Episode 2, Culture of Improvement and Safety, Models for Creating More Effective Organizations. In moving towards an understanding of organizational culture in relationship to quality improvement, as we noted in the prior episode, a culture of quality creates and maintains core beliefs, core values, attitudes, and actions that are deeply grounded in fostering quality and safety everyday, at every level, in every process, by everyone in the organization. It is also important to revisit the concept of adjust culture, which is a critical component of a culture of quality. Consistent with these principles, the Agency for Healthcare Research and Qualities, patient safety, network summarize some of the key features of a culture of safety. These include, first, acknowledgement of the high risk nature of an organization's activities, and the determination to achieve consistently safe operations. Secondly, a blame free environment, where individuals are able to report errors, or near misses, without fear of reprimand or punishment. Thirdly, encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems. And fourth, organizational commitment of resources to address patient safety concerns. To integrate these concepts with work on organizational excellence, we will briefly discuss the work of Peter Senge, founder of the Society for Organizational Learning. Senge's work defines what it takes for an organization to be excellent, and to sustain a competitive edge. The first, and perhaps most important factor, is for an organization to be able to continually learn and adapt to change. Senge knows that while culture can be defined as the way an organization does things, there are three levels of culture, including practices, values and unquestioned assumptions. Practices are really what can be observed, such as how do people dress, what the environment looks like, how people are greeted, and how they appear to be engaged in their work. Values are reflected in what we say and do within the organization. And finally, unquestioned assumptions are those assumptions that are so deeply and unquestionably held about the organization and how it works. Challenging unquestioned assumptions is perhaps where the biggest challenge in an organization can be made, because this is where significant organizational learning can actually take place. Learning is, in essence, about achieving something you could not have done before. An example of an unquestioned assumption for a healthcare organization may be that there's enough resources to become the best in the country. This assumption may be made for many reasons. But if one's challenged and brought to the light of day, work can be done to move towards being the best. In Senge's book, The Fifth Discipline, he identifies five disciplines that need to work together to create a learning organization that can continuously change in order to achieve its highest aspirations. The first discipline is personal mastery. It's described as the discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively. And second, mental models are really deeply ingrained of sumptuous or generalizations, or images that influence how we see the world and interact with it. Work with mental models starts with turning the mirror inward and recognizing the mental models that hold us back. Next, is building shared vision, this excites people that want to learn and excel when there was a genuine vision. This is not about building the vision around the charismatic leader, it's about creating pictures of the future that foster genuine enthusiasm throughout the organization. The next is team learning, which is about working in teams, and working in teams that get great results, and that grow from personal experience. Team Learning starts with dialog with team members, suspending assumptions and thinking together, allowing the group to have insights they would not have alone. It is essential to recognize patterns that undermine teamwork. It is vital that teams learn, because they are the fundamental unit of the organization, not the individual. And finally, systems thinking is a conceptual framework, a body of knowledge to help us see the full pattern of things, and not just snapshots that are linked to one particular area. Systems thinking is the integrator that allows the five disciplines to work together. Clearly, from what we have examined in health care in prior modules, Senge's work appears to be very applicable to health care organizations. We would encourage you to ready Senge's book, as revised in 2006. It's full of examples of change, and a very rich source of information and motivation. Since change and overcoming resistance to change, is one of the key factors in becoming a learning organization, it's instructive to examine the work of Kurt Lewin, who put forward a three stage change model in the 1950s. His model includes unfreezing certain behaviors and attitudes by creating the right environment, supporting the desire to change, and then refreezing those changes, in order to anchor and sustain the change. This model of change, while relatively easy to understand, can be very powerful in recognizing the need for transitions in human behaviors. In the unfreezing stage, people need to get to the point of understanding the need for change. The more urgent the need for change, the more likely the change will be adopted. Lewin proposed that the notion of a force field analysis, meaning that when forces for change outweigh the forces of resistance, change will happen. Another model of change is the results pyramid introduced by Tom Smith. Smith presents his model in the book Change the Culture, Change the Game. His model identifies three components of the pyramid, experience, beliefs, and actions that lead to results. These factors contribute to the way people think and act in an organization. In order to create a culture of, for instance quality, a leader will need to create experiences of quality culture that lead to beliefs that a quality culture is important. And then will lead actions, such as, engaging in quality improvement activities and getting the results, such as, improved processes and outcomes. A problem that leaders often have in changing the culture is they focus on the actions and the results part of the pyramid, without taking care of the experiences and beliefs. Another way to look at changes, John Kotter's 8-Step Model. This model combines a step, by step, by step approach to change with a focus on in preparing for and accepting change, not on the change itself. Kotter states that the reason's organization engage in change, is one, increase their revenue and profits, and two, to increase their effective and efficiency or both. Let's briefly review Kotter's eight steps. The first step is to create a sense of urgency. In doing this the leader has to connect with both the heads and hearts of their employees. Simply stating the facts is not going to engage a workforce. By the way, it's estimated that in general, about 70% of the workforce at any one period is pretty disengaged from what they are doing. The second step is to build a guiding coalition from within the ranks to coordinate and communicate the work being done and to be done. Kotter estimates that is about an 80% correlation between collaboration and innovation. The third step is to form a strategic vision and initiative. Companies with a well-stated missions have a 30% higher return on key indicators than those who do not. The fourth step is to enlist what you might call a volunteer army. In order to make a big change, you've gotta have large numbers of employees who are on board with the change to have it happen. The fifth step is to enable action by removing barriers. This is about creating an environment where people can implement change and are not stymied by burdensome and processes, or hierarchical decision making. The sixth step is to generate short term wins. Kotter believes that wins are the molecules of results, wins should be identified, tracked, and communicated throughout the organization. Many small wins can actually lead and add up to large change. The seventh step is to sustain acceleration. This means that leaders must continue to move forward, adopting to outside and internal changes, in order to stay vibrant, to continue towards their goals, and fulfilling the mission. And finally, the eighth step is to institute the change. Employees need to have a clear awareness of the connection between changing behavior and the organization's success in fulfilling it's mission. There are many, many other models that describe change. The common themes among all of these models however, is that people have to be ready for change. They have to have organizational support to embrace it, and that big change, such as, creating a culture of quality, will take the buy in and work of virtually everyone in the organization. But the leaders need to lead, it is one thing to acknowledge change models and another thing to make change happen. In the next episode, we will talk about how leaders can create and overcome resistance to change.
