May 31, 2018; New York Times
It should come as no surprise that hospital culture impacts the quality of care received, but that does not make changing that culture to deliver better care easy, notes Dr. Pauline Chen in the New York Times. Of course, at NPQ, we have noted the importance of organizational culture in many areas—including addressing equity, diversity, and inclusion. These lessons, it turns out, are also highly applicable in delivering quality health care.
In particular, Chen observes, new research indicates that one key strategy for improving hospital care is to empower the entire medical team (i.e., nurses, technicians, and administrators, as well as clinicians) to have a say in medical decisions, rather than relying solely on MDs. For example, Chen writes that, “Heart attack patients who are treated at hospitals where nurses feel powerless and senior management is only sporadically involved in patient care tend to fare more poorly than patients hospitalized at institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results.”
One way to implement such changes systemically involves getting hospitals to create what researchers call a “guiding coalition.” This involves, Chen explains, having “a group of more than a dozen staff members, ranging from high-ranking administrators to clinicians, nurses and technicians from across the entire institution. The coalition members participate in regular workshops, discussions and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice.”
This approach was piloted by a group of 10 hospitals, which formed the Leadership Saves Lives (LSL) collaborative. “To assess the clinical effect of the intervention, the researchers decided to look at heart attack patients, individuals whose care depends on the staff in several departments in a hospital,” Chen says. The full study results are available here. The research team included public health and medical researchers from Vassar, Yale, Columbia, and the Mayo Clinic.
Chen writes that, “The researchers found that all 10 hospitals changed significantly, but six hospitals experienced particularly profound cultural transformations.” At the six hospitals that showed the most favorable results, one key was an institutional shift from a frame of “because I said so” to one of “focusing on the why’s.” Also important was empowering medical teams to treat patients as individuals rather than following the same clinical protocols for all patients in a given class. As Chen explains, “Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols…it became more important to provide the data that proved such rituals were actually helpful.”
Nurses and technicians in these high-performing hospitals said they felt that they were newly empowered to voice opinions in “more of an equal role, no matter what position you are.” By contrast, at the four lower-performing hospitals, there remained “persistent expectation of deference to authority” as well as a work environment where staff remained, in the words of one staff member, “so squarely in the box that we can’t even see the edge.”
Chen gives one example of how empowering technicians led to better health outcomes:
One hospital in the study, for example, had been struggling for years with poor outcomes because patients often had long wait times between the onset of heart attack symptoms and the initiation of appropriate in-hospital care. Many of the hospital’s administrators and clinicians assumed that little could be done because of their rural location. But the hospital’s EKG technicians knew of a new and relatively inexpensive transmitter that could immediately relay EKG results to the hospital.
“But the EKG technicians never felt empowered to speak up,” recounted Dr. Elizabeth H. Bradley, president and professor of science, technology and society at Vassar College.
In Great Britain, Dr. Patrick Geoghegan, professor of mental health and social care at Anglia Ruskin University, is spearheading a similar program in the National Health Service. “You can have all of the best policies, procedures and strategies, but if the hospital’s organizational culture is not receptive, then you will fail,” Geoghegan observes.
Bradley, who was part of the research team, notes that if more hospitals held regular meetings that bring together hospital staff from all disciplines “in a psychologically comfortable and trusting place to speak the truth and to have meaningful conversations,” then these relationships and the cultural changes they inspire will “drive the sustainability of your improvements.”
“It takes bringing people together and redefining leadership as a role that anyone at any level can take,” Bradley notes. “We think we just need to get the best doctor,” Bradley adds, “but witnessing how staff treat each other is a pretty strong signal for how they will treat and care for you.”—Steve Dubb