Leading culture change in health care.

1. Culture, Leadership & Performance: On Leading Change in Health Care
William P. Macaux, Ph.D. MBA
What causes people to identify with and form an emotional attachment to an organization? Many
would say culture. And what is it that motivates people to persevere in a common cause or
mission? Values of course, especially when they are understood, shared by, and reflected in their
leaders. This article examines the role of leadership in culture change, the kinds of change
needed to promote reform in our health care system
Culture
"Organizational learning, development and planned change cannot be understood
without considering culture as a primary source of resistance to change." Edgar Schein
Why should top management care about culture? Because culture makes a difference in
performance. Studies indicate that 50% of mergers fail to achieve the benefits that were used to
justify them, and 60% of Six Sigma projects fail to realize their goals. Much of this is thought to
be attributable to the psychosocial variables that are shaped by culture.
Nowhere has organizational culture become more cited as a critical factor than in health care.
Consider the phenomenon of "disruptive behavior," which has been carefully analyzed in a
recent whitepaper by Pascal Metrics (2011). We know that reform initiatives affecting quality,
safety, patient experience, and cost demand change in how work is done. But how easy would it
be to realize a coordinated course of change with these kinds of behaviors prevailing?
Disruptive Behavior Questionnaire Domains and Items*
Domains Behavioral Description
Divisive Behavior 1. Intentionally excludes others from the group
2. Talks about people behind their backs
3. Treats new people harshly
Intimidating Behavior 4. Sets others up to fail
5. Bullies other people
6. Tries to publically humiliate others
Disrespectful Behavior 7. Yells at other people
8. Turns their backs before a conversation is over
9. Hangs up the phone before a conversation is over
Inhibiting Behavior 10. Violates HIPAA
11. Uses a personal phone in ways that interfere with work
12. Fails to respond to phone calls, pages, and/or requests
Offensive Behavior 13. Touches people in overtly sexual ways
14. Makes comments with sexual, racial, religious or ethnic slurs
15. Shows physical aggression (e.g. grabbing, throwing, hitting, pushing)
*Pascal Metrics Inc. (www.pascalmetrics.com/doc/PascalMetrics_DisruptiveBehavior_WhitePaper_v1.0.pdf), 2011.
Pascal summarizes research on the adverse effects of disruptive behavior: It is associated with
medical errors, lower patient satisfaction, poor teamwork, and increased staff turnover.
Unsurprisingly, it is also thought to reduce the effectiveness of electronic health records. Health
care system leaders know this and still disruptive behavior continues to be prevalent in health
care settings. Why?
1
© Generativity LLC

2. There appears to be no lack of "hard" business reasons to justify culture change, and they are not
the only kinds of reasons that matter. Patients and their families present in a state of vulnerability
with expectations of getting the best care possible. When organizational culture impairs our
ability to meet those expectations, most would agree there is a moral imperative at stake. We are
letting them down!
Nor are we lacking calls to action or proven methods and practices for improving quality, safety,
and the rest. Still, the adoption and spread of these improvements is slow, which leads to great
variability in care between health systems and within the operating units of a single health
system.
Most would agree that what underlies these problems goes beyond financial, technical, or
managerial constraints alone. Ultimately, it is a question of leadership, the right kind of
leadership, and perhaps having enough leaders. I believe that is what John Kotter might
conclude.
This occurred to me as I reread his classic HBR article, What Leaders Really Do (1990). His
views seem as relevant today as they did then: "What leaders really do is prepare organizations
for change and help them cope as they struggle through it."
Leadership
"No one yet has figured out how to manage people effectively into battle; they
must be led." John Kotter
Management and leadership are complementary "systems of action," according to Kotter. The
former serves to bring order and consistency to performance. It formulates plans and goals,
organizes roles and resources for execution, and controls performance to ensure realization of
plans within budget. Most would agree that management of this kind is critical wherever quality
and safety are issues.
Leadership sets direction, a vision for a future state; not some mystical long-term destination, but
an end state that meets the needs for reform. It identifies needs for change and formulates
strategies for making changes. While management focuses on organizing, leadership seeks to
align, inspire, and empower people. They are complementary; good management is a practical
reality check on leadership.
Like leading organizational psychologists (Czander, 1993; Schein, 1992; Boyatzis & McKee,
2005), Kotter believed that leading culture change requires tapping into peoples' feelings,
helping them find their own reasons (values) for caring about change. Only with this kind of
leadership, and in sufficient numbers, will an organization be able to sustain their change efforts
in the face of the inevitable obstacles that arise along the way.
Of the functions that leaders perform (setting direction, aligning people, motivating action),
perhaps setting direction is the most practiced. In a recent review of health care improvement
initiatives, Perla, Bradbury, and Gunther-Murphy (2011) observed: "The movement to improve
the quality of healthcare does not lack established interventions, powerful ideas, and examples of
2
© Generativity LLC

