Viewpoint: The change in hospital culture that could help save lives

A more open and egalitarian culture among hospital staff can help patients have better outcomes, surgeon and columnist Pauline W. Chen, MD, argues in The New York Times.

Eight insights from the op-ed:

1. In exploring the effects of a hospital's organizational culture, Dr. Chen discussed an experience she had as a surgical trainee in the 1990s, where her organization's ongoing resistance to a changed culture was best demonstrated by an unofficial register of patients waiting for a hernia operation. "By the time I was training at the hospital, every prospective hernia patient had to submit to an endless drill of testing and specialist visits before even setting foot in the operating room," Dr. Chen recalled. These patients spent months waiting for the fairly common procedure.

"No matter how much we trainees bristled at the wait and the antediluvian regulations our patients had to tolerate, we felt powerless to question them," Dr. Chen wrote. "We understood our place at the bottom of the hospital totem pole, and the ritual seemed too deeply entrenched to ever change." One of Dr. Chen's colleagues compared their hospital's rigid organizational culture to an elephant. "This hospital is like an elephant," the colleague said. "When she goes to the right, you must go to the right. When she goes to the left, you must go that way, too."

2. "Healthcare experts have long known of a link between patient outcomes and a hospital's organizational culture, or the way hospital employees feel about their roles and their interactions with one another," Dr. Chen wrote. For example, heart attack patients treated at hospitals where nurses feel they have no voice and senior management is not consistently involved in patient care tend to see worse outcomes than patients at hospitals where nurses regularly provide input and hospital executives hold frequent meetings to review patient results, according to a study published in Annals of Internal Medicine.

3. "The problem has been getting large hospitals — the proverbial elephants in our healthcare jungle — to make those types of changes, measuring those cultural changes, then gauging if those changes result in improvements in how patients do," Dr. Chen said.

Researchers have traditionally had no way to measure hospital culture or assess if any cultural changes made at hospitals were statistically significant, Dr. Chen wrote. But one group of researchers recently developed a set of strategies that target hospital organizational culture and a way to reliably measure how these strategies affect hospitals.

4. In a recent study, the strategy, called "Leadership Saves Lives," showed hospitals could implement significant cultural changes that could affect patient outcomes in as little as two years.

"Leadership Saves Lives" requires each hospital to create a "Guiding Coalition," a group consisting of more than a dozen staff members, including top administrators, clinicians, nurses and technicians from across the facility. These members participate in regular workshops, discussions and national forums on ways hospitals might improve. They then help their hospital put these strategies into clinical practice.

5. The researchers launched "Leadership Saves Lives" in 10 hospitals that varied in region and size, but all treated large numbers of heart attack patients and shared below average patient outcomes. Over the course of two years, the research team regularly surveyed and interviewed each guiding coalition member using the research tools they developed to measure cultural changes in hospitals.

6. The study revealed each of the 10 hospitals changed significantly, but six hospitals experienced especially effective cultural transformations. Staff from these hospitals attributed the changes to an institutional shift from focusing on "because I said so" organizational culture to "focusing on the why's."

"Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols, for example, it became more important to provide the data that proved such rituals were actually helpful," Dr. Chen said.

7. On the other hand, the study revealed providers who worked in hospitals without these significant changes described expectations of deference to authority, a tendency to blame and make promises without follow-through and a work environment "so squarely in the box that we can't even see the edge," one provider said in an interview.

8. Moreover, the researchers found the degree of an institution's cultural change was directly tied to patient outcomes. The hospitals that underwent more substantial changes in their organizational culture saw larger and more sustained drops in heart attack mortality rates.

"What is different about this work is that it has proven that cultural change is possible and can save lives," said Dr. Patrick Geoghegan, professor of mental health and social care at Anglia Ruskin University in Britain, who is leading a program based on Leadership Saves Lives in the National Health Service. "You can have all of the best policies, procedures and strategies, but if the hospital's organizational culture is not receptive, then you will fail."

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