooding and forest fires, the department showed vast improvement in its culture in just one year. Top
Literature review
Health care literature is replete with evidence of the importance of engaged workers as a driver of quality patient care.2,3 An emotionally engaged workforce is one of the solutions to what currently ails the low quality of care that defines Canadian health care.3 Engagement statistics provide evidence that what is being done on the management and leadership front to shift health care culture toward increased engagement is not working well. The Canada Human Resources Centre3 states that only about 25% of people are actively engaged at work. Management and leadership are consistently at the top of the list of complaints.4 Top
Changing the culture of teams so that they are emotionally engaged and take ownership of their work would seem to be a herculean task. There are no recognized therapists for dysfunctional health care teams as there are for dysfunctional families; instead health care organizations expect their leaders to know how to address these issues. However, this type of culture problem cannot be solved using the traditional command-and-control leadership style often seen in health care, but instead requires a major paradigm shift.5 This begins with an understanding of the difference between technical and adaptive problems.
Technical problems are those where cause and effect are understandable. Many problems in health care fall into this category, and solutions come in the form of best practice guidelines, evidence-based medicine, and the like.1 Traditional change management approaches can be successful in solving technical problems.
Adaptive challenges are those where cause and effect do not apply.1,5 An example is ensuring optimal patient flow through the ED. Teams must come to a common understanding of their current state and adapt their behaviour to achieve a new state, which is the definition of culture change. The solutions are not known at the outset, which means traditional change management approaches are less likely to be successful. Top
Culture-driven challenges are often characterized by a cycle of failure and a persistent dependence on authority. Understandably, leaders gravitate toward using technical solutions, especially those that have worked in the past, because they reduce uncertainty and are easier to apply.1,5 Practising adaptive leadership requires helping people navigate through a period of disturbance. This disequilibrium can catalyze conflict, frustration, avoidance, panic, confusion, and fear.6
The consequence of using command-and-control leadership practices to solve adaptive problems is what Chris Argyris6 calls “organizational traps.” Organizational traps arise when workers feel unable to speak their mind openly and without fear. When there is fear of reprisal, issues go underground and become undiscussable. The results include cultures with unhappy workers, dysfunctional teams, and disengagement. Many packaged, off-the-shelf products designed for enhancing team effectiveness focus on symptoms or by-products of undiscussables, rather than the undiscussables themselves. Top
The people connected to the problem must own it and do the work together so that solutions emerge.5 This requires leaders to abandon traditional command-and-control methods that demand fail-safe business plans with defined outcomes.1 Instead leaders must allow team members to experiment, to fail, and to try again. Leaders must learn to facilitate adaptation.4
Neuroscience7 teaches us that for adaptation to take place, the brain needs to create new neuropathways, rather than fighting against old, entrenched ones. The more we focus on the problems we have, the more ingrained we make them. Rather than trying to re-wire or deconstruct existing neuropathways, neuroscience suggests that we leave the problem wiring where it is, and focus wholly on creating new wiring. This is the essence of adaptation and culture change.4 Ensuring that the new way of working arises from the ideas of workers where the problem exists allows new neuropathways to emerge in their brains and creates adaptation.
Leaders are often promoted for their technical knowledge and decision-making capabilities.6 Thinking for others and solving problems have historically been core functions of leadership roles, with intrinsic and extrinsic rewards often validating this approach.4,5 The juxtaposition of traditional leadership behaviours (solving problems and making decisions for employees) and recent neuroscientific findings related to brain wiring and re-wiring illuminates many factors contributing to the disengagement and apathy that exists in health care, with direct application and relevance for leadership and management practices.4 Top
Methods
The ED culture work required a mixed methods design. The ED and KGH site leadership, with the help of an organizational effectiveness consultant (OEC) agreed to the method. (Figure 1)
The following steps in the process reflect actions, which include adaptations to the planned method based on findings that emerged as the work progressed.
- An Engagement Steering Committee was established to provide oversight, insight, and feedback on the process as each step unfolded. Its membership consisted of: one service director, the head of the Medical Department, the ED manager, a BC Nursing Union representative, and the OEC. The committee convened before and after each step to coordinate logistics, planning, adaptations to the process, and information sharing.
- 28% of the ED staff and physicians (n = 43) participated in confidential interviews. An additional 11 interviews were conducted with a representative sample of clinical stakeholders who interact with the ED. The purpose was to uncover the strengths, challenges, and issues potentially impacting the ED team’s effectiveness and culture. The themed data gathered from the interviews became the key content for a customized engagement survey. Clinical stakeholder summary themes were also shared in step 3 (focus groups). Early engagement with medical staff was a key to the project’s success.
- A customized engagement survey was designed to measure the specific themes that emerged from the confidential interviews. The 63-question survey was used to gather qualitative and quantitative data to develop a baseline measure of the culture. The summary themes reflected in the various comments sections provided context and specificity to help illuminate the quantitative results. The results were tabulated and presented in chart and graph format by ED role and an all-roles combined report. A 72% response rate for the survey was achieved.
- The survey results were shared in seven facilitated focus groups, which included 51 participants. Each group prioritized the issues to be worked on and developed proposed solutions for the highest priorities. After the focus groups were finished, the data were analyzed to integrate the priorities and proposed solutions into one ED action plan. Six out of the seven key priorities identified were within the ED’s scope to influence and improve.
- An ED Liaison Committee — consisting of the ED manager, representative site leadership, and the ED department head — and an ED Engagement/Quality Working Group that included physicians were established to support the ongoing work of implementing the action plan. A re-survey was completed at the 16-month mark after the initial survey. The participation rate was 48% for the ED, with 60% of the physicians completing both the baseline and re-survey. This completion rate for physicians is atypical and signifies that the process of engagement was also atypical and effective.
