Monday, December 5, 2011

How Will We Reach The Tipping Point in Changing Hospital Culture?

A friend and fellow healthcare leader sent me a email indicating his frustration with the "group-think" culture of leadership:

"Executive meetings of large corporations have people who have shared values and assumptions, who play a positive and necessary role in holding that group together. But when a team of senior managers suffer from collective denial and self-deception – when they can’t unearth and question their shared assumptions - they can’t innovate or make course corrections effectively. That often leads to business and ethical disasters ..."
He questioned what we could apply from Malcolm Gladwell's Tipping Point theory about how to change social culture. This theory holds that culture is "epidemic" and is sustained through "transmission" from one agent to another. Also like epidemics, it can go along at a steady state until a "tipping point" is reached which destabilizes the equilibrium. This can occur both for what we may consider "positive" or "negative" social behavior.

It occurs to me that the tipping point is a great paradigm for understanding the microcosm of an individual institution's culture. The "culture of an institution" is the collective representation of its staff, managers, leaders, as well as its clients and customers. If the institution is overrun by "nay-sayers", "defenders of the status quo", "managers by repression", the culture will be mirrored as the same. However, culture can change if a few individuals start emulating the behavior that they believe the institution needs to aspire to, ensuring that they are the positive "role models" for the change that they are espousing, and start building towards the "tipping point" by assimilating other like-minded individuals, and infecting as many others as they can.

The concept of the "critical number" to get to a tipping point can help these change agents to target a critical mass that they have to build their "culture change movement" to in order to get the culture of their institution to tip. I'm not aware of data to support what this number needs to be for "institutional culture change", and certainly there are many factors that would influence such a "number", including size of the organization, roles of people involved, depth of culture change required, etc. However, based on my experience with leading culture change at small to medium-sized healthcare organizations, 25 appears "intuitively"to be the number to target. If one can get 25 leaders, managers, staff, and physicians involved in the movement, the culture is quite likely to "tip" in favor of the change agents.

Another concept fundamental to Gladwell's tipping point is the "non-linear" nature of social phenomena: "There is no steady decline: a little change has a huge effect." There may be no output related to change activities for a prolonged period of time and/or effort, and then a little change could produce a dramatic result.

The concept of "non-linear social phenomena" is not very dissimilar from what Jim Collins referred to in "Good to Great" when he discussed "the flywheel effect". In organizations that he studied that went from being average to significantly outperforming their counterparts, there was a collective effort of "shoulders to the flywheel". There was no magic moment that suddenly led the average companies to take off, and all turns of the flywheel did not produce the same output; but consistent, cumulative efforts at turning the flywheel at some point led to dramatic results.

Perhaps further research will elucidate what the "critical number" may be at which organizational culture change "tips", however, healthcare leaders would be wise to recognize the "epidemic" nature of change, the concept of "critical mass", how "non-linear social phenomena" work, and bring all of these to bear in revolutionizing their organizations.

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