Why It Matters
"The way you’re behaving and communicating as a leader right at this moment is a key determinant of culture."
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Pay Now or Pay Later: The Value of Taking Time to Shape Culture

By Neil Baker | Tuesday, February 12, 2019

There’s a lot of talk about culture today in health care, but not necessarily much clarity on how to change it for the better. In the following interview, IHI faculty Neil J. Baker, MD, describes how leaders shape culture whether they realize it or not. Baker will be a presenter for D5/E5: Managing the Risks of Power in Shaping Culture at the IHI Summit (April 11–13, 2019 in San Francisco, CA, USA).

What do you mean when you talk about culture? Why is it important to address?

I believe that culture is the way we do the work. If you and I are working on a team, it’s how you and I communicate, how we identify and handle conflict, how we run meetings, how we solve problems, and how we give and receive feedback. Culture is the way we make decisions, how leadership is expressed, and how accountability is managed. It’s the stuff that’s woven into what we’re doing every day that can be invisible because, in the high pressure and stress of work, it is so easy get pulled into focusing mainly on the technical aspects of the work and getting things done right now.

Culture defined in this way matters because there’s a lot of evidence across different fields that it has an impact on a whole range of outcomes. I’m talking about performance outcomes, quality, safety, profitability, productivity, customer retention, and employee turnover. It’s clear that an environment of empowerment, that taps into intrinsic motivation, and provides psychological safety is a key determinant of those outcomes.

It’s also important to note that leaders with positional authority — those who have hiring and firing power within a hierarchy, do performance appraisals, and manage resources — have an outsized effect on what happens in the culture.

Would you elaborate on the impact of culture on patient and workforce safety?

An important determinant in achieving the best results in all the outcome areas I mentioned —including patient and workforce safety — is the ability to have open and honest conversations. This means people feel safe to express concerns, ideas, disagreements, and negative feelings and know that [what they say] will be explored and heard as opposed to discounted or negated. In a safe environment, people don’t fear being embarrassed [if they raise a concern]. The ability to have open and honest conversations may sound simplistic or reductionistic, particularly in health care where we get so used to complex algorithms of care and work processes. But it is powerful, important, and fragile. 

What makes the ability to have open and honest conversations so fragile?

While we have a professional image of ourselves as rational, analytic, and in charge, we’re also human. As humans, we were hardwired early in our evolution to be highly sensitive to the environment in order to survive. In modern times, these survival systems make us highly sensitive to each other and, often outside of our awareness, can make situations feel unsafe. Multiple studies across different industries have shown that small differences in behavior can influence the ability to sustain open and honest conversations. This includes people speaking up when there are safety concerns. So, sustaining open and honest conversations requires constant attention.

Leaders are core to that. Everybody needs to encourage open and honest communications, but leaders automatically set where the attention is and how behavior goes. They are also key to making course corrections if things get off track.

How have leaders focused on culture to address burnout?

When I look at leaders who have been able to accomplish joy in work — a very engaged, empowered workforce — they are constantly paying attention to how they’re behaving and communicating. They understand that they need to encourage open, honest communication and quickly make corrections when things get off course. Leaders who cultivate psychological safety and joy in work know how people are doing because it’s at the center of everything for them.

Some of the best leaders may not even realize they’re focusing on culture in this way. I have asked such leaders what culture means to them, and they not infrequently say, “I don’t know,” but, as I talk to them about what they do each day, I find out they’re checking in with people all the time: “How’s the work going?” “We’re hiring a new care manager. What do you think about that role?” “You were kind of quiet at the last meeting. How are things going?”

I think [burnout has become a problem] partly because leaders exist in the same kind of high-pressure, high-complexity, fast-paced, results-focused culture everybody does. It’s so easy to be pulled out of paying attention to the human side of health care [in that kind of environment]. To solve burnout, I think a key component that we need to address is a gap in leadership.

LEARN MORE: IHI Summit on Improving Patient Care, April 11–13 in 
San Francisco, CA

What do you mean by a gap?

As humans, remember we are all hard-wired for survival reactions and we will have blind spots for that. This happened to me as a leader. Under the stress and pressure and complexity of daily work, I could be provoked into driving work according to tasks and timelines — that is, mainly focusing on getting things done instead of taking time to really listen to people.

What I learned is that I needed to increase my self-awareness to recognize the gap between what I espoused to be as a leader and what I was actually doing. This kind of self-examination requires humility and vulnerability.

If I didn’t make changes with this kind of self-examination, I was more likely to get signs of burnout in my staff. To address burnout I have to be able to stop and listen. That is hard to do. And, I think health care systems too frequently fall short in providing an environment to encourage that.

It might be understandable if a very busy leader — with so many demands on their time and attention — said, “I don’t have time to ask people how they’re doing. I don’t have time to build relationships in the way I’d like. I don’t have time to shape culture.” What would you say to that?

I have compassion for leaders because I’ve been one. I’ve been a leader who has gotten off track, gotten too task-oriented, and didn’t spend enough time engaging people. It’s hurt people, inadvertently. I don’t want to ever do that again, and I want to help other leaders avoid that.

The problem is that culture is happening right now whether you like it or not. The way you’re behaving and communicating as a leader right at this moment is a key determinant of culture. By saying you don’t have the time, you are choosing to shape culture in an unintentional, unsystematic, and inconsistent way. Without a clear intention and determination to [shape culture] by behaving and communicating in a certain way, you are likely to fall prey more often to the hardwired tendencies toward focusing on tasks, timelines, and to-do lists. This will undermine psychological safety and development of intrinsic motivation. 

The result will be an increase in burnout and turnover and failures in innovation and poor results. The costs to the system can be gigantic. You have to pay now by taking the time to be intentional about culture or you will pay later by spending more time and money trying to make course corrections. The bottom line is that it is an illusion to think we can set culture aside because we don’t have the time. 

Editor’s note: This interview has been edited for length and clarity.

Learn more from Neil Baker, MD, during session D5/E5: Managing the Risks of Power in Shaping Culture at the 2019 IHI Summit on Improving Patient Care (April 11–13, 2019 in San Francisco, CA, USA).

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