Performance Improvement Tip of the Day: Culture Drives Performance

The culture of an organization determines behavior, decision-making, and ultimately outcomes. It is "baked into the design" of every (clinical) process. Therefore, in order to improve outcomes, one must understand and shape culture. This requires intricate analysis, leadership support, and a broad enough span of time to accomplish the changes required.

Within the context of most performance improvement projects, we generally think about operating "within the cultural paradigm" of the institution, otherwise many targeted interventions may get rejected by the organization.

However, in order to achieve "breakthrough performance", the organization's culture has to be changed as it is in large part the culture that is constraining outcomes. Thus, performance improvement specialists have to be adept at gauging what "cultural change" they can successfully advocate for and implement within the course of their projects in order to lead the organization to higher-level performance.

"Culture" makes its presence felt in many subtle ways. Even in the "simple" case of implementing order sets, the following are variants of interventions that can be implemented based upon "what the organization's culture is ready to handle":

• use of order sets 
• mandating use of order sets 
• implementation of "opt out" orders 
• use of nurse or therapist-driven protocols 
• pharmacist or nurse "pulling the chain" to stop the process for any unclear orders

This blog from Ron Ashkenas on HBR Blog Network presents a nice, concise analysis of culture, its impact on performance, and a few tips on how to assess culture:

"Any management team can assess its culture by asking these kinds of simple questions across a range of organizational behaviors. For example: To what extent do we reward individual vs. team results? To what extent do we share information broadly or parcel it out narrowly? To what extent do we encourage or discourage risk?"