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November | Culture by Design | Read time: calculating...

Treating toxic culture in the healthcare sector

Working in healthcare has long been recognised as a stressful occupation, a reality further compounded since the COVID-19 pandemic began.

 

Considering the foundation of the medical corpus is based on healing, it’s disheartening to read countless reports of toxic cultures, bullying and demoralised staff. Such issues are about more than ‘job satisfaction,’ affecting patient outcomes and employee safety, as evidenced in a WorkSafe improvement notice recently issued to a regional WA hospital.1

In September, the WA AMA released the findings of their biennial morale and engagement survey, completed by 600 senior doctors working in the public sector. It found poor morale and doctors feeling victimised are among the ‘damning and disturbing evidence’ that it says exemplifies the state’s health system crisis.2

The report from an independent inquiry into the death of a seven-year-old girl at a Perth hospital stated that emergency department staff were “exhausted” and “demoralised”.3 Health Minister Roger Cook said all recommendations from the report would be accepted and acted upon.4

The world of healthcare also has reported problems with sexual harassment, including a bias against female doctors considering motherhood. This unhealthy culture further contributes to doctor burnout and career dropout.5 The Royal Australasian College of Surgeons’ Operating Respect Committee was created in the wake of damning reports of sexual harassment in the specialty and an investigation by RACS that exposed an endemic, toxic culture.6

The symptoms are apparent and horrifying. Yet, for those who feel this pain in their profession, it can be challenging to know what treatment should be prescribed to get at the root cause.

While these challenges are complex, they are surmountable. Our founder and Executive Consultant, Allan Keogh, has worked with more than a dozen medical and aged care organisations to transform their businesses and culture.

Allan has overseen interventions across Australia and New Zealand, helping address issues such as the unacceptably high turnover rate of Registered Nurses, improving productivity and cost efficiency, addressing toxic cultures, and reviewing the HR function of these enterprises. Working with several public health service enterprises across Melbourne over several years, he helped transition them from a position of “technical insolvency” to being commercially viable enterprises with positive, thriving cultures.

“To heal patients, you must first heal staff. The wounds within the organisation need to be tended to first.” — Allan Keogh.

While each client we work with will need a bespoke approach to their particular challenges, he distilled the seven critical ingredients for success — which he likes to call The Magnificent Seven.

1. Purpose building for “Culture by Design”

It’s imperative to understand the current culture and how it is experienced across all stakeholder groups, including senior clinicians, families of patients and the broader community. By working with these same groups, we can begin to surface the current and desired culture for the organisation.

Formally articulating the aspirations of the Board and Executives — the organisation’s strategic aims — will help align the culture with the business strategy. Culture and strategy exist in a symbiotic state, each supporting the other.

2. New methods of communication and engagement

If you can’t visualise a brighter future, how can you hope to believe in it?

The start of a transformation really kicks into gear with the co-creation of a coherent narrative that articulates the ‘why’ behind the significant change. By involving those in and of the current culture to create a compelling vision, we’ll be better able to plot the organisation’s journey to achieve it.

The use of a visual storyboard can greatly support this process. Getting the ideas out of our heads and onto the wall to ‘paint the future together’ also works as a powerful piece of collateral for leaders to use in their ongoing communications — a constant reminder for all staff of the vision and journey.

It’s no stretch to claim that the healthcare industry is intensely hierarchical — and those who’ve earned their place will fight vehemently to protect their position. Usually, the more specialised the job title, the greater the attachment to it. This also means that traditionally messages about the ‘company line’ have come from the top of the mountain in a one-to-many broadcast.

The organisations we’ve worked with have found great success in flattening this extreme hierarchy gradient. So while the formal townhall announcements remain necessary, we advocate for our health partners to create more opportunities for informal, relaxed group discussions, one-to-one dialogues and feedback sessions.

We explicitly encourage staff participation in the transformation process through focus group discussions and the appointment of task force teams assigned to strategic and transformation initiatives. As such, solutions are internally generated, and ownership of these solutions and their implementation is well managed and supported

3. A fundamental review and refresh of systems, processes, and procedures

Unlike internal organisational change-makers, an external consultant can offer insights through the lens of an unbiased ‘organisational anthropologist’. For example, in working with healthcare and aged care services, we may spend a portion of time observing and documenting the key rituals and routines that reinforce current culture, including an analysis of how staff utilise the spaces and buildings in which they work.

By looking at routines and workflows, we can better understand staff movement patterns, whom staff interact with regularly, how instructions and communication are passed on, origins of information, and ultimately how decisions are made.

Taking a holistic view of the network of interaction nodes — doctors, nurses, HR, administration, professional ancillary services (e.g. pharmacy, pathology) — almost always uncovers areas requiring a fundamental revision of systems, processes, and procedures. Ideally, changes will be led and championed by the staff themselves, such as the outsourcing and insourcing of ancillary services based on cost recovery, income generation, economies of scale and commercial reality.

4. Leadership and people development

The link between leadership and culture cannot be ignored. Through coaching and mentoring the board and the executive team, we help leaders show up authentically and role-model the desired changes. Whether or not they embrace their new set of leadership commitments is a critical factor in a successful transformation.

