When a positive culture runs deep, it permeates every part of an organisation. Its influence is evident in every interaction in healthcare – from a patient’s initial contact with the provider to the organisation’s vision, team morale and overall cohesion.
Hospitals stand or fall on their ability to pull all human resources together, with employees acting in coordinated harmony towards a collective vision of clinical excellence, safety and success. This is crucially important for healthcare facilities, because the right culture can make an organisation considerably greater than the sum of its parts. It’s also a vital element in staff attraction and retention, employee performance and health, enhanced teamwork and productive inter-departmental collaboration. To achieve this cohesion, employees need to combine in a successfully functioning team to best serve patients’ needs while pursuing the organisation’s overarching vision.
The task of uniting hundreds of hospital staff across multiple departments, disciplines and organisational silos is a necessary but often fiendishly difficult phase in establishing a positive workplace culture. Leadership, mutual respect and open communication channels are central to achieving that. But so, too, is a fundamental understanding of the fact that no matter how good we are, we all make mistakes. This is one of the most challenging barriers to establishing a positive culture.
Why?
Because it’s not in the nature of human beings to admit their mistakes. We find it awkward exposing ourselves to detailed scrutiny and don’t generally enjoy hearing others critique our expertise, efforts or performance. What’s more, we lean towards negative reactions – which fool did that? – rather than asking why and how did that happen?
But we all make mistakes, and we need the people around us to be able to tell us when we’re wrong.
Learning from mistakes: how to improve healthcare culture
Our aversion to admitting mistakes means that to achieve true success, hospitals must establish a supportive, no-blame framework for calling out errors, large or small, and get buy-in from all staff so errors can be transformed into valuable learning opportunities. And ‘just’ cultures – supportive work environments that by-pass blame but promote accountability and learning in equal measure – can drive up employee satisfaction and performance.
A no-blame or just culture creates the freedom to identify errors on the one hand, and the confidence that committing an accidental error will be assessed constructively, on the other. And when genuine errors can be exposed with no repercussions for either party – especially when the courage to speak out is seen as a central pillar of organisational success – it can serve as the foundation for an entire culture of open communication, respect and accountability.
The tragic case of Elaine Bromiley – a 37-year-old patient in good health who died of hypoxic brain injury whilst undergoing a routine nasal procedure in the UK’s National Health Service (NHS) – often features in safety- and human-factor training circles for what it tells us about team interaction and communication breakdowns. But it was the subsequent reaction of Elaine Bromiley’s husband, Martin Bromiley, that really informs our current approach to just cultures and how we can best learn from tragic errors.
A commercial airline pilot with a vested professional interest in the practice of human-factors science and crew resource management, Mr. Bromiley suggested that, after an independent review, those responsible for the errors not be punished. As aviation-safety experts, Baines Simmons, point out, Mr Bromiley believed that the team present that day were the people least likely to ever make those same mistakes again. And more to the point, they were also the ones best placed to inform and educate others on how to avoid those errors in the future.
Communication, respect and teamwork
As customer-facing enterprises, healthcare organisations need to promote a positive culture that permeates an organisation’s every pore, across every employee, every department and every discipline. As an old friend of mine in dentistry was fond of saying, “your receptionist is the MD of first impressions”.
Communication
But it’s not just patients who deserve and demand respect – every team member is important. Each will have something worthwhile to add, so it’s crucial to establish a culture of open communication in which everybody is heard, given equal weight and treated with respect. In other words, an end to a blame culture in which negative responses like ‘which idiot did that?’ give way to a more constructive and nuanced approach that prioritises learning.
And valuing team members in a supportive environment produces results. There’s plenty of evidence to suggest that when staff feel they’re an integral part of an excellent team, they enjoy higher levels of satisfaction, performance, and health, which leads to fewer patient complaints and reduced hospital mortality.
Respect
Baines Simmons highlights research that shows that the single biggest contributor to poor performance in team settings is a lack of respect for colleagues. “Many of us work in teams”, they note, “and… the biggest factor in performance detriment, in normally high-performing teams, is incivility or rudeness.”
As the safety experts reveal, humans’ ability to handle high workloads very quickly evaporates when faced with conflict, hostility or rudeness. “On a good day”, they say, “most of us can deal with around 5 to 7 things at once.” However, a distraction can reduce that capacity to three or four simultaneous tasks, and when conflict or rudeness is added to the mix, our ability to handle higher workloads is severely diminished, leaving us with barely enough bandwidth to perform just one task correctly. “We are now,” says Baines Simmons, “in prime error-making territory”.
Teamwork
We’ve seen how clinical errors might be avoided through more positive workplace cultures, but operational processes will also benefit hugely from the effects of a positive culture. Successful referral pathways across hospital departments rely on good teamwork and seamless coordination between departments and specialities, and without a collaborative culture focused on the most effective care for patients, referral pathways will be inconsistent, leading to further problems down the line. The right culture will allow hospitals to target the most suitable medical expertise at the most effective time for patients, with full communication and coordination between clinical teams, offering a fuller picture of capacity across departments.
What can healthcare learn from other industries?
The principles of aviation safety that guided Mr. Bromiley’s response can offer healthcare facilities valuable insights into safety and operational performance. In fact, two of the central tenets of aviation safety – the two-pilot rule and the sterile flight-deck rule – have much to commend them in clinical settings due to the oversight and problem-solving redundancy they provide, as well as the freedom from unnecessary distractions during the critical phases of flight. With a high chance that they’ve never flown together or met before, the combination of commander and first officer on a flight deck – where one takes the role of ‘pilot flying’ whilst the other performs the ‘pilot monitoring’ duties – means that air crews are constantly cross-checking each other’s tasks and performance with the freedom to challenge everything.
Clinical settings, on the other hand, have not historically lent themselves to the habit of challenging authority; often characterised by differing cultural perceptions of seniority and deference, they tend not to align well with the established principles of a safety culture. In fact, as we can see from the tragic case of Elaine Bromiley, outdated notions of respect and deference mean that challenging authority can be awkward and often fruitless. It’s something staff generally receive no training in – it transpired the nurses involved in Elaine Bromiley’s case “didn’t know how to broach the subject with the doctors” – and is rarely seen as a good career move. And that needs to change.
Permeating an organisation’s every pore
Toxic work environments are known to negatively impact performance and success. Healthcare facilities built on blame cultures do nothing to encourage an understanding of how or why errors occur. In fact, mistakes are more likely to be concealed, given the fear of retribution that festers in blame cultures.
To combat the negative effects of poor environments – such as unsafe working conditions, low morale, and poor employee satisfaction – it’s vital for healthcare facilities to establish a guiding vision. This should be used to create a supportive culture that fosters learning, improves teamwork and drives clinical excellence.
