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.

No Ego in Performance Improvement

This recent blog post by David Witt in Blanchard LeaderChat stimulated me to think about the role of ego in performance improvement. There are lots of authors writing about this topic recently - my favorites being Deepak Chopra's "The Soul of Leadership" - which coincidentally talks about the potential of soul-driven vs. ego-driven leadership; and Jim Collins' "Good to Great", which talks about "level 5 leaders having a unique combination of intense will combined with personal humility". 

Performance improvement is ultimately all about leadership, so one is compelled to think about the impact that ego-driven leadership can have on improvement efforts. I think the issue is the same as identified by David - ego can drive ambition and results (a la "the activated internal champion"). However, when it comes to creating sustainability, generating buy-in, and managing behavior - all critical aspects of performance improvement - its ultimately the "team-player" that wins out. 

The leader (or PI Specialist or Project Leader) who can "channel her ego" into building the following performance improvement components will not only achieve success in short-term goals, but also has a greater likelihood of sustaining the gains.

• Culture Aspects
• "No blame" 
• Feedback provided constructively
• Accountability provided fairly
• Systems Aspects
• Multidisciplinary team drives problem-solving
• Platforms for awareness 
• Forums for education 
• Channels of communication 

How to Address Cleanliness Violations at Hospital? New Building or Performance Improvement

The LA Times posted this article about UCLA Harbor Medical Center's safety violations stemming from "lack of cleanliness".

The plan for correction: "Los Angeles County is spending nearly $323 million to construct a 190,000-square-foot building at the hospital that will replace both the surgical facilities and the emergency room. "

As some of the comments to the story point out, its not all about the facility - its also about management and leadership. I've worked with organizations that have faced even older infrastructure, and yet we have improved their cleanliness with good old fashioned management and systems:

• Leadership recognized the difficult situation but resolved to address it.
• Management threw its shoulder "to the flywheel" and made it turn.
• A voluntary team of "cleanliness inspectors" toured the hospital on a regular basis and documented cleanliness of high risk areas - in a manner that could be measured, easily disseminated, and compared.
• Performance improvement systems were installed to ensure improvement:
• Pulled together a "performance improvement team" to oversee the issue.
• Measured the results.
• Made the measurement consistent and reliable.
• Disseminated the findings.
• Developed policies for cleanliness that could be adhered to by all.
• Ensured accountability by reporting on the team's findings to the governing body through the appropriate oversight committees.
• Made the "clicks of the fly wheel visible to all" by showing that some departments (that were just as resource-starved as the others) were able to make improvements.

Perhaps a new building is necessary at UCLA Harbor for many reasons, but in order to reform healthcare, we as a society have to start recognizing that adding costs (staffing, equipment, and buildings) to solve a problem are not sustainable interventions. Improving leadership, management, and systems are.


ADDENDUM 11/1/11: This story published subsequently in the Daily Breeze provides further details about a corrective action plan being put into place at UCLA Harbor. "Those fixes include a reorganization and restructuring of the hospital's infection prevention and control unit, identifying problems with the physical plant and enhancing efforts to assure staff members are washing their hands and practicing good hygiene." All of these actions appear to be appropriate, however, the key to real and sustained improvement from the "corrective action plan" is to ensure that the actions are monitored regularly, and that comprehensive performance improvement systems are implemented.

Performance Improvement Tip of the Day: Lesson about Motivation from Jim Collins, Author of "Good to Great"

Performance Improvement is ultimately about changing outcomes - which is about either changing behavior or stimulating people to change systems - both of which can be daunting tasks in an organization already burdened with its numerous day-to-day challenges.

Jim Collins - best selling author of Good to Great - delivers a powerful lesson that can help to drive motivation for change in this short video about "letting the people see and feel the clicks on the flywheel".

These are the small victories on the path to the bigger goal. Try to capture them, measure them, and make them visible; they will in turn generate more buy-in, enthusiasm, and support from your staff.

Linking Greatness - Structures within Structures

At a recent discussion about applying "Good to Great" principles at our institution, one our our department leaders talked about a sophisticated structure he had built up over the years to identify and develop talent within his department. He described as a "hierarchical" model, which moved talented individuals from "field staff" to "leaders" to "gold badges". It was clearly well thought through, disciplined, and understood by all members of his department.

The key points that generated from this discussion were:

• did this structure enable this department to move down the path of "greatness"? how would he know?
• this structure clearly allowed him to identify the good players, however, did it help him to identify the "ones who should not be on the bus"?
• and, by the same token, did the structure help him to "move the wrong people off the bus"?

Moreover, it was quite likely that this was the only department in the institution that had set up such a structure raising further questions of:

• should this model be emulated by other departments?
• what is the impact to the drive for greatness to have different such structures within different departments?

Questions like these allow us as managers to dive deeper into our constructs and understand better how to connect our work with the overall work of an institution and to ensure that our department-specific activities are helping to drive the overall institution to greatness.

Putting "Good to Great" in Practice

A few of us at Quincy Medical Center have been engaged in a "discussion group" re. Jim Collins' bestseller "Good to Great", a fantastic book laying out some of the elements common to great companies that Collins and his team identified through research. While none of the elements are revolutionary by themselves, the framework developed by Collins is very elegant - it resonates with "management intuition", is easily accessible by all levels of management, and is fairly practical to implement (although not necessarily without rigor).

One of the ideas that our group keeps coming back to in various discussions is that the journey to Greatness begins with the right people. Many of us "know" this, but still get caught up in a race to develop "visions", "goals", "processes", or "business models". Collins' research patiently urges us to first focus on ensuring that the "right people are on the bus", and by the same token, that "the wrong people are off the bus" before we can engage in any meaningful task defining "what" these people should be doing.

Another practical application that we have developed using this framework is that, even though Collins developed his framework based on research on companies, the principles can also be applied to "departments" to help guide managers and directors in their drive for greatness. This makes the material eminently accessible to all levels of an organization.

One more concept that our group is now exploring is developing a model for monitoring the progress towards greatness. We've found that a number of individuals and departments have been persevering towards greatness for some time, but have not been able to adequately measure their progress towards the same. Our team is now developing a "performance improvement" model that can help such individuals in this endeavor.