Executive coaching for the CEO and COO has been fundamental in all of the health services culture transformations we’ve implemented; however, it’s crucial to build the capability of leaders at all levels.

Keogh helps design and facilitate bespoke programs for those leading the change to help them embed new ways of working. That might include managing performance differently, creating an environment of psychological safety, motivating teams and individuals to perform at their best, or leading continuous improvement. These might be delivered through professional development workshops or task-focused workshops.

One such task-focused workshop is a facilitated Work Out — a problem-solving methodology popularised by GE’s Jack Welch — to provide high-impact solutions. The thinking goes that the staff most affected are best placed to address issues, which might include reducing ramp times, reducing inventory use, better utilisation of space and buildings, improving workflows, or streamlining ancillary services.

5. Reducing harm through courageous truth-telling

The consequences of making mistakes in healthcare are significant – and healthcare cultures do not always facilitate the constructive discussion and resolution of these mistakes.

However, when people speak up and aren’t believed, or reporting isn’t collated, managed and made transparent, organisational wounds are being allowed to fester.

One could argue that the Hippocratic Oath, Primum non nocere (first, do no harm), ​​establishes a culture with an expectation of perfection, one that dissuades us from openly discussing the harms medical professionals routinely cause.4

In a 2016 piece on medical ethics, MD Jonathan M. Evans asks us to reframe the Oath, writing, “Harm results from the lack of action as well. In the extreme, a lack of action equals neglect” and “… doing no harm means lifelong learning and a willingness to embrace necessary change.”5

We must liberate the capacity of individuals to voice their opinions and be heard. Thus, shifting the culture from fear to courage, from hiding mistakes (however severe) to telling the truth and meeting that with compassion.

It’s no easy task and must be managed carefully. It takes powerfully empathetic leadership to create the environment, space, and opportunity for people to speak up without fear of repercussion; coaching and upskilling leaders to promote, support, encourage, recognise, and celebrate these acts of courage – both big and small. This change at a leadership level ensures that people’s feedback and suggestions are listened to, implemented, and reported on.

Across our healthcare culture transformations, we’ve encouraged and facilitated “truth and reconciliation” sessions, where patients, the community and staff can openly share the impacts of negative experiences and mistakes and work together to find solutions. Equally as important is encouraging positive feedback and acknowledging best practice that fosters, liberates and leverages excellent ideas.

6. Deconstructing hierarchy and flattening the power gradient from a safe vantage point.

Helping leaders break down hierarchical barriers has been a key ingredient for success. We can employ many techniques, but a particularly successful one has been the use of corporate actors.

Roleplay is so effective because rituals in health care settings can be likened to a well-drilled performance. Take the operating theatre, for example – there are clear roles, everyone plays a key part, events occur in a specific sequence, there’s drama and tension, and some traditions are passed on through generations.

Creating an accurate roleplay scenario takes a little research to set up, including employee interviews and a non-invasive study of situations. Actors then use that knowledge to demonstrate how hierarchy plays out in those specific healthcare settings. Leaders watching the roleplay are able to see the negative and positive impacts of their behaviours on outcomes in ways that are less threatening but incredibly illuminating.

These innovative techniques have helped many leaders in healthcare and aged care to unpack unhelpful behaviours. We’ll then work with them to shape the changes they want to make, create what these future scenarios should look like, and help them to adopt the new ‘performance playbook’.

7. Connecting with your purpose

The key instrument that makes all of the above work is returning the spotlight to why people enter the industry in the first place. The role of healer in society deserves respect; it is difficult work, both physically and emotionally. Still, the reason here is to care for patients and restore them to health and wellbeing.

In every one of our interventions, that purpose was the unifying bonding factor — the ‘true north’ returned to time and again — that prompted all key stakeholders to sign up for and commit to the change journey.

In Summary

These key ingredients form the components of an overarching transformation strategy and guide the enterprise as it moves from where it is to where it needs to be. The CEO must enthusiastically sponsor the strategy, ably steered by the executive team, with leaders well supported to implement the change.

  1. https://www.abc.net.au/news/2021-09-09/bunbury-hospital-issued-workplace-improvement-notice/100448374
  2. https://www.abc.net.au/news/2021-09-28/doctors-victimised-low-morale-in-wa-hospitals-ama-finds/100496296 (Accessed 9 November 2021)
  3. https://www.smh.com.au/national/aishwarya-aswath-report-perth-children-s-hospital-emergency-staff-were-exhausted-demoralised-20211109-p597bv.html (Accessed 12 November 2021)
  4. https://www.abc.net.au/news/2021-11-09/aishwarya-aswath-new-report-into-perth-childrens-hospital-death/100605522 (Accessed 9 November 2021)
  5. https://www.marieclaire.com.au/the-toxic-culture-failing-our-female-doctors (Accessed 12 November 2021)
  6. https://www.smh.com.au/healthcare/kill-myself-or-leave-female-surgeons-reveal-horrifying-conditions-20190208-p50wiy.htm (Accessed 9 November 2021)
  7. Justin Morgenstern. Stop saying “First, do no harm”, First10EM, 2020. Available at: https://doi.org/10.51684/FIRS.21347 (Accessed 9 November 2021)
  8. https://www.caringfortheages.com/article/S1526-4114(16)30243-8/pdf (Accessed 9 November 2021)