All the leaders involved in this report highlighted the importance of a quality-oriented culture, not just among leaders but throughout the organization. Continuous measurement and a clear sense of accountability are intrinsic values rather than imposed obligations. This manifests in: trust and respect for each other’s roles (especially between managers and professionals); a constructive approach to errors that does not seek to blame individuals; and a sense of belonging to a team coupled with a drive to excel and not accept complacency.
“Much of this isn’t very sexy. It is the small stuff that matters the most, and it is sometimes hard to get everyone to focus on that.”
Ralf Kuhlen, Chief Medical Officer, Helios Kliniken, Germany
Staff is urged to recognize soft signals, such as stress, or a reluctance to speak up. There is also a zero tolerance to any breaches of safety, especially from individuals that feel they are above the rules. Leaders may have to confront entrenched attitudes among medical professionals in particular, while also questioning their own assumptions over safety and behavior.
Building a culture tuned to quality takes time and calls for collective effort and common goals. The board’s role is crucial and goes beyond the creation of organizational structures and reporting lines. Board members will have to reverse their traditional deference to professionals, and take an active involvement in defining and measuring quality and safety, and acting upon any poor examples, to boost awareness.1
As with all high-performance cultures, leadership has to demonstrate an aversion to being average, and a willingness to empathize with patients, families and the involved professionals following incidents where patients have been harmed. Embracing the right values is every bit as important as reporting structures and dashboards, and sets an example for the entire organization, as Georgina Black, head of KPMG Health in Canada explains: “The tone at the top from the board and senior management is crucial. The board needs to be informed, engaged and asking questions of management. Management in turn needs to treat quality as a core business of the organization and set a culture that promotes trust, inquiry, transparency, collaboration, ongoing learning and excellence. Structured methods of learning enable front-line staff to inspire each other and exemplify the drive to excellence.”
“We don’t operate with a standard, top-down recipe book. Top clinicians are the crucial element, and they have to become owners, to ensure that the standard is a joint endeavor rather than a management initiative.”
Dr. Panigrahi, Head of Medical Operations, Fortis Healthcare, India
This training needs to demonstrate practical examples of safe working and operational excellence as a means of achieving higher performance levels, according to David Dalton, CEO of Salford Royal Foundation Trust, UK: “The top leaders need to understand and be engaged with clinical micro-systems. We have involved around one-third of our staff – over 2,000 people – in building capability, skills and competence in improvement.” Board members must also be educated, in what the Institute of Healthcare Improvement calls: “bringing boards on board,”3 a point echoed by Dr. Lee Chien Earn, CEO of Changi General Hospital, Singapore: “In Singapore, all new board members of public hospitals are briefed on the importance of quality and safety, and the roles of the board.”
“Being satisfied with average can lead one to slowly start to accept the most appalling levels of quality” says Malcolm Lowe-Lauri of KPMG in Australia. “As minor breaches of standards become gradually accepted, so major failures will follow.” This ‘normalized deviance’ led to disasters as varied as the NASA Challenger Shuttle and the UK’s Mid Staffordshire Hospitals. The reports coming out of the system merely confirmed that the organizations were not doing too badly, yet this concealed the fact that no-one was prepared to ask aggressive, challenging questions that would keep everyone on their toes.
Examples of normalized deviance are: low hand washing compliance before patient contact, or minimal/zero consultant oversight of hospital care on weekends. The culture of tolerance makes it easy for such organizations to slide further downhill, with individuals believing that “rules are for others.” Without strong examples from senior role models, any corrective patient safety initiatives are doomed to failure.
A lack of response to organizational deviance at a community and regulatory level has similar dire consequences, with members unlikely to fear any punishments for violating formal standards of behavior.2
1For an in-depth discussion, see: Baker, G. et al. "Effective governance for quality and patient safety in Canadian healthcare organizations." Ontario/Alberta. Canadian Health Services Research Foundation and Canadian Patient Safety Institute, 2010.
2Source: For the term ‘normalized deviance’ (and story on the NASA shuttle disaster) see: The Challenger launch decision, Vaughan, D. Chicago: University of Chicago Press, 1996.
3"The power of having the board on board." Institute for Healthcare Improvement, August 2011