The qualitative and quantitative data gathered showed that significant positive changes had taken place. Figure 2 highlights the areas of most significant improvement for physicians.
Figure 3 highlights the most significant improvements for nurses.
Actions
Although many changes took place, the following actions are believed to have had the most significant impact.
- Daily participation by the ED manager in interdisciplinary team huddles
- Staff huddle board/communication boards created
- Front-line led working groups established
- Development of standard work and communication processes
- At triage, physician included with a triage nurse to improve timeliness of patient access to services
Every day, the ED manager would be physically present to hear concerns from the front line, face-to-face, much like a Gemba Walk used in LEAN methodology. On the staff huddle board, staff could post improvement ideas, and progress on their suggestions was monitored and presented weekly. This proved to be better attended and more effective than the typical department staff meeting. This simple change allowed all staff to feel their voices were heard and to begin to trust that management was taking their concerns seriously. Having one’s voice heard, understood, and acted on when appropriate is recognized as a powerful engagement strategy. Physicians and front-line workers were supported in their suggestions for improvement. Top
The addition of front-line team leads to each discipline in the ED was proposed and supported. It allowed for improved communication between the disciplines and patient care coordinators and had the added benefit of improving succession planning.
Improved one-to-one engagement of management with their staff in the form of performance feedback and reviews allowed each staff member to communicate to their manager their purpose and interest in ED work, thus increasing engagement and ownership of the delivery of safe and effective quality care.
Discussion
Organizational and team cultures are layered and complex living organisms.1 In many regards, getting to the root causes of team ineffectiveness is like peeling back the layers of an onion. Focusing on the “above ground” issues alone would not have resulted in the transformational results evidenced in the re-survey data. In this instance, more significant engagement of the KGH site leadership was a key adaptation to the process, once an understanding of the key issues and challenges surfaced through the interviews. Leadership awareness and support is critical for addressing various bottlenecks and improvements, and ED leadership participation in key ED engagement meetings became a strategic lever for realizing improvements over time. Those involved included site leaders, managers, physician leads, and charge nurses. Top
Although the issues and outcomes are specific to this ED, the process and method are relevant and applicable to all sorts of teams experiencing ineffectiveness, conflict, lack of cohesion, mergers, acquisitions, and other significant changes.
The changes that took place within the Emergency Department over the course of a year are correlational, not causational. Other factors and influences in the system may have contributed to and/or caused these significant changes to occur. However, by devoting time and attention to the issues at hand and by providing support for the process to surface and generate the root causes and solutions, the conditions were primed for positive change.6 Top
Copious amounts of literature and theories exist surrounding the topic of organizational culture and culture transformation. What appears to be missing is the roadmap for facilitating such change. External cultural change agents are advantageous to build the trust that must pre-exist before the surfacing of undiscussables can begin. Once the below-the-surface issues are being discussed, the team can address them and collectively work through the associated emotions to develop solutions.
Conclusions
Culture is the way business is done in any organization. It is predictable that, when an organization goes through any type of change, the culture will be affected.
Organizational culture determines and limits strategy8; this is evident when significant changes are introduced or take place. Although there is no one magic bullet, leaders who can anticipate and prepare for significant changes to culture processes will have the advantage of developing more adaptable, collaborative, and resilient teams. Top
When the culture of an organization gets in the way of its mission, a well-defined, albeit arduous, process can be implemented to uncover the undiscussables and allow those involved to advance relevant and sustainable solutions.
This case study highlights a method leaders can use to uncover staff barriers when needing to implement change and impact workplace culture. Top
References
1.Heifetz R, Grashow A, Linsky M. The practice of adaptive leadership: tools and tactics for changing your organization and the world. Boston: Harvard Business Press; 2009.
2.Sawka C, Ross J, Srigley J, Irish J. The crucial role of clinician engagement in system-wide quality improvement: the Cancer Care Ontario experience. Healthc Q 2012;15(special):38-41. doi:10.12927/hcq.2012.23157.
3.Employee engagement. Toronto: Canada Human Resources Centre; 2017. https://tinyurl.com/l923bjh
4.Dickens P. Facilitating emergent change in a healthcare setting. Healthc Manage Forum 2013;26(3):116-20. doi:10.1016/j.hcmf.2013.05.003.
5.Snowden D, Boone M. A leader’s framework for decision making. Harv Bus Rev 2007;Nov.
6.Argyris C. Overcoming organizational defenses. Facilitating organizational learning. Boston: Allyn and Bacon; 1990.
7.Rock D. Your brain at work. Toronto: HarperBusiness; 2009.
8.Schein E. Organizational culture and leadership (4th ed.). San Francisco: Jossey-Bass. 2010. Top
Author attestation
Demetri Karogiannis and John Cabral are the lead authors and contributed substantially to leading the changes noted in the study and article preparation. Doreen Perschon was the process facilitator for the changes noted in the study and contributed substantially to preparation of the article. Devin Harris was instrumental in leading the changes noted in the study. Laura Calhoun contributed the literature review and article preparation. All authors approved the final version of the article.
Authors
Demetri Karogiannis is manager, Emergency Services, Kelowna General Hospital, Interior Health.
John Cabral is health service director, Emergency and Ambulatory Care, Interior Health.
Devin Harris, MD, is executive medical director, Quality and Patient Safety, Interior Health.
Doreen Perschon, MA, is a principle with En-Gauge Consulting.
Laura L. Calhoun MD, FRCPC, MAL(H), CEC, practises psychiatry and has a role as a physician leader in Alberta Health Services.
Correspondence to:
This article has been peer reviewed.