Promoting Cultural Change in Critical Care: Moving Away from the Traditional Mindset Andrew Egol, DO, MBA, FCCM Jay Cowen, MD Joanne Lindberg, RN, MN Thomas Rainey, MD, FCCM As Dr. E. entered the intensive care unit (ICU) of WeWereGreat Memorial Hospital (WMH), he wondered with apprehension what the day would bring. Dr. E. was hired recently as the new medical director of critical care at WMH. He finished training at WeAreTheGreatest Medical Center (WMC), one of the most prestigious and successful hospitals in the country. His training was rigorous but positive, and he expected a similar experience as he entered into his position. Soon, he learned the hospital recently underwent significant administrative changes, and staff retention issues evolved as a result. Despite these challenges, he felt confident that he could provide the type of leadership needed to turn things around. With each passing day, however, it became clear the veneer of greatness at the hospital was eroding quickly. Last week, he expressed his desire to establish a data-driven outcomes program in the ICU. He was told a committee would be formed to look into it, but he wondered if such an effort would ever produce results. This week, after suggesting the hospital institute multiprofessional ICU rounds, he was told the hospital lacked the staff to implement such a program. And yesterday, when he mentioned moving toward evidence-based care in the ICU, he was told it wouldn’t work in a hospital like WMH. Last night, while having dinner with his wife, he vented his frustration and confusion about running into barriers at WMH. To ease his frustrations, his wife explained the concepts of culture gaps, credo, glueware, artifacts and espoused values. These new ideas peaked Dr. E’s interest. He was not exposed to them in his training, and he wanted to know more. Culture is one of the most mysterious and deeply rooted issues in organizations. Many complete their ICU training without ever formally being exposed or introduced to organizational culture. They finish training without knowing what it is, how to measure it or how to change it, or why one would want to do any of this. Every organization has an invisible quality -- a certain style, a distinct character, or a particular a way of doing things -- that may be more powerful than the dictates of any one person or formal system. This invisible quality is defined as the organization culture, and it dictates how effective the organization is. While organizational culture can be adaptive and change in response to times and markets, it also can be dysfunctional and prevent an organization from changing when needed. It’s tempting to simplify organizational culture and say “this is the way we do things around here.” In fact, this is a common definition for organizational culture. A better way to think about culture is to realize that it exists on several levels, and individuals must understand and manage the deeper levels. Most importantly, culture matters because it is a powerful, latent and often unconscious set of forces that determine both our individual and collective behavior, ways of perceiving, thought patterns and values.1 Hospital employees often foster their own distinct culture as a group, but subcultures also exist among physicians and nurses as well as within departments such as critical care. This makes the discussion and the dissection of hospital culture even more difficult and complex. It is important to note that the desire to initiate cultural change often emerges after one is faced with resistance to change. While this certainly can be a result of a dysfunctional culture, it also can be the result of a difficult person in a functional culture or a dysfunctional subculture. Making the differentiation is the key to solving the problem, as it will determine the method needed to invoke change. Figure 1 provides assistance with separating issues associated with individuals, groups or cultures. Assessing and impacting ICU sub-culture is not for the faint of heart. It is often a long, difficult and painful process that should be reserved for situations where it is clear that the ICU sub-culture is the main issue. Any prospective culture change can launch anxiety and resistance. This article focuses on assessing and changing the sub-culture within critical care and assumes that it is separate and distinct from the overall hospital culture. If a separate and distinct culture exists in a critical care unit making an impact in the unit is easier than if the unit’s culture is blended significantly with others in the hospital. When inconsistencies exist between artifacts (what is seen) and espoused values (what is said or written), a deeper level of thought and perception begins to drive overt behavior. These are the shared tacit assumptions. Shared tacit assumptions (referred to as norms) are the essence of an ICU’s culture. Norms are essentially invisible. To understand them, one must think about the history of the organization, and who initially imposed their beliefs, values and assumptions on the people who work there. At this point, those trying to change the culture should become more analytical and reflective about culture. Critical care personnel typically do not have an extensive background in the process of changing culture. Because they are too close to the culture, an outside facilitator who understands the concept of culture usually assists with the process. The facilitator must create the setting, provide the model, ask provocative questions and move forward until norms are brought into consciousness. Adopting a cultural change strategy to create an adaptive culture requires risk and trust; critical care personnel must support one another's efforts to identify problems and sponsor cultural change initiatives. Goals can only be accomplished through a conscious, well-planned and united effort to manage cultural change, the secret to which is establishing trust. Trust is earned as the critical care team works together. Everyone must be supportive through their actions and words. To manage ICU culture change successfully, continue monitoring and assessing norms. If the cultural change is not managed explicitly, it may be a matter of time before the ICU is disrupted again. Ongoing attention to the ICU culture can yield significant improvements in both morale and performance. Dr. E intently listened and voraciously read about organizational culture change. He worked with the ICU management and staff to initiate a critical care cultural change program. Slowly, the veneer of greatness was reapplied at WMH. He now is busy doing multiprofessional ICU rounds as he prepares to implement the critical care database to track outcomes and performances. References are available at SCCM’s Web site, www.sccm.org. (DAVE PLEASE ARRANGE THIS IN A GRAPHICS BOX) Changing organizational culture Define the three levels of culture 1. Artifacts -- These are the physical things that people see, hear and touch when they occupy the ICU. 2. Espoused values -- Strategies, goals and philosophies of the ICU. 3. Shared tacit assumptions -- The sub-conscious perceptions, thoughts, and feelings often taken for granted. These also are referred to as norms, credo or glueware. Implement the three-step method to cultural change 1. List all the norms in the critical care unit. More than 90% of the norms likely will contain at least mildly negative connotations. 2. Discuss where the organization is headed and what type of cultural change behavior is necessary to move it forward. Reflect on the ideal critical care unit. 3. Develop a list of new norms. Determine the cultural gaps that reflect the differences between the actual norms and the desired norms. These norms are divided into four categories that reflect the various parts of the culture. 1. Support – sharing information, helping other groups, and addressing efficiency 2. Innovation – creativity 3. Social relationships – socializing and mixing friendship with business 4. Personal freedom – self-expression, discretion and pleasing oneself Example of an innovation norm pair Old norm – “Don’t rock the boat” New norm – “Always try to improve” (DAVE – PLEASE NOTE FIRST 3 PARAGRAPHS ITALIC/ LAST PARAGRAPH ITALIC. THIS STORY COMES WITH A FLOW CHART GRAPHIC) Is The Problem Prevalent Throughout the Hospital? Yes es Is the Problem With One or Multiple Issues? Multiple Issues Single Issue Yes No Is the Problem Prevalent Only in the No ICU? Yes No Is the Problem Present Only With a Single Group? No Individual Issue Cultural Change Organizational or Sub-Culture Problem Oriented Change Figure 1 – Culture Change Flow Chart Delete the graph if no room??