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The culture of organisations: 

The culture of organisations Add name of presenter

Why?: 

Why? …bother thinking about this thing called ‘culture’?

because…: 

because… Working across the whole patient journey involves working with a number of different organisations… …all of which have their own patterns, idiosyncrasies, rules (written and unwritten), beliefs, perspectives, attitudes and behaviours… …which make up what can be called their ‘culture’.

because…: 

because… It helps to understand the sort of organisation you are trying to work with It can give you insight into your own expectations, behaviours, habits etc. and how that affects trying to work with others It enables you to think of the process of translation that you might need to undertake to help people from different cultures to understand each other

and because…: 

and because… It can help answer questions like: why are GPs always late for meetings and have never read the papers? why can managers only talk about ‘budgets’ and ‘strategy’ and ‘meetings’? why do hospitals always take so long to make decisions? why do paramedics always carry lots of things clipped to their belts?

A case study…: 

A case study…

The trials and tribulations of primary care anticoagulation management: 

The trials and tribulations of primary care anticoagulation management

Picture the scene:: 

Picture the scene: Increasing numbers of anticoagulated patients Struggling hospital anticoagulation services General practice interest in service provision Secondary care support for service development Acknowledgement of patient preference

GP equation:: 

Thus, each anticoagulation patient costs X pounds per year. GP equation: Typical amount of Doctor time spent reviewing INR result costs about… Typical amount of nurse time spent seeing anticoagulation patient costs about... Admin. staff time spent contacting patient and processing notes etc costs about... Overheads (postage, telephone calls etc.)… Multiply cost per visit by how many times a patient typically comes in a year...

Health authority equation:: 

Thus, each anticoagulation patient costs Y pounds per year. Health authority equation: Closing down the anticoagulation clinic at hospital A saves... (No money available from hospital B because anticoagulation done in general out-patients) Number of anticoagulated patient across the city is roughly... Divide the available money by the number of anticoagulation patients...

…and of course: 

The Health Authority Y is considerably smaller than the General Practice X …and of course

…which leads to:: 

…which leads to: Health Authority: GPs are greedy and only concerned about money. GPs: the Health Authority wants more work done on the cheap and is insulting us.

What is culture?: 

What is culture?

Dictionary definition…: 

Dictionary definition… “The total of the inherited ideas, beliefs, values, and knowledge, which constitute the shared bases of social action” “The way we do things round here”

Key NHS cultural differences:: 

Key NHS cultural differences: Primary vs. secondary (vs. tertiary?) Managers vs. clinicians (particularly Doctors) Practice vs. practice vs. practice etc. SHAs vs. everybody else Collaboratives vs. ‘traditional’ management PCTs? Ambulance service? Community trusts?

A few cultural differences: 

A few cultural differences “Currency” Language Written materials Time Unit of organisation Autonomy

Is culture important?: 

Is culture important? Culture can be both an accelerator and a brake to organisational performance Reflects the management style and atmosphere of an organisation Culture can lead to both adoption of and resistance to change

Cultures within cultures: 

Cultures within cultures Each organisation and each part of an organisation and professional group has a culture and a structure and systems appropriate to that culture Individuals each have a preferred culture (Just to complicate matters)

Defining and diagnosing: 

Defining and diagnosing ‘The process of influencing an improvement culture starts by understanding the existing culture’ How can we understand the culture of an organisation? spend time there observe approach with an open mind learn the language

What are the key dimensions?: 

What are the key dimensions? ‘Business’ focus ‘Patient’ focus Team Individual Large, urban practice with idealistic GPs and frequent all-staff meetings Wealthy two-partner practice in leafy suburbs with no cross-cover Large-ish, rural, former fund-holder practice with many in-house procedures Single handed, inner-city GP with virtually no staff and who almost never closes

What are the key dimensions?: 

What are the key dimensions? Command & control Team autonomy New build Been around forever Policing Helping Them and us In it together Hospitals PCTs

An emerging culture within a PCT…: 

“ I would describe my organisation as being like a developing country with lots of different regions within it, each having slightly different accents and levels of autonomy. It has a good domestic policy with staff being very involved, its regional governments feed into central government effectively. The country believes in freedom of speech. Because it works well in partnerships with other agencies it, therefore, has a good foreign policy…” An emerging culture within a PCT…

A deeper understanding…: 

A deeper understanding… What are the values? What are the behaviours? Compare the stated values and behaviours Search for the unwritten rules Decide which unwritten rules matter Understand the background to the rules

Culture in organisations: 

Culture in organisations Contentious point: You can’t change culture (at least not quickly or easily or predictably). The way to work is to understand and work within cultures, making cultural traits apparent where necessary and promoting multi-cultural understanding. This way, the organisation will be helped to learn and develop itself.

A culture for improvement: 

A culture for improvement

The improvement culture: 

The improvement culture Patient centeredness Belief in human potential Innovation and change are encouraged Recognition of the value of learning Effective team working Honesty and trust Communication What an improvement culture is:

Does an improvement culture exist?: 

Does an improvement culture exist? Change and learning – does this occur frequently or is this resisted? Power – do individuals believe they can make things happen? Identity – do individuals identify with the organisation or immediate teams? Conflict – do individuals handle conflict positively?

