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Showing posts with label culture. Show all posts
Showing posts with label culture. Show all posts

Thursday, 22 October 2015

Micro Culture within Organisations: What is it? Why does it matter?



Culture is the ideas, customs and social behaviour of a particular people or society (Oxford English Dictionary). Organisational culture is the behaviour of humans within an organisation and the meaning that people attach to those behaviours (Wikipedia). The operative part of the ‘definition’ of organisational culture is the ‘meaning that people attach to behaviours’. It immediately becomes apparent that it is not about how we behave; it is all about what others who work with us think what our behaviour means. That is why getting organisational culture right is very tricky if not impossible. Understanding the concept of microcultures could help us in this difficult area.



Culture in Society



The society we live in has macro and micro-cultures. Macro-cultures are thought to be the majority groups whose norms are very visible and these become dominant, overarching and can be seen across historical timelines which means they are often long lasting. Interestingly within the macro-cultures there may be dominant small groups whose influence on the macro-culture is significant and overwhelming. For instance, parliamentarians are a small group who have disproportionate influence on society, they are representative which means we choose them to influence us. An example of a dominant small group within the macroculture who are non-representative are Oxbridge. There are many other examples of dominant small groups.



Society also has micro-cultures. The microcultures are generally thought of as being numerically small, voluntary, short-lived, situation specific, weak, non-dominant and not so visible.  However there are very numerically large groups within the population who form microcultures, for instance ‘women’ and unions amongst others. We can also see micro-cultures that have been around for a very long time such as the Amish and yoga. There are also microcultures that are very powerful such as think-tanks, activists, extremists, etc; some microcultures have been so powerful in their times as to change the society in permanent terms for instance the antislavery movement in the west. Microculture has always been viewed by the macroculture of any specific period in time with suspicion, as a threat, as very different and generally poorly understood.



There is another cultural entity called subculture which is distinctly different from yet often misunderstood as being a dominant small group within macrocultures or being a microculture.



It seems that macro-culture is similarity based who do not mind, often understand and even tolerant of reduced values. Microcultures are value based meaning that there are strong traits of equality, morality, ethicality and other traits held precious with microcultures feeling that they are forced to tolerate similarity. Subcultures are based on difference and variance ‘I am better than you. You are worse than us’ etc and exploit those differences without exploring the contexts adequately, often to personal benefit or detriment of the members of the subculture.



Organisations and MicroCultures



Organisations mirror society and within organisations there are micro-cultures. In organizations, especially in healthcare organizations, ‘micro-cultures’ have not been subject to proper study. There is a general assumption that it is best for everyone in an organisation to have a similar culture i.e. an overarching organisational culture. In reality, there are numerous cultures within an organizational culture, which is only normal. However, there may be some good micro-cultures which may want to observe and learn.



The micro-cultures have similar structure, activities, qualifications, finance, job descriptions, titles and staff specifications as the macro-culture but the expressions and the results of these vary significantly from the organisational macro-culture.



How To Do It



What or how are the specifics of a good microculture that enable a different expression and better results?



In the micro-culture that I experienced, we did whatever was statutorily required of our organization and mandatorily required by our organization. The micro-culture related methods and behaviour are over-and-above what was required of us; it was not a replacement behaviour neither did we think it was an add-on. It was just the essence of the way we worked.



My observation suggests that what we do more of some things and less of others. Here is a brief list:



We did more of
We did just the amount required of us
Feed-forward
Feedback
Support
Challenge
Direct specific communication
Emails/memos/ ‘cascade’
Generic incremental ‘planning’
Formal planning
Taking responsibility for others
Holding to account
Praise
Criticism/complaint
Learn small & frequent
‘Formal’ learning
Routines for us
Variations for the patients
Upstream
Downstream
Talk often and short
Long speeches and big meetings
Internal recognition
External recognition
Yes
No



Due to these methods and techniques we were able to have a supportive and friendly environment.



