How can we raise cultural standards in health and aged care?

Culture plays a vital role in aged care and health, across clinical governance, standards of service delivery and patient care for the vulnerable. How can boards best set the tone from the top to ensure that positive culture filters across the whole organisation.

The Aged Care Royal Commission emphasised the critical role organisational culture plays in providing good clinical care and the liability and consequences when it is neglected. The connection between culture and clinical care is not a new concept. Good care is associated with a robust culture of safety, where everyone feels empowered to speak up, and graciousness is the basis of all interactions.

While the above seems obvious, culture can be perceived as a concept that is hard to measure. To add to this complexity, governing health and aged care organisations has unique cultural challenges. Firstly, a mosaic of sub-cultures makes it difficult for the board to understand the entire cultural picture. Secondly, patient safety and dealing with vulnerable people require special efforts, as teams constantly deal with difficult situations. For example, some team members may experience aggressiveness and physical injuries from one patient, while another patient may fall and get significant injuries during a trip to the bathroom because no nurses were available to help.

So, how can boards lead culture?

1. Understand the cultural mosaic
2. Identify where culture negatively influences clinical care
3. Lead cultural changes

Understanding the cultural mosaic

Healthcare organisations are a cultural mosaic of multiple subcultures fractured by subgroups, such as:

• Specialties and occupations (i.e., nurses, doctors)
• Hierarchy and power
• Lines of service

Each healthcare organisation has its own cultural DNA comprising stable and widespread positive and negative cultural traits, while other attributes are shared among subgroups only.  Hence, the board needs to understand data relating to  specific cultural mosaic and review clinical care and people across the organisation and according to the different subgroups.

Cultural characteristics that influence clinical care include:

• Accountability vs blame- how safe do all team members (across professions, hierarchy and line of services) feel speaking up and raising concerns and initiatives?
• Continuous learning and improvement environment – Are issues and mistakes hidden or adequately investigated? When investigated, are they treated as opportunities for learning and growth?
• Leadership - How close are leaders to what is happening on the floor? Are they corporate-style leaders? Are they role models of caring, safety and graciousness?
• Safety, psychological safety, fairness and wellbeing - are they the core principles of every activity? How widespread are behaviours such as bullying and harassment? How are they handled?
• Teamwork and collaboration - What are the team dynamics, collaboration and information sharing levels between teams, across teams and importantly - in ad-hoc teams?
• Ethical decision making - Are the teams trained to consider what is the right thing to do? What they ought to do? What they should do? Or do they simply follow what can they do and what they are told to do?
• Quality and transparency - How thorough are clinical care practices, and are they adhered to? Is there complete transparency across the organisation?
• Respect, inclusion and diversity - Do team members and patients feel respected and included? How is the organisation encouraging diversity and treating patients from diverse backgrounds?

Identifying toxic culture that influences clinical care

The above cultural characteristics are intertwined, especially in toxic cultures. For example:

• Teamwork and collaboration are associated with the successful implementation of quality improvement practices. In contrast, cultures that emphasise formal structures, regulations and reporting lines are negatively associated with quality improvement. For example, finger-pointing, silos, hiding information, and bullying affect both clinical care and the team's ability to learn from mistakes and improve the quality of care. Often, people do not feel safe speaking up in these environments, even when they identify crucial risks.
• Aggressive- defensive and passive-aggressive cultures encourage competitive behaviours, defensive and superior attitudes (presented even when clinicians lack the necessary knowledge, skills, and experience). Employees in these cultures report low job satisfaction and high stress, which affect their ability to care for the vulnerable and to deal with the ongoing challenges of their roles. “And that stress is as poisonous for physicians as it is for nurses—resulting in poorer quality care” (New England Journal of Medicine).

There are many other scenarios of toxic cultures. Hence boards must look for red flags of toxic cultures:

• Clinical data - such as falls and mistakes in medicines indicate areas of toxic subcultures
• Employee related reports - turnover, exit interviews, grievances, bullying, OHS injuries, and employee satisfaction surveys flag areas of concern
• Policies - ensuring they emphasise safety to speak up, inclusion and fairness
• Patients and family’s satisfaction surveys - provide the client experience that is the consequence of the culture
• Walk around the floor – observe, ask and monitor the feel of different areas
• Pay attention to the leadership behaviours in and outside the boardroom
• WYSIATI - always remember that our brain keeps sending us messages of “What You See Is All There Is”. When reviewing reports, remember to look for what is missing. What has been left out of the information that could potentially paint a different cultural picture?
• External cultural diagnosis provides an objective picture, which is often different from how executives experience and report on the culture.

Leading cultural change

While growing research evidence connects culture to quality of care, the relationships between culture and quality, safety and efficiency are not straightforward. The challenge is to understand each organisation's exact culture within each subgroup and which components influence care. Good treatment starts with an accurate diagnosis. An external cultural diagnosis, based on qualitative interviews, provides an accurate picture.

• Team members are often more open with an external consultant than with the HR team and internal auditors.
• You get a set of unbiased and objective eyes to review internal processes connected to the culture.
• Consultants who specialise in diagnosis are often also experts in change management and can provide insightful recommendations.

Remember that to become a clinician there is no requirement to study leadership. However, all clinicians are leaders and they need to understand how their behaviours influence each other and the organisational culture. One of the challenges facing boards and executive teams is that the older the institution is, the deeper its cultural roots are embedded throughout practices, processes and behaviours.  Hence the cultural change program must be built on an explicit cultural statement.

Most organisations have values on their websites and walls. But do they guide behaviours on the floor?  We should not assume that the leadership team will organically develop the culture the board wants. Having a short, focused, cultural statement that clarifies the culture and holding executives accountable for that culture is a crucial part of change management. No cultural change program will work if it is not clear what culture is desired.

The Aged Care Royal Commission highlighted the importance of organisational culture for good care.  The pandemic brought to the surface the good and bad cultural DNA of organisations. It accelerated the use of technology and opened opportunities for the health industry, but also showed us that we need to make some critical changes. It is now clear that the future of health and aged care organisations depends on their ability to change, increase agility, and develop resilience continually. This is the time for boards to embrace the opportunity to design a new organisational culture focused on safety, care and graciousness.

Dr Zivit Inbar GAICD is the founder and CEO of DifferenThinking, a consulting practice that specialises in people, culture, leadership & performance strategies for growth. She is a board member of Rural Northwest Health and author of  ’The Ethical Kaleidoscope: Values, Ethics, and Corporate Governance’ (with Doug Long), 2017, Routledge Publishing, UK

Further reading

• Understanding organisational culture for healthcare quality improvement
  
• Organizational Culture among Public Sector Nurses
  
• Implementing culture change in health care: theory and practice