The improvement culture: 

The improvement culture Slow and un-responsive decision making Not getting the basics sorted Not sharing information Seeing training and development as a means to ‘tick the box’ Acceptance of inefficient systems Keeping your head down and doing the minimum required One that does not promote improvement could include:

Organisations with the highest potential for innovation: 

Organisations with the highest potential for innovation Are exposed to many external influences from other organisations, industries and countries Use collaboration as an essential part of the innovation process Have board-level champions for innovation Conduct R&D and significantly value the importance of design and new technology in innovation Support a creative and rewarding culture and involve staff, customers and suppliers in ideas generation Regularly audit their innovation process and set targets to help improve their innovation performance

Generative relationships: 

Generative relationships

Generative relationships: 

Generative relationships Adapted from the work of Brenda Zimmerman and Bryan Hayday (York University, Toronto, Canada) Paul Plsek

Definition of a ‘generative’ relationship: 

. Definition of a ‘generative’ relationship The relationship produces something which one of the members of the relationship could not have produced alone. The source of value (new product or service) was created by the interaction between the parties

Types of relationship: 

Key point: generative relationships in complex systems hold the greatest potential for creativity and innovation Types of relationship Contentious Distant Routine Competitive Generative

Generative relationships: 

“…occur when interactions among parts of a complex system produce valuable, new, and unpredictable capabilities that are not inherent in any of the parts acting alone.” David Lane and Robert Maxfield Generative relationships

Generative relationships: 

Generative relationships Four component parts of generative relationships Framework for understanding and analysing relationships Comes with a catchy acronym

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Generative relationship “STAR” S T A R Separateness Tuning: talking & listening Action Reason to work together

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Separateness or differences: there need to be differences is background, skill, perspective or training of the parties. If all of the parties are similar, they may enjoy heated debates but leave untouched or unchallenged the assumptions upon which both sides of the argument are based; you cannot challenge and assumption that goes unnoticed. Differences allow the partners or group to see things from a different perspective. They allow ‘facts’ to be seen as ‘interpretations’. Components of a ‘generative’ relationship: Separateness

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Talking and listening: there need to be real opportunities to talk, and listen, to each other with permission to challenge the status quo, ‘sacred cows’ or implicit assumptions. The conceptual changes in a complex context can be profound - opportunities for reflection allow parties to grow and learn. Components of a ‘generative’ relationship: Tuning

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Action opportunities: talking is the first step, but unless accompanied by actions, new ‘sources of value’ will not be created. The parties to the relationship need to be able to act together to jointly create something new. Components of a ‘generative’ relationship: Action

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Reason to work together: the parties need to have a reason to work together, share resources and/or ideas, or to act as allies, even if only for a short period. There has to be a perception of mutual benefit. If the parties do not see the value of working together, or if they see each other as adversaries, it is unlikely they will mutually create something of value. They may talk and learn from each other, but then do the work of creating something new alone. Components of a ‘generative’ relationship: Reason

Slide41: 

Relationship maps complement process maps and flowcharts to give a fuller picture of complex systems ICU Staff Ward Staff Manager Manager Surgeon Patient/Family ? ? ? ? ?

Slide42: 

Assessing relationships S T A R A S T A R

Group Work: 

* units, wards, practices, departments, individuals etc. Group Work Pick two ‘parties’* that you know Rate them on each of the four components (low, medium, high) What might this mean for their working relationship? How might this framework help them improve their relationship? How might the generative relationship idea help you in your work?

Slide44: 

Separateness: there need to be differences is background, skill, perspective or training of the parties. Tuning - talking and listening: there need to be real opportunities to talk, and listen, to each other with permission to challenge the status quo, ‘sacred cows’ or implicit assumptions. Action opportunities: talking is the first step, but unless accompanied by actions, new ‘sources of value’ will not be created. Reason to work together: the parties need to have a reason to work together, share resources and/or ideas, or to act as allies, even if only for a short period. There has to be a perception of mutual benefit.

Culture defined:: 

Culture defined: “The total of the inherited ideas, beliefs, values, and knowledge, which constitute the shared bases of social action”

Slide46: 

The ladder of inference A common mental pathway of increasing abstraction, which can lead to misguided beliefs

Slide48: 

A ladder of inference: The meeting was called for 9:00 am and John came in at 9:30. He didn’t say why John knew exactly when the meeting was to start. He deliberately came in late. John always comes in late We can’t count on John. He’s unreliable

Slide49: 

For example: The ‘Midland Mainline’ experience

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Ladder of inference “Data” I select “Interpretations” I make “Meanings” I conclude “Conclusions” I draw “Actions” I take or recommend Advocacy Inquiry What is discernible After Argyris, Schön

Using the ladder of inference: 

Using the ladder of inference Improve your communications through thinking and reasoning (reflection) Make your thinking and reasoning more visible to others (advocacy) Inquire into others’ thinking and reasoning (inquiry) Important to balance advocacy and inquiry

Balancing ‘inquiry’ and ‘advocacy’: 

Balancing ‘inquiry’ and ‘advocacy’ Tendency in teams to promote ‘advocacy’ approaches (‘fighting your corner’) Too much advocacy: hectoring Too much inquiry: sitting on the fence Better: lay out reasoning and invite challenge

Using the ladder of inference: 

Using the ladder of inference What is the observable data behind that statement? Does everyone agree on what the data are? Can you explain your reasoning? How did we get from these data to that abstract assumption? When you said (“your inference”) did you mean (“my interpretation of it”)

Slide54: 

…and finally: “Just being difficult…” or Competent, committed professionals who have valid and understandable reasons for their attitudes to change.