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Showing posts with label organisational development. Show all posts
Showing posts with label organisational development. 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 







Sunday, 9 June 2013

Whose job is it in the NHS to reduce deaths and complications?


Recently there is an increasing concern about mortality and morbidity in the NHS. Let us for simplicity say that people are asking whether the death rates and complication rates can be reduced. People are asking if there are any avoidable components in relation to deaths and complications and whether those avoidable problems can be eliminated or at least reduced to minimum. People are also want to know who is responsible or accountable for ensuring lower death and complication rates.

NHS Directors

NHS trusts are in the business of delivering healthcare to their populations – that is the essential purpose of their existence. So it may be reasonable to assume that the directors, who are the top bosses of these trusts  and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical quality parameters of which deaths and complications are core.

Apparently not. The contract for the managers especially when it comes to pay uplifts and bonuses are very specific. I quote:


''It is an essential criterion of the performance bonus scheme that the organisation achieves its financial control target as agreed with its grand parent organisation (see paragraphs 64 and 65 below).



Where an organisation fails to do this, all its very senior managers will be treated as Category D performers and so no awards (either annual uplift or performance bonus payment) will be paid to them



The annual uplift will be applied to the basic pay being paid to the post holder (which would include any long-term RRP payment), provided that:



the organisation achieves its financial control target; and



the individual concerned is judged as performing at Category A, B or C.



Those in Categories A, B and C will receive this annual uplift to their basic pay, which will be pensionable



Those in Categories A and B will receive, in addition to the annual uplift, a non-consolidated bonus payment, provided the essential criterion is met

i.e. that the organisation achieves its financial control target. Bonus payments will be non-pensionable, non-consolidated one-off payments


So it is seems the only officially contracted criteria to be eligible for a pay uplift and bonus is meeting the financial target (and something woolly about being classed as A, B or C. In any case if you don't meet the financial target it is an automatic D which means no pay uplift or bonus irrespective of how much quality is improved and mortality/morbidity is low

What do you think might be happening in a manager's mind when priority setting? Which director will be prepared to have a very low mortality and morbidity and yet be classed as a failure and given a D. If ever a CEO was prepared to do that what do you think that their directors's mind would think given the fact that various director's pay are set as a percentage of their CEO's pay. What does it tell Jo public when the Finance Director's pay is linked to and set at 75% of the CEO pay and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think the emphasis will lie? No guess work – it is explicit – financial control target it is and nothing else.

Now do I think for a minute that any CEO or director gets to work and says 'kill patients but save money', heck no. But we have all heard about subliminals, motivation, contractual obligations playing a part in how we perform. It does not sound sweet.

REGULATORS

We then have regulators to oversee that trust bosses who are contractually only obliged to serve the financial agenda are still meeting some sort of standards that matter to a publicly funded healthcare system – i.e. clinical quality with death and complications at its core.

Lets look at some of the regulators purposes:

Monitor: Our main duty is to protect and promote the interests of patients. We do this by promoting the provision of health care services which is effective, efficient and economic, and maintains or improves the quality of services.
CQC: We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and we encourage them to make improvements.
GMC: Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

But let us look at how it actually works out

CQC

The CQC talks about safety and quality but when you look into what they actually say there is no specific mention that organisations will be assessed against their death and/or complication rates
For God's sake how else do you assess care quality if you do not start with death and complications.


MONITOR

It is the government's aim to provide independence to NHS trusts by allowing them foundation trust status. Clinical quality especially reducing mortality and morbidity is not a criteria for affording independence (though there is assessment on whether the trust is governed properly)
With 10 out the 14 trusts under Keogh review being Foundation trusts, it is reasonable to wonder what actually the question 'well governed' means for Monitor.

BOSS' BOSS – The Grandparent Organisation is DoH

It looks like the department of health may have the overall responsibility for mortality and morbidity reduction though those are not explicitly spelt out in their website

It has taken nearly a decade and half after HSMR was introduced that DoH is making some moves to look into this. Perhaps better late than never. But as the grandparent organisation DoH is responsible for setting the contractual framework like it is in the first place.

What about doctors and nurses?

Doctors 

Doctors bonuses in the form of CEAs are based on quality of service and hopefully given to excellence. There is no requirement to demonstrate reduction of mortality or morbidity but the hope is that those two essential measures of quality will be considered explicitly when these awards are made. That is sometimes the case, sometimes that is not the case. In theory it is possible for even the highest award holders to hold the awards without ever demonstrating a decrease in mortality or morbidity.
Then of course there is the GMC who will come down on doctors who are caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format demands 'quality improvement' though does not explicitly demand reduction of deaths and complications. 

Nurses

Agenda for change does not speak explicitly about improving clinical quality or reducing mortality/morbidity.


So who is responsible for deaths and complications in the NHS?

It is everyone's job but no one is required to do it and nobody is responsible or accountable for it.

It does not say in anyone's job description or contractual terms that 'it is your contractual duty to seek and achieve a reduction in mortality and morbidity of your patients and when it is not achieved to provide a reasonable explanation of why they have not been achieved and what you will do to achieve them'. Nobody's pay scale is linked to a reduction of mortality and morbidity. Therefore no one is responsible or accountable for deaths and complications. People do it as an optional extra, as a gesture of goodwill, from the goodness of their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.

That is why it is so very impossible to deal with and so very difficult to get meaningful sustainable improvements. The contractual requirements, recognition and reward structures are all wrong in the sense they are not geared to look for quality improvement. Looks like this is a case where the structure and process results in just the expected poor outcome.

There are solutions – it is to use healthcare management methods to manage healthcare and not to use as we do now - business, financial, manufacturing, service industry or other management methods for healthcare. Whether there is enough interest, knowledge or expertise to do so is highly questionable.


©M HEMADRI 
Follow me on twitter @HemadriTweets

Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013