Culture Eats Strategy For Breakfast: Five Fundamental Beliefs to Facilitate Change

Culture Eats Strategy For Breakfast: Five Fundamental Beliefs to Facilitate Change

By Kara Benedict, Director, Risk and Compliance, Covenant Care

Kara Benedict_Director Critical ServicesThe words “risk management,” as I knew it when I was a brand new nurse, immediately brought this image to my mind:  Some old lady with reading glasses, gray hair in a tight bun, and really bad shoes, appears from “upstairs in management.”  She then “sequesters” the record, announces that she will be interviewing all staff, and she drifts back out of the unit, bad shoes and all.

The scenario I described above was cloaked in secrecy and usually ended with someone being blamed and often getting fired.  As a coordinator in Emergency Medicine, I often verbalized my frustration regarding how unfair it was that healthcare providers were faulted for mistakes that were usually out of their control.  “How can we point at one person and say it is that person’s fault this went sideways?  It’s not that simple!”

Fast forward seven years, when I moved into performance improvement in Trauma.  As I began to learn how to improve human and system performance, I came across a piece of literature that changed my life.  “To Err is Human,” a consensus study from the Institute of Medicine published in 2002, told us how to build a safer healthcare system by looking at the system rather than individual performance.  This publication set forth a national agenda to improve healthcare, not by continuing to focus on the prevention of human error, but by changing the system so mistakes are harder to make.

Angels were singing! It was like everything I had ever thought about medical errors and those who commit them, but I could never really articulate it.  And right there in front of me was what I had been thinking and saying for years, and there was actual RESEARCH to back it up!  I began to search and read everything I could about this new concept.

Fast forward another eight years, and the movement has continued to gain momentum in healthcare.  Here is what I know with more confidence than anything in my professional career:  risk management and patient safety come down to organizational culture.  I’ve said it many times but it bears repeating again.  Culture eats strategy for breakfast.  Every.  Single.  Time.

I can strategize and plan great things, but if I want to reduce risk, I have to make certain I establish the right culture before I attempt to change anything else.  How do I do that?  Well, it starts and ends with my beliefs as a leader.  What is it they say?  If you want to change your life, you must first be willing to change your thoughts.

In order to drive a culture of safety, every leader should fundamentally believe these five things:

  1. People are inherently good and want to do the right thing.

If you do not believe this, you really shouldn’t even be a leader. Most people care and want to perform well.  Some people want to be great, and some are content with getting by, but studies show that most employees want to get it right.

  1. Good and bad employees make mistakes, and making an error in judgment doesn’t make someone stupid, lazy, or indifferent. It makes them human.

I’ve always said, “I hope people don’t judge me by my mistakes, because I would have been fired from every job I ever had.”  Normal human reaction when things go wrong is to chalk it up to something that we feel can be controlled immediately.  If the one who messed up is to blame, I can fix this problem by removing them from the equation.

If you think that works, you are dead wrong.  Studies show that only about 5% of your employees actually need to be removed.  The majority of failures are actually caused by latent system problems that go undetected because, wait for it ….. People are afraid to report mistakes or near misses for fear of punishment.

  1. I should always be asking questions to understand, rather than judge.

If my goal is to seek understanding rather than be judgmental, everything I say will be driven by compassion, kindness and empathy.  Genuine consideration builds trust, and trust is key to creating a safe environment.  If I have already made a judgement (and determined they are somehow incompetent and to blame), my attitude will be arrogant, harsh and condescending.  Even if I think I am not being any of those things, my internal beliefs will influence how I am perceived.  I can deliver a message gently, but if my underlying beliefs are judgmental, the employee will know, and I will drive people to hide mistakes rather than help fix them.

  1. There are three types of behaviors, and as a leader, I must differentiate between them clearly when something goes wrong.
  • Human error is simply that.  It’s a lapse in judgment, a slip-up or a mistake.  In this scenario you should be consoling the person and trying to think of way to prevent others from making the same mistake.
  • Risky behavior is where people know the risk and, for whatever reason, they do not acknowledge or understand it.  Think of this as cutting corners.  We all cut corners at some point or another, so we as leaders have to keep asking “why is this happening?” We have to figure out how to incentivize the right behavior and draw clear lines.
  • Reckless behavior is just that.  It’s a reckless disregard for the known danger.  This is typically less than 5% of the errors we see in healthcare, but if found, should be dealt with swiftly and firmly.
  1. Accountability is a series of thoughtful, consistent and fair decisions made over time by leaders who strive for continual improvement.

The outcome of an event should never dictate the response.  If employees are not following the rules, we shouldn’t wait until something goes wrong to take action.  If we do, people associate being caught as what defines “accountability.”

Let’s use medication errors as an example.  What if we only investigate and respond to a medication event if there is a negative patient outcome?  What if patients have gotten the wrong medicine hundreds of times?  Think of all the missed opportunities for improvement!  We either follow the protocols or we don’t, but we cannot wait for an untoward event before we decide to hold people accountable.

As leaders, it’s our job to draw the lines between acceptable and unacceptable behavior, and it is up to us to adapt and move the line if we determine the expectation is unrealistic.  But make no mistake, once I draw that line, if I do not hold everyone to it, my credibility is at stake and my team will never reach their full potential under my leadership.