MEASURING THE SUCCESS OF ORGANISATIONAL MICROCULTURE



We may attempt to measure the successes of micro-culture in many ways. Since culture is often defined as the ‘way we do things here’, I have chosen to measure it by some of the things we did differently. Many of these methods were exclusive to us, some have been done much ahead of time before other areas. I have chosen our record of innovation as a ‘measure’ to demonstrate the success of our micro-culture. I have already published about the innovations http://successinhealthcare.blogspot.co.uk/2014/10/innovations-in-small-hospital.html

The results in general principle, result in happier staff, lower costs, quicker times for patients, often better results, better retained learning and such other positive impacts.



Culture and its effects are difficult to measure. Surveys have been used with staff self-reported scores and users perceptions. These are useful up to a point. The tangible link between micro-culture methods, processes and behaviours to outcomes will always difficult to elucidate. However, we believe that while a happy working environment is vitally important, we also believe that such an environment should result in some relevant outcomes. We believe that while our structure, activities, specifications, qualifications and knowledge are more or less similar to any organization and its specific departments our expressions of these and our results are different and take the form of the innovations which have been described above.





What can we do with the concept of Organisational MicroCulture?



Microcultures are often appreciated but at the same time often criticized. Some microcultures seek attention, some often shun the limelight.



The point is to assess the micro-culture on the basis of contextual impact, what is good for one may not be good for another, what works at one time may not work another time, what is seen as bad may become acceptable at a later point of time. (Mandela, IRA, PLO)



In organizations firstly micro-cultures should be allowed. We know that often there is no single recognizable so called organizational culture especially within the healthcare context. Next, more importantly supported on the basis of results that matter for the patients (and not on some vague notions of what a pan-organisation culture ought to be).



If you were a senior person in an organization, as you support a micro-culture you will also have this burning desire to ‘spread out’ ‘roll out’ an identified brilliant culture and reap the benefits of results and happiness for the whole organization; unfortunately it does not work like that. We may love the way that the Amish live today but we will be unable to roll it across the world or even use it for us. Products can be rolled out, packaged popular cultures can also be rolled out (eg MTV) but work place behaviours seem to be too personal, too individual, too variable, hence too complex to roll out.



What we can do is to grow our own, micro-propagate. We can become aware and make others aware of effective micro-cultures, managers can encourage and enable interaction with micro-cultures. Managers should be aiming for an environment of varying positive microcultures (and not necessarily one large single positive culture which generally exists in management books). Managers should not be aiming for a coalescing of cultures, though that sometimes happens on its own. Processes and activities can be copied, a culture cannot be copied.





Though I have described our observed methods, there is no real ‘model’ and hence there is no proper way to ‘replicate’ it. However, there are principles which can be reflected upon which can then result in growing your own micro-culture. We are not issuing a self-assembly kit – we are sowing some ideas some of which you may want to use to create your own beneficial micro-culture. It is our view that micro-culture cannot be replicated but can be propagated.







©M HEMADRI







Follow me on Twitter @HemadriTweets



PS:
A) There is a particular academic reference to the first few paragraphs of this blog which I have misfiled and will post it here when I find it
B) This topic was presented at the Clinical Microsystems Festival, Jonkoping, Sweden in 2015 







Wednesday, 24 April 2013

My Conversation with Dr Ravindran, Chairman of Aravind Eye Care


I had the privilege of meeting Dr Ravindran, Ophthalmologist and Chairman of Aravind Eye Hospitals, India, at the International Forum for Quality and Safety in Healthcare London 2013. I had a general informal conversation but it was of course an eye opener - you bet he has experience in that!

I share some of the conversation here. 

Clinicians' Selection processes at Aravind

Doctors

It is well known that Aravind has processes that are followed really well by the staff, especially doctors who work there. Protocols and processes are very important for their pathways and systems to work. It is also well known in healthcare that it is very difficult to get doctors to follow organisational protocols. I asked Dr Ravindran on how they do that.

Aravind appoints doctors after a 3 day selection process. Applicant to appointment ratio is a minimum of 3:1. Fellows and residents work and spend time with staff on those three days. Doctors then provide feedback to the appointments panel on the suitability of applicants. Anyone blackballed by existing staff are not selected. The main if not the only criteria for appointment is if the doctor is 'suitable for our culture and basic values'.

They obviously get people who are already high flyers with research credentials, publications, etc but Aravind's attitude seems to be that they want only normal average people to work with them and their system and culture will then make them do good work. (This sounds very similar to Toyota Chairman Cho's statement that they get brilliant results from average/normal people when other car manufacturers get average results from brilliant people). These high flyers, if they are not suitable for the Aravind culture are told that they are likely to be very successful outside the Aravind systems.

