Perched atop a hill overlooking a major thoroughfare, the massive brick tower was a holdout from decades earlier. With green tiles lining the walls, black and white linoleum flooring, and hallways redolent of an antiseptic whose recipe hadn’t changed since the 1950s, the hospital had a distinct postwar feel, and an unchanging culture to go along with it.
For surgical trainees like me in the 1990s, the institution’s resistance to change was best embodied by a four-page, single-spaced document affectionately known as “The Hernia List.” An unofficial register of patients waiting for a hernia operation, the list had come about because every time a patient experienced an operative complication, a new clinical rule was added to the list of preoperative prerequisites. 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. Patients spent months “on the list” waiting to get “clearance” for what was considered a relatively 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. We understood our place at the bottom of the hospital totem pole, and the ritual seemed too deeply entrenched to ever change.
“This hospital is like an elephant,” sighed a fellow trainee one afternoon as he thumbed through the infamous list. “When she goes to the right, you must go to the right. When she goes to the left, you must go that way, too.”
I remembered the list and my colleague’s words after reading a recent study in BMJ Quality and Safety proving that, in fact, hospitals can change and that a more open and egalitarian hospital culture can help patients do better.
Health care 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. Heart attack patients who are treated at hospitals where nurses feel powerless and senior management is only sporadically involved in patient care tend to fare more poorly than patients hospitalized at institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results.
Researchers have had no way to measure hospital culture; and even with generous support from nonprofit organizations and pressure from government entities and patient advocacy groups, institutions that have attempted to transform had no way to assess if those cultural changes were statistically significant. Many ended up making changes not across an entire hospital but in only a single department like the emergency department or in only one aspect of patient care like the infection rates of catheters placed in major veins.
But over the last few years, one group of researchers has discovered both a specific set of strategies that target hospital organizational culture and a reliable way to measure the effect of those strategies. Implementing that strategy, called “Leadership Saves Lives,” the researchers were able to show in their most recent study that hospitals could undergo significant cultural changes that could affect patient outcomes in as little as two years.
“Leadership Saves Lives” requires that each hospital create a “Guiding Coalition,” a group of more than a dozen staff members, ranging from high-ranking administrators to clinicians, nurses and technicians from across the entire institution. The coalition members participate in regular workshops, discussions and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice.
To assess the clinical effect of the intervention, the researchers decided to look at heart attack patients, individuals whose care depends on the staff in several departments in a hospital. The researchers implemented “Leadership Saves Lives” in 10 hospitals of varying size and from different regions that all treated large numbers of heart attack victims but shared below average patient outcomes. Over the course of two years, the researchers regularly surveyed and interviewed all the guiding coalition members using the research tools they had developed specifically to measure cultural change.
The researchers found that all 10 hospitals changed significantly, but six hospitals experienced particularly profound cultural transformations. The staff of these hospitals spoke of an institutional shift from “because I said so” 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. Staff members in these hospitals also said they received, and appreciated, increased support from senior management and a newfound freedom to voice opinions in “more of an equal role, no matter what position you are.”
In contrast, providers who worked in hospitals without such profound changes described a persistent expectation 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,” in the words of one provider interviewed.
One hospital in the study, for example, had been struggling for years with poor outcomes because patients often had long wait times between the onset of heart attack symptoms and the initiation of appropriate in-hospital care. Many of the hospital’s administrators and clinicians assumed that little could be done because of their rural location. But the hospital’s EKG technicians knew of a new and relatively inexpensive transmitter that could immediately relay EKG results to the hospital.
“But the EKG technicians never felt empowered to speak up,” Dr. Bradley recounted. “The hospital C.E.O. never even knew that the problem of relaying EKG results existed but could be solved until he came together with the technicians in their hospital’s Guiding Coalition.”
The researchers discovered that the degree of an institution’s cultural change was directly linked to how patients did. Hospitals that made more substantial changes in their work culture realized larger and more sustained drops in heart attack mortality rates. Among the four hospitals in the study that experienced less dramatic cultural changes, there were improvements in patient outcomes, but the improvements were not sustained.
“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 spearheading 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.”
Dr. Bradley noted that if hospitals respond to challenges by embracing practices modeled in the Guiding Coalitions, like regular meetings that bring together hospital staff members from all levels and disciplines “in a psychologically comfortable and trusting place to speak the truth and to have meaningful conversations,” then these relationships and the cultural changes they inspire will “drive the sustainability of your improvements.”
“It takes bringing people together and redefining leadership as a role that anyone at any level can take,” she observed.
More research is needed, but in the meantime it is clear that for patients, having some sense of a hospital’s organizational culture can be a critical part of deciding where to get care, since the attitudes and interactions among administrators, doctors, nurses and other providers can affect outcomes. “We think we just need to get the best doctor,” Dr. Bradley noted, “but witnessing how staff treat each other is a pretty strong signal for how they will treat and care for you.”