Abstract: The problem is not the problem. All too often, the real problem is not what is broken but the culture that allowed the ‘problem’ to develop and persist. This article discusses toxic and dysfunctional culture.
I was listening to a group of managers debating the hospital’s preparedness for a regulatory survey. A lot of concern was being expressed about the fact that there were a number of known variances from standards. The longer I listened to this, the more frustrated I became. At the breaking point of my patience, I stood up and said, “OK, that’s enough.” “Everyone in the room, take off your clothes.” The shock and awe were palpable. People sat staring at me as they tried to comprehend what they had just heard. I said, “I’m serious. Everyone. Take off your clothes right now.” My audience was dumbfounded. I suspect some of them were wondering if the psychiatrist was in the building.
I said, “Let me ask you folks a question. If I continue to press this point, my prediction is that at least one of you will take the position that you will not take off your clothes. You will refuse to do this because you have modesty, morals, ethics, decency, or religious conviction upon which you will base your refusal.” My question was, “If you have standards that prevent you from taking your clothes off when all that is involved is a violation of modesty, how do you rationalize having knowledge of regulatory deficiencies in your area of responsibility and not having done enough to resolve them when patient safety may be compromised?” Remember the line from the movie, ‘A Few Good Men?’ Tom Crews asked, “Can you explain this?”
And so I had another head-on collision with entrenched dysfunctional culture. Several years ago, I had the privilege of doing work with Northside Hospital in Atlanta. Northside’s culture with respect to regulatory compliance is very simple: Every department is expected to operate 100% compliant with regulatory standards 100% of the time. As a result, a regulatory survey is expected to be a non-event at Northside. This is dramatically different from the culture in most hospitals I have worked in that go through episodes of shock and horror when they are in the survey window and word comes that surveyors have been spotted in the next town. These hospitals have a culture that says it is OK to take a laissez-faire attitude and approach toward a regulator or surveyor until they think they might be surveyed then there is a mad rush to get into compliance.
I told the leadership team that the Board had decided to submit the hosptial to industry accreditation. Therefore, the question as to whether or not managers are expected to follow regulations is off the table. Anyone that does not agree with this decision should ‘punch the clock and get over the hill,’ as my dad would say. I went on to tell the group that in deciding to comply with standards, the Board had a reasonable right to expect that the standards were being followed on a continuous basis and not just when the hospital was in the survey window.
I told the group that I needed a volunteer, someone that could explain to the Board if the survey turned out as bad as they predicted how the organization had developed a culture of tolerance of areas of non-compliance with applicable regulations. Much to my chagrin, I did not get a volunteer. I told the group that this depressed me so bad that I was going to buy a bottle of wine and drink the whole thing, I was then going to bring the bottle back to the next weekly meeting and use it to play spin the bottle to determine who the spokesman to from the group to the Board would be. I then exited the room.
Over the next couple of weeks, the leadership team of the organization responded beyond my wildest expectations. There was no need for me to go back to the meeting to play spin the bottle. Every manager of every department went to work, around the clock in some cases to bring their areas into compliance with applicable regulations. Sure enough in less than two weeks, the surveyors showed up. The hospital had one of the best if not the best surveys in its history.
Was this result of a speech? I don’t think so. All I did was challenge the hypocrisy of a dysfunctional culture that in some. cases was potentially putting patient safety at risk. What changed was that a group of managers decided independently that they were no longer going to be associated with substandard compliance in their areas of responsibility. There is a one-liner that states, “You don’t have to move all of the cattle to change the direction of a heard. All you have to do is to change the direction of the lead steer. Peer influence in an organization is eremely powerful. This is what led me to define my own definition of culture. Webster defines culture as the beliefs, customs, arts, etc., of a particular society, group, place, or time: a particular society that has its own beliefs, ways of life, art, etc.: a way of thinking, behaving, or working that exists in a place or organization (such as a business). I define culture as the lowest level of excellence a group will accept as tolerable and normal. Groups in my experience do a very good job of enforcing the culture of the organization on their peers for better or worse.
So I end with a question of you. To what degree are you being limited by the culture that is surrounding you in your present situation? What are you doing to change the culture? Do you have the support you need to get the culture from where it is to where it needs to be?
Remember the challenge to take off your clothes. Why is this so hard in a business where seeing naked people is a fact of everyday life? Go figgure.
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