Chairman Ravindran says 'we want everyone to be pleasant and professional to each other. If we detect even a small amount of arrogance during the selection process, we will not appoint the person. Arrogant people can offend and upset others which will disrupt team work and increase staff turnover - we cannot have that'.

Nurses

Student Nurses are selected after a written test and an interview. The test is a hand written test where they answer a question on a social concept. Hand writing is thought to be important (if you cannot read a person's writing the value of their documentation and written communication becomes a future problem). As for the content, it is thought that if a young aspiring nurse cannot write with genuine empathy about a socially important issue they would not fit in with Aravind's culture and communication.

Now comes the interesting part of the process. While interviewing the applicants is what everyone does anyway, Aravind interviews the parents of the applicants. They see this as very important. Attitudes of parents and aspects from home have an influence on how people behave and work. This is accounted for in the interview and selection process.

Once they are selected to be nursing students, Aravind pays for their training, accommodation etc. These students after graduation get to work for Aravind.

I probed their thinking - I said that the society will have many different types of people and their organisation will/should have different type of people; including and excluding some types will not reflect the society. Dr Ravindran was very clear with his answer, he said that of course the society  will have many types of people but in his organisation they only want the type of persons who can share their basic value.

Their basic value is compassion.
 
He also said that many in the organisation including the senior people continue to engage with the staff and their lives, he said 'I know a lot about many people who work with us, what they enjoy, what problems they have at work, what issues they have outside work and in general a lot about their lives. Due to this we are able to support them very early.'

Learning

I specifically asked him about where and whom he and his organisation learns from. He says that their main learning is from within their organisation, they try to improve everyday and share it with their internal colleagues -  mutual learning within the organisation. (This blog has in a previous post stated this as the fourth fundamental condition if healthcare is to be successful http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html )

No external consultant has even been contracted. No lean specialist, no management consultant. They get regular visitors trying to learn from the Aravind system. Aravind staff do visit hospitals around the world to explore what might be suitable for adaptation.

Attitudes

When asked about how they deal with the high volume of patients Dr Ravindran said 'If we have more patients we simply start early - all of us. We do not put patients on a waiting list, we do not turn patients away'.
I asked about being lean and quick and his response was 'It is not about being quick. It is the attitude of not wasting anything. So if we don't waste time it looks like we are quick. We do not throw away anything; if a bed sheet is torn you can be sure it will re-appear in some other form to help with some other function'.


I think my commentary is not really needed as the conversation is very illuminating and self-explanatory. Their website shows that eight out of ten directors of their board are doctors - does that say something? I think we can learn a great many things from Aravind Eye Care and their practices. I wonder what we can actually adapt and use for healthcare delivery in the western world?

©M HEMADRI 
Follow me on twitter @HemadriTweets
Links
Aravind Eye Care http://www.aravind.org/

Monday, 25 February 2013

The Pretence of Better Communication

This blog was first published at doc2doc http://doc2doc.bmj.com/blogs/doctorsblog/_pretence-of-better-communication It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.



5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.



Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.



Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.


The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond markets...an error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'


Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.


Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.




©M HEMADRI 
Follow me on twitter @HemadriTweets

Saturday, 9 June 2012

High Mortality Hospitals Cannot Afford To Pay


In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 
 
A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 
 
It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

QUALITY IS INVERSELY PROPORTIONAL TO COST 
 
And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 
 
If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation
But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 
 
Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better
 
My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

©M HEMADRI 
Follow me on twitter @HemadriTweets

Sunday, 3 June 2012

Any links between bank holiday pay and mortality?


The Queen's diamond jubilee celebrations are going on right now. The government declared a 'bank holiday' on Tuesday 5 June 2012 (http://www.direct.gov.uk/en/Nl1/Newsroom/DG_183806). Some of us will still be working over the celebration period to keep essential and emergency services going. This includes NHS staff. Individual NHS organisations can decide on whether they will treat this extra holiday as 'bank holiday' or 'public holiday'; they do not have to follow the government declaration of a 'bank holiday'. 'Bank holiday' attracts a higher rate of pay for those who work on that day along with some other terms advantageous to the employees. 'Public holiday' does not attract a higher rate of pay.