3. success and breakthrough results. Uptake of these advances, however, is limited uneven and
slow."
What, then, is the kind of leadership we need in order to address these issues? How does the
legacy culture restrain change? What kind of critical mass of energy and effort is required to spur
action and ensure an increased pace of adoption and spread throughout the organization?
Building the leadership capacity and culture of an organization begins at the top. There are
important things that senior management can do, and then there are also ways in which they need
to get out of the way after doing them in order to empower next-generation leaders throughout
the organization. Here are some simple suggestions for how senior leadership can make a
difference:
1. Identify and engage a larger number of high-potential leaders earlier. It is your job to spot
them, and they should be representative of all levels and all departments.
2. Involve these leaders in the direction-setting task, i.e. analyzing data, targeting
opportunities for improvement, and creating a vision of an alternative future and
strategies for change.
3. Promote informal communications networks among leaders through which relationships
develop that can support alignment checking and coordination of action.
4. Get to know your people and encourage them to get to know one another, their
interdependencies, as well as what drives them, i.e. interests, experience, values, and
motivations.
5. Use what you learn about one another: appeal to shared values, recognize progress,
encourage others when times are tough, and build a sense of cohesion.
6. Rely on encouragement rather than control, include rather than exclude, offer feedback
rather than criticism, and surface issues early rather than letting them fester.
There are individual and group development methods that can be tailored to the organization and
help foster this relational pattern of interaction among the growing cadre of leaders. As this
group of leaders develops (forming/storming/norming/performing), authentic cultural norms,
which promote positive change, will also quite naturally emerge. Not only do these leaders
acquire accountabilities for these norms, they also cultivate an even deeper, person-based sense
of responsibility for them.
This course of action by senior leadership prepares the organization for change. Helping them
cope as they struggle through the change process then becomes an ongoing priority. Part of that
struggle consists in breaking old habits associated with the legacy culture, whose purpose may
have been to restrict and control with hierarchy and closed departmental boundaries. If the new
culture is to empower leadership and initiative at all levels more open boundaries and delegation
of authority will be needed.
Performance & Development
To summarize, there are reasons for management to care about culture and culture change.
Indeed, it is inconceivable that any health system could navigate the challenges of reform absent
3
© Generativity LLC

4. significant culture change. The business of culture change concerns leadership more than
management, hence successful health systems will need to build a bigger more able group of
leader-managers. Performance will depend upon development, adaptive development.
I have written elsewhere about the challenge-development curve. Increasing levels of challenge,
like those associated with stretch assignments or organizational culture change, stimulate
learning and development up to a point (b) beyond which further increases in challenge
overwhelm us (b-c).
This curvilinear relationship between level of challenge and gains in development (a-b-c) is
moderated by access to resources: expert advice, stakeholder feedback; group problem solving;
and mentoring. These effects are represented in the green line b-d, which leads to adaptive
change.
The effect of moderators is mediated by other, person-based factors: a practiced capacity for
reflection; openness to self-examination and personal change; and an ability to communicate
openly and repair ruptures in relationships.
Keep this graphic image of adaptive change in mind. Recall Kotter's definition of leadership:
"What leaders really do is prepare organizations for change and help them cope as they struggle
through it." Now let's consider a few practical design features (how-to's) that senior management
might wish to incorporate in their approach to leader development and culture change.
First, preparing for change and coping with the struggle is largely about effectively addressing
what I have called moderating and mediating variables in the challenge-development curve.
Moderating variables provide "scaffolding," they consist of resources that enable people to
stretch out of their zone of current competence and try new ways of doing things. Mediating
variables (openness to feedback), catalyze the effect of moderating variables (stakeholder
feedback).
4
© Generativity LLC

