The culture of organisations

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The culture of organisations

• Add name of presenter

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Why?

• bother thinking about this thing called
  culture?

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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.

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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

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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?

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A case study
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The trials and tribulations of primary care
anticoagulation management
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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

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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...

Thus, each anticoagulation patient costs X pounds
per year.
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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...

Thus, each anticoagulation patient costs Y pounds
per year.
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and of course
The Health Authority Y is considerably smaller
than the General Practice X
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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.

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What is culture?
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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
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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?

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A few cultural differences

• Currency
• Language
• Written materials
• Time
• Unit of organisation
• Autonomy

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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

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Cultures within cultures
(Just to complicate matters)

• 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

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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

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What are the key dimensions?
Large-ish, rural, former fund-holder practice
with many in-house procedures
Large, urban practice with idealistic GPs and
frequent all-staff meetings
Team
Businessfocus
Patientfocus
Single handed, inner-city GP with virtually no
staff and who almost never closes
Wealthy two-partner practice in leafy suburbs
with no cross-cover
Individual
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What are the key dimensions?
New build
Command control
Teamautonomy
PCTs
Them and us
Been around forever
Helping
Policing
Hospitals
In it together
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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
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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

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Culture in organisations

• Contentious point

You cant 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.
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A culture for improvement
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The improvement culture
What an improvement culture is

• Patient centeredness
• Belief in human potential
• Innovation and change are encouraged
• Recognition of the value of learning
• Effective team working
• Honesty and trust
• Communication

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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?

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The improvement culture
One that does not promote improvement could
include

• 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

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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 RD 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

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Generative relationships
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Generative relationships

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

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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

• .

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Types of relationship

• Contentious
• Distant
• Routine
• Competitive
• Generative

Key point generative relationships in complex
systems hold the greatest potential for
creativity and innovation
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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
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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
Separateness
Reason to work together
Tuning talking listening
T
R
A
Action
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Components of a generative relationship
Separateness

• 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.

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Components of a generative relationship
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.
• The conceptual changes in a complex context can
  be profound - opportunities for reflection allow
  parties to grow and learn.

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Components of a generative relationship
Action

• 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.

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Components of a generative relationship
Reason

• 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.

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Surgeon
Patient/Family
?
?
?
?
ICU Staff
Ward Staff
?
Manager
Manager
Relationship maps complement process maps and
flowcharts to give a fuller picture of complex
systems
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Assessing relationships
S
S
T
R
T
R
A
A
A
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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?

units, wards, practices, departments,
individuals etc.
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• 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.

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Culture defined

• The total of the inherited ideas, beliefs,
  values, and knowledge, which constitute the
  shared bases of social action

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The ladder of inference
A common mental pathway of increasing
abstraction, which can lead to misguided beliefs
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A ladder of inference
We cant count on John. Hes unreliable
John always comes in late
John knew exactly when the meeting was to start.
He deliberately came in late.
The meeting was called for 900 am and John came
in at 930. He didnt say why
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For example The Midland Mainline experience
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Ladder of inference
Actions I take or recommend
Conclusions I draw
Advocacy
Inquiry
Meanings I conclude
Interpretations I make
Data I select
What is discernible
After Argyris, Schön
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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

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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

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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)

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and finally
Just being difficult
or
Competent, committed professionalswho have valid
and understandablereasons for their attitudes to
change.