HomeMay 2016Does culture or process make a difference?

Does culture or process make a difference?

There has been a lot of talk about leadership recently in the healthcare service. One definitely needs leaders to change the way we do business. And it is thought that the development of both clinical and managerial leadership should be done in partnership – it is not one or the other. It is regrettable that often the relationship between management and clinicians has been adversarial. Perhaps now is the time for a new partnership to develop and for us to study those teams that work well together.

Dr. Peter Lachman
Dr. Peter Lachman

As soon as one talks about change one ends up discussing the culture of healthcare and of different organisations. One is often led to believe that change cannot happen due to the cultural barriers that lie in the path of the improver. It has been said that the different professional groups wield their power and that it is their culture that determines the way we will change. First change the culture and then all will follow.

Managers have a mandate to facilitate the continual improvement in the interactions providers have with their patients.

In the April edition of the Harvard Business Review (https://hbr.org/2016/04/culture-is-not-the-culprit) this difficult issue is discussed by Lorsch and McTague who start of by stating definitively that “the corporate leaders we have interviewed—current and former CEOs who have successfully led major transformations—say that culture isn’t something you “fix.” Rather, in their experience, cultural change is what you get after you’ve put new processes or structures in place to tackle tough business challenges like reworking an outdated strategy or business model. The culture evolves as you do that important work.” The article then uses three case stories to demonstrate that process can define and change culture. All of the studies have particular relevance to management of healthcare, though one example will demonstrate this. One CEO demonstrated the idea that the frontline knows best and should be trusted with decision-making and problem solving. This sounds very similar to Deming’s 14 principles in which the liberation of the frontline workers from inspection and targets was recommended.


This is taken up in the approach on frontline ownership by Liberating Structures which is another take on allowing those who deliver care to be actively in charge of improving care. http://www.liberatingstructures.com/

The other case histories are about developing collaborative cultures by changing the process of working within the organization. On reading this HBR article I began to wonder how we could transpose this to the healthcare setting? Clinical Microsystems are considered to have a key role in affecting change and the culture of an organization will reflect how effective they are. The changes that take place occur at the healthcare provider and patient interface. https://clinicalmicrosystem.org/. Managers have a mandate to facilitate the continual improvement in the interactions providers have with their patients. Decision made at all levels will positively or negatively impact on what happens at that interface. Quality improvement requires frontline ownership of the problem and the solution. By allowing the frontline staff to solve the problems and by creating effective processes that facilitate, we could possible see a culture of person centred and safe effective care develop across healthcare. This runs against the usual command and control model that is common in healthcare.

So while “culture eats strategy for breakfast,” we need processes aimed at the facilitation of a person centred and safe culture within a collaborative management style. Perhaps we should all reflect on our management processes and how we work collaboratively with the frontline staff. Instead of exhorting them to achieve, setting them targets and then inspecting them against standards that we set, we could work collaboratively to achieve the common purpose we all have.