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What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety

Sara J. Singer, MBA, PhD | September 1, 2013 
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Lives depend on the ability of health care leaders to enable practitioners to work together effectively and manage the increasingly complex systems in which care is delivered. To accomplish these aims, leaders must understand and transform organizational culture—the system of shared values, attitudes, and norms in an organization. Research suggests six principles for guiding these efforts.

Contemplate culture. Books and articles attesting to the importance of patient safety culture in health care are now plentiful. They describe four important elements of a culture of safety: psychological safety (members feel safe to take interpersonal risks [1]); learning orientation (members emphasize learning from experience and from others, especially when errors occur [2]); systems orientation (members recognize that people and processes are connected through systems that require fool-proofing and careful risk management [3]); and clinical and non-clinical safety leadership that enables the other three elements. Books and buzzwords provide an important starting point, but they are incomplete.

Establishing a strong culture of safety and learning requires deep engagement with the unique overall culture of a given organization and its subunits. Leaders must carefully assess the current culture, especially the unspoken assumptions that guide people's behavior. Only then can they discuss the type of culture its members would prefer and how to move there given the current state. Conversations around vision, mission, and goals are essential for developing a shared sense of direction.

Embrace leadership. Who can lead? Everyone. Leadership is an action, not a job description. Physicians, whether they like it or not, are viewed as captains of the team (4), so have a de facto leadership role. As such, physicians' words and deeds take on disproportionate importance as others seek cues to determine desirable behavior.(5) This means that small actions can have major consequences and present big opportunities. A word of thanks or encouragement from a physician can make a lasting impression. A story about one's mistakes gives others permission to acknowledge their own vulnerabilities and creates psychological safety.

Creating a culture of safety requires leading differently. Aspiring leaders need to abandon the image of the self-reliant, heroic leader in favor of a shared leadership model characterized by humility and partnership. Humility means a leader does not presume to have the answer, but rather strives to ask questions that elicit ideas and participation, engendering consensus and commitment to the execution of a shared plan. In other words, leaders should enlist and motivate others and guide a process of collaborative learning through cycles of preparation, trial, reflection, and trying again. Evidence suggests this process is effective for leading organizational change.(6) It also models a learning orientation for organizational members. In contrast, health care leaders can undermine their ability to affect lasting change and create a learning orientation by focusing on just getting the job done and viewing themselves as capable of working in isolation.

Leading through partnership means understanding that no amount of time, interest, information, and skill is enough for affecting complex change alone, even if someone is truly passionate. Leaders need others to form a guiding coalition with access to information, resources, complementary skills, and formal and informal networks necessary for building consensus.(7) They also need to empower others to act in order for change to become widespread.

Focus on problems. A common complaint among health care professionals is that there is "never enough time to work on culture." However, culture can often be changed as an outgrowth of effectively tackling specific problems. Culture change requires profound transformation in the way people in organizations think and feel. Culture change inevitably occurs slowly, through cycles of action and interpretation.(8) Problem solving gives action focus and motivation, while achieving observable results. A focus on problem solving also reinforces the learning orientation that is core to a culture of safety while building problem-solving capacity. For example, getting practitioners to use information technology is a critical, technical challenge. Overcoming challenges associated with getting practitioners to achieve "meaningful use" of information systems necessitates addressing issues (e.g., willingness to use decision support or share information across settings) that will ultimately impact organizational culture.

Align systems and processes. Inertia is a powerful force. Tradition causes people to revert to old norms, like teeth after braces. To make change stick, critical organizational processes must support and reinforce desired behaviors.(9) Budgeting, hiring, performance management, and monitoring and control processes all signal the kinds of behavior the organization supports and rewards. Systems and processes are often the responsibility of managers, but frontline clinicians can also play a critical role by identifying inconsistencies between systems and culture. In addition, anyone can promote systems thinking through language, for example, by using words like accident or failure instead of error, and examination or study instead of investigation.(10)

Relish resistance. Clinicians cringe when people describe them as resistant. Often considered "the problem," resistance may be more productively and accurately viewed as the key to potential solutions. If one believes that health care professionals want to do what's best for patients, then one can approach resistance with genuine curiosity and as a source for learning. Where does resistance come from? We all have beliefs, assumptions, and values that shape the way we select and interpret data.(3) As a result, the conclusions we draw, given a fixed set of data, can differ. This suggests that understanding the rationale for someone else's conclusions can reveal opportunities for improvement that may not have been evident from a different perspective.

Count on coaching. Leaders can help promote a learning-oriented culture by providing coaching to clinicians. Effective coaching requires respectful interaction that guides (rather than tells or criticizes) and fosters learning through self-reflection.(11) Coaching can also help internalize organizational goals when it balances advocacy (stating an observation) and inquiry (genuinely probing the rationale).(12) For example, "I noticed that you didn't follow a guideline our group has established, can you help me understand why?" may lead to insights about how guidelines need to change to better support patient care.

In summary, research suggests a number of concrete actions that leaders can take to help promote cultural change to improve patient safety. These actions include: understanding an organization's existing culture, acting humbly and as a partner, developing psychological safety through coaching and constructively leveraging resistance, creating a learning orientation by focusing on problems and problem solving, and embracing a systems orientation by carefully constructing and aligning supportive systems and processes.

Sara J. Singer, MBA, PhDAssociate Professor, Department of Health Policy and Management, Harvard School of Public HealthAssistant Professor, Department of Medicine, Harvard Medical SchoolAssistant in Health Policy, Mongan Institute for Health Policy, Massachusetts General Hospital



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9. Kotter J, Cohen DS. The Heart of Change: Real Life Stories of How People Change Their Organizations. Boston, MA: Harvard Business Press; 2002. ISBN: 9781578512546.

10. Edmondson AC, Roberto MA, Tucker AL. Children's Hospital and Clinics. Cambridge, MA: Harvard Business School; 2005. HBS Case #9-302-050.

11. Knight J. Instructional Coaching: A Partnership Approach to Improving Instruction. Thousand Oaks, CA: Corwin Press; 2007. IBSN: 9781412927246.

12. Argyris C, Putnam R, Smith DM. Action science. San Francisco: Jossey-Bass Publishers; 1985. ISBN: 9780875896656.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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