Unite Union surveyed their members and found that 113 NHS organisations were treating this as a 'public holiday' and hence no extra pay for staff. (http://www.unitetheunion.org/news__events/latest_news/_named-and-shamed__-_nhs_emplo.aspx) They have called this 'mean-spirited' and called their publication 'named and shamed'.

My interest includes hospital mortality and I wanted to find out what the high mortality hospitals and low mortality hospitals did in terms of the bank/public holiday pay arrangements. I took the list of 21 low mortality hospitals and 19 high mortality hospital from drFoster's hospital guide and then cross checked with Unite's named and shamed list. The findings are interesting to put it mildly.

My findings are:

7 OUT OF 21 LOW MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not pay bank holiday rates)

14 OUT OF 21 LOW MORTALITY HOSPITALS ARE NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

14 OUT OF 19 HIGH MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not paying bank holiday rates)

5 OUT OF 19 HIGH MORTALITY HOSPITALS NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

Low Mortality Hospitals (as per dr Foster)

Unite's named-and-shamed list

Barnet and Chase Farm Hospitals NHS Trust In Unites' list
Barts and the London NHS Trust In Unites' list
Cambridge University Hospitals NHS In Unites' list
Chelsea and Westminster Hospital NHS Not in Unite list
Epsom and St Helier University Hospitals Not in Unite list
Frimley Park Hospital NHS Foundation Trust Not in Unite list
Guy’s and St Thomas’ NHS Foundation Trust Not in Unite list
Imperial College Healthcare NHS Trust† Not in Unite list
King’s College Hospital NHS In Unites' list
Kingston Hospital NHS Trust† Not in Unite list
Newham University Hospital NHS Trust† Not in Unite list
North West London Hospitals NHS Trust Not in Unite list
Royal Devon and Exeter Not in Unite list
Royal Free Hampstead NHS Trust Not in Unite list
Sheffield Teaching Hospitals NHS In Unites' list
South London Healthcare NHS Trust† Not in Unite list
St George’s Healthcare NHS Trust Not in Unite list
The Whittington Hospital NHS Trust† In Unites' list
University College London Hospitals Not in Unite list
University Hospitals Bristol In Unites' list
West Suffolk Hospitals NHS Trust Not in Unite list


High mortality hospitals (as per dr Foster)

Unite's named-and-shamed list

Blackpool Teaching Hospitals NHS Not in Unite list
Buckinghamshire Healthcare NHS Trust Not in Unite list
Burton Hospitals NHS Foundation Trust Not in Unite list
Dartford and Gravesham NHS Trust In Unites' list
George Eliot Hospital NHS Trust Not in Unite list
Hull and East Yorkshire Hospitals NHS Trust In Unites' list
Isle of Wight NHS Primary Care Trust Not in Unite list
Medway NHS Foundation Trust In Unites' list
Mid Cheshire Hospitals In Unites' list
North Cumbria University Hospitals In Unites' list
Northampton General Hospital NHS Trust In Unites' list
Northern Lincolnshire and Goole Hospitals In Unites' list
Shrewsbury and Telford Hospital In Unites' list
The Dudley Group of Hospitals In Unites' list
The Royal Wolverhampton In Unites' list
United Lincolnshire Hospitals In Unites' list
University Hospitals of Morecambe Bay In Unites' list
Worcestershire Acute Hospitals In Unites' list
York Teaching Hospital In Unites' list

Caution: This is a write up based on information that is publicly available so far. This analysis may not be accurate. We can find out the correct situation only when either NHS employers or individual trusts tell us whether they have paid extra treating it as a bank holiday or not paid extra treating it as a public holiday. So further enquiry and analysis would be needed to validate this. What is presented here is a mere observation and does not suggest cause and effect.

On the basis of current information (this may change when we have accurate information) it seems like there may be attitudes and cultures of organisations, management and staff, playing a bigger part in mortality and morbidity than we previously have assumed.

Please let me know if there are any factual errors in the above and I am only too willing to correct them.
©M HEMADRI 

Follow me on twitter @HemadriTweets