5. Second, we know that transfer of learning is a critical factor in development. That is why action
learning is the design of choice. Each future leader applies his/her learning directly to a
strategically important project. All projects are vetted by management to ensure relevance. What
facilitates learning is a combination of peer interaction, group-based learning modules, and
facilitated reflection to deepen insight into the psychosocial factors essential to leading culture
change.
Third, a fundamental principle that is reinforced throughout the action learning leader
development program is systemic attribution of cause. As Don Berwick of IHI is wont to say,
systems are perfectly designed to deliver the results they are currently delivering. There is
seldom a simple division of good guys and bad guys, know-it-alls and know-nothings. We all
play a role in the system that generates our current problems, so let's focus on what needs to
change not on blaming one another.
Fourth, culture change via action learning is a practical, trial-and-error process. Therefore, we
must inoculate against setbacks by properly framing expectations. Sometimes we will get it
right very quickly. Other times we may repeatedly fail. Winston Churchill said, "The secret to
success is learning how to go from failure to failure without loss of enthusiasm."
Finally, communication must be a key theme for development. You only need to consider the
examples of disruptive behavior mentioned above to appreciate how verbal and nonverbal
communications can hinder progress. Beyond that, it is helpful to distinguish between
communication for understanding and communication for influence. Unless the former precedes
that latter people can feel disrespected and change can feel manipulative.
Conclusion
Nothing in this brief article should surprise the average health care executive. However,
intellectual awareness is not the point. We must ultimately recognize what keeps us from
advancing and dealing with culture change. Most often it is not mere practical matters alone
(money, skill, time, etc.). Our readiness to act on our awareness of problems and needs for
change is more frequently driven by feelings of fear and uncertainty, a lack of how-to
knowledge, or concerns about having a leadership team equal to the task.
The way we disarm any of these inhibitions is to face them directly. Pascal Metrics has not only
written a whitepaper on disruptive behavior, they have developed and validated a tool for
measuring this important and problematic aspect of culture. Consider using it as one pathway
into culture change. Setting direction requires data, information, analysis, insights, and ideas.
And by all means, involve others in the process. If you have not done a very good job of
identifying high-potential leaders, work on that first.
If you need help from experts who have worked with other senior leadership teams on these
matters, then seek it out. This is not something you can or should delegate to your head of human
resources. Building leadership capacity and navigating culture change are in the wheelhouse of
top management; they are matters of governance and fiduciary duty. Delegating the things you
find most daunting or least ready for is usually not the answer.
5
© Generativity LLC

6. If you have specific questions on how to apply the ideas presented here in your company, please
contact the author at bill.macaux@generativityllc.com.
Bill Macaux, Ph.D. MBA
Principal & Consulting Psychologist
Generativity LLC
Helping executives unleash their potential to lead and make a difference
References
Boyatzis, Richard and McKee, Annie (2005). Resonant leadership. Boston: Harvard Business
Czander, William M. (1993). The psychodynamics of work and organizations: Theory and
applications. New York: Guilford Press.
Kotter, John P. (2001). What leaders really do. Harvard Business Review, 85-96.
Pascal Metrics, Inc. (2011). Measuring disruptive behavior: The disruptive behavior
Questionnaire (www.pascalmetrics.com).
Perla, R. J., Bradbury, E. and Gunther-Murphy, C. (2011), Large-scale improvement initiatives
in healthcare: A scan of the literature. Journal for Healthcare Quality. doi: 10.1111/j.1945-
1474.2011.00164.x.
Schein, Edgar H. (1992). Organization culture and leadership, 2nd ed. San Francisco: Jossey-
Bass Publishing.
6
© Generativity LLC