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Intervening in Culture: A guide to practice
Part 4 of a short series on 'Culture' in patient safety
Satyan Chari
August 29, 2024
AI generated image Illustration of a chimeric beast representing culture, composed of everyday objects and societal symbols.
Culture is a useful lens when managing and understanding processes of change in complex healthcare organisations. But simplistic attempts to manage or engineer culture change from above, based on old ideas from the 1980s, airport bestsellers, are unlikely to succeed.
Introduction
Welcome to the final instalment of a four-part series on culture and patient safety. In the previous three issues of The Human Stream, we looked at the origins of the ‘safety culture’ concept and how it has come to be defined and measured in healthcare. We then reviewed popular initiatives that are employed to influence safety culture within our sector. Along the way, we touched on some of the many contradictions and debates that plague the question of culture and safety in healthcare.
Several key points are worth revisiting quickly, especially if you have not been following along through previous issues (these are presented in the box below).
In this issue we try to present a practical take on how to navigate questions of safety culture enhancement and in parallel explore how contemporary thinking on cultural models can be applied in our other efforts to enhance safety.
Recap of key points
‘Safety culture’ emerged as a container term rather than a causal explanation. ‘Safety culture’ was coined in the aftermath of the Chernobyl disaster to describe the complex social, political and managerial characteristics that precipitated degradations in safety practices, organisational attentiveness to critical risks and related mitigation efforts.
The idea that positive safety cultures are protective was added later: While initial use of the phrase did not suggest that certain “positive” safety cultures were protective against failure (only that culture had some bearing on the genesis of certain accidents), the notion of positive safety culture (as a goal) emerged quickly thereafter.
Work on safety culture markedly diverges from conventional cultural research: Influenced partly by developments in management theory, safety culture was progressively “instrumentalised”, in that it came to be treated as something measurable, aspects of which could be manipulated independently of other things within organisations. This “instrumentalisation” of culture is widely rejected by fields that primarily study culture such as anthropology and sociology. Similarly, healthcare sociologists have flagged the contradiction that while it would be more in line with the science to view cultures as something that healthcare organisations ‘are’, it has become more commonplace to treat cultures as something organisations ‘have’ (‘essentialising’ or reducing the concept of culture in order to relate to it in an instrumental fashion).
The safety culture concept continues to be viewed with suspicion by safety scientists: Many prominent safety scientist have remained unconvinced that a) the concept of safety culture adds any explanatory value to the genesis of accidents, b) available measures of safety correlate in any reliable way with the actual capacity for producing safety in complex organisations and c) these can be manipulated in the ways that organisations typically attempt to.
From container term for things that did not fit, to one that encompasses everything: Another point of concern among informed commentators has been the trend towards drawing more and more aspects of organisational safety under the umbrella of safety culture (a trend seen in patient safety as well), making it into an even more nebulous concept.
Contradictions persist: Fundamental issues exist at the level of definitions, and debates continue on whether culture is a cause of important safety practices (like reporting) or the effect or both, and whether safety culture represents a phenomenon that is amenable to intentional modification.
Newer concepts don’t resolve existing problems: The concept of safety climate has evolved within the safety culture literature and seeks to provide a readily measurable “snapshot” of the organisational mood around safety. This is not without its own problems as the relationships between safety climate, safety culture and organisation culture are yet to be explicitly traced, with insufficient clarity on the pathways of effect to generate valid hypotheses for intervention.
Changing culture to change practices
There are vast differences in how culture is conceptualised across the many fields that offer perspectives on the topic - from management science to sociology and applied complexity science. These differences become amplified as we move from theory into practice and even more so as move from the science into the realm of management consulting, media experts, best-selling authors and bloggers.
With so much contradictory and confusing material out there, it can be tempting to disengage from the culture conversation entirely. Yet, culture is a major pillar of contemporary patient safety programs, and we intuitively recognise that background "cultural stuff” does shape our pursuit of patient safety goals even if we cannot fully describe what we are dealing with. We often need to intervene in an organisation’s cultural systems directly (such as in the aftermath of serious failures in safety) and at other times we need to understand and manage its impact on more routine efforts. Ignoring culture does not seem to be on the menu, so what can we do?
In the “Making Culture Happen”, Russell Mannion presents an up-to-date picture of current thinking on culture change in healthcare, drawing in some of literature pertaining to aspects of safety culture (such as the reporting of transgressive behaviour). The original article is well worth a read, but we can abstract a short list of general culture change axioms from it. Namely:
Recognise and account for the existence of subcultures within an organisation.
Make leadership support visible and believable.
Create ownership and buy-in among staff at all levels.
Do not ignore the influence of professional cultures, organisational structures and the external context.
Focus on changing both observable behaviours and underlying beliefs/assumptions.
Be alert to the potential for unintended consequences of culture change initiatives.
Create coalitions for change and apply political astuteness to manage resistance and build support for changes.
Yet, for those interested in real-world translation, many questions remain. How exactly do we surface the possible ways that professional cultures might shape the course of a change initiative? What unintended consequences should we be on the lookout for? What does a politically astute path look like in a specific situation? How do we influence underlying beliefs? Does any of this lead to the shifts in practice that. we seek?
While a lot of the culture change literature stops short of that level of granularity, there are other ways of thinking about culture that can help us go further.
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Change practices to change culture
A lot of our cultural models originate from meaningful shared experiences which are indelibly tied to the organisation’s “means of production”, which is a simple way of saying that if you are a hospital, then you have cultural models that are tied to what hospitals do. This is because the task environment - the environment in which you have to thrive in, survive in and make sense of everyday - delimits the types of cultural models that will have adaptive value in that environment.
In his 2020 book “Disrupting Corporate Culture”, cognitive anthropologist and organisational transformation expert David G White suggests a different path.
Drawing on cognitive science and anthropology, David argues that culture is not primarily about values, beliefs, or visible artefacts, but rather emerges from shared cultural models (tacit knowledge) or "dominant logics" that develop through collective experience.