More than 15 years after To Err Is Human (1), our health care system has reached a crossroads. On the one hand, the importance of safety culture is widely recognized and acknowledged; on the other hand, we're still not making enough progress toward improving it.(2) Strengthening safety culture remains one of the greatest and most elusive challenges faced by health care organizations today. Achieving success requires understanding how culture changes and what actions can be taken to achieve those gains.
How Culture Changes
Colleagues and I explain culture change as an evolutionary cycle, involving enabling, enacting, and elaborating components.(3) Leaders, who may include frontline workers as well as policymakers and executives, enable culture by acting in ways that motivate pursuit of some outcome. What frontline workers observe these leaders do or say is often described as climate.(4) Workers interpret leaders' actions and enact culture by acting in ways that reflect their interpretation of the signals they have received. If leaders have enabled a safety-oriented culture, then workers' actions are more likely to reflect a safety orientation.(5) Workers then observe the outcome of their own and others' actions and select those worth extending. In doing so, they elaborate culture.
Several important insights emerge from this evolutionary conception of culture change. First, leaders' actions matter because they drive this cycle. Second, culture may benefit most from interventions that simultaneously or collectively seek to enable, enact, and elaborate culture. Third, enacting culture refers to performing work in ways that embody the desired culture, rather than working on culture itself. Fourth, interventions should fit and build on an existing culture. This latter insight may strike some as a revolutionary idea; it suggests that different organizations will benefit from different interventions and that off-the-shelf interventions are unlikely to work in many organizations. The fact that 70% of change initiatives are estimated to fail supports this theory.(6) How, then, can leaders act to achieve culture change?
What Actions Achieve Culture Change?
I recently had the good fortune to participate in a discussion with a state-based coalition of health care leaders (including consumer, state, hospital, professional, health plan, employer, policymaker, and research representatives) where I gained insight about how to answer this question. The group reviewed recent safety climate survey data from 16 hospitals in the state. Data were compared to the national average and broken down by dimension, staff role, and unit type. Meeting participants broke into groups to review and discuss the data, and then they reported back to the whole group additional information that would be helpful, insights they noticed, and what they thought the coalition and individual hospitals should do.
Several insights emerged. First, to deepen their understanding, they would need additional detail to understand, for example, residents' experience as distinct from practicing physicians and nurse practitioners, with which residents were currently grouped (residents, physicians, and nurse practitioners were in the same group). Additionally, there were concerns that response rates were low and that results for the state were drawn from only 16 hospitals. Participants also wanted to compare the findings presented to those from state-based hospitals using other culture surveys. While these insights and concerns are legitimate, they risk "analysis paralysis," particularly since the multiple demands on people's attention make it unlikely that leaders will address this agenda without becoming permanently derailed.
Even as the group yearned for more and better data, they did develop some thoughtful recommendations. The group proposed (i) to reach out to the hospital in the data set that had demonstrated the greatest improvement in order to identify opportunities to facilitate shared learning; (ii) to ask each hospital in the coalition to determine areas where they are proud of what they've accomplished and to make themselves available to other members for consultation; (iii) to develop one or more strategies targeting safety in the emergency and surgical environments specifically?areas in which the state's hospitals were below the national average. In addition, the group proposed to request that the survey firm provide more detailed information about differences in safety climate perceptions between attending physicians, nurse practitioners, and residents; to advocate for reducing the length of the survey to encourage higher response rates; and to conduct a qualitative investigation about why hospital environments in the state are so punitive. Notably, the group?s desire for more data was balanced with the intent to act on what they had already learned.
What then, based on the experience of this stakeholder coalition and my experience working in the field for about 20 years, does it take to achieve culture change?
Data based and action oriented. Having data to serve as the basis for motivating action and directing decision-making about how to pursue improvement is critical. However, as this coalition exemplifies, it is important to do something. Prior research has shown that, particularly where many actions would be beneficial, it is critical not to get stuck in deciding where to begin.(7) One could select a starting point based on data-derived evidence of need for improvement (8), as with the coalition's choice to develop interventions for the emergency and surgery departments. However, the presence of a champion (9), adequate expertise and financial resources for undertaking change (10), and the opportunity to build improvement capacity may also justify selecting an initial target for success.(11)
Tailored. By asking each hospital to contribute consultation based on its strengths and to seek assistance from others based on its perceived weaknesses, the coalition's proposed approach allowed interventions to be customized to meet the needs of each organization. Such an approach increases the likelihood of engaging participants because they can focus on work they perceive to be of high value, while continuing to benefit from motivation that derives from peer pressure driven by other organizations that have demonstrated that success is possible.
Collaborative. The coalition's approach recognized the importance of broad engagement in order to build on the strengths of all members. Their consultative approach is flexible, but requires everyone to participate in a leadership role while giving everyone the opportunity to benefit from learning to improve from others. Such an approach deepens ties and builds the mutual respect that serves as the basis for successful collaboration.(12)
Process oriented. By engaging members in efforts to develop strategies for improving safety in the emergency and surgery departments, the coalition recognized that culture change occurs through enhancing work processes. Such improvement benefits safety directly by fixing the root of the problems. It also benefits safety indirectly, by demonstrating the importance that the organization places on fixing the problems. Through efforts to improve processes, workers experience opportunities to enact the climate they perceive as desirable, and by observing and spreading successful efforts they can elaborate the culture even further.
Multifaceted and multi-level. The evolutionary model of culture implies that culture change doesn't happen through one big fix, but rather through a continuous cycle involving multiple small fixes. Differences in perceptions by hierarchical level attest to the need to involve stakeholders at all levels to foster shared vision and understanding. Sustained changes require teams to act locally, organizationally, and in collaboration with colleagues, as coalition members are proposing to do.
Strengthening culture is elusive because it isn't easy and because there is no standard recipe. Understanding how culture changes and what kind of actions are required to achieve culture change prepares health care leaders to help their organizations undertake the journey.
Sara J. Singer, MBA, PhD Professor Department of Health Policy and Management, Harvard T.H. Chan School of Public Health Department of Medicine, Harvard Medical School Mongan Institute for Health Policy, Massachusetts General Hospital
1. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System.Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
2. Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015. [Available at]
3. Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 2013;34:373-396. [go to PubMed]
4. Zohar D. A group-level model of safety climate: testing the effect of group climate on microaccidents in manufacturing jobs. J Appl Psychol. 2000;85:587-596. [go to PubMed]
5. Zohar D, Luria G. Climate as a social-cognitive construction of supervisory safety practices: scripts as proxy of behavior patterns. J Appl Psychol. 2004;89:322-333. [go to PubMed]
6. Beer M, Nohria N. Cracking the code of change. Harv Bus Rev. 2000;78:133-141,216. [go to PubMed]
7. Tucker AL, Singer SJ. The effectiveness of management-by-walking-around: a randomized field study. Prod Oper Manage. 2015;24:253-271. [Available at]
8. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q. 2001;79:429-457. [go to PubMed]
9. Schon DA. Champions for radical new inventions. Harv Bus Rev. 1963;41:77-86.
10. Lee SYD, Weiner BJ, Harrison MI, Belden CM. Organizational transformation: a systematic review of empirical research in health care and other industries. Med Care Res Rev. 2013;70:115-142. [go to PubMed]
11. Tucker AL. An empirical study of system improvement by frontline employees in hospital units. Manuf Serv Oper Manage. 2007;9:492-505.
12. Fragale AR, Overbeck JR, Neale MA. Resources versus respect: social judgments based on targets' power and status positions. J Exp Soc Psychol. 2011;47:767-775. [Available at]