linda betts & associates 2004 rmit health service leaders: how is the role changing? counting...

Linda Betts & Associates 2004

RMIT Health Service Leaders: How is the role changing?

Counting the Cost of Caring: Deciphering the culture in a public hospital Division and the implications for

change implementationLinda Betts - Project Consultant

RMIT Masters Of Business (Management) by Research student


An Organisational Development Approach Organisations are more than rational systems

and processes OD focuses on human and social aspects of

organisations OD takes a strategic and planned approach to

change that factors in people & behavior The culture of an organisations is seen as key My personal observations of the impact of

change in health over last 14 years…...


Defining culture

What is ‘culture’?

“the shared values, beliefs, norms and patterns of behavior in an organisation. It is similar to the personality of an individual…a hidden, yet unifying theme that provides meaning, direction and mobilization” (Gibson et al 1994 p. 62)


Defining culture

Alvesson (2002) - common assumptions about culture in the literature

They are related to history and tradition; They have some depth, are difficult to grasp and account

for, and must be interpreted; They are collective and shared by members of the group; They are primarily ideational in character, having to do

with meanings, understandings, beliefs, knowledge and other intangibles;

They are holistic, intersubjective and emotional rather than strictly rational and analytical. (p.6)


Why is culture important?

Since 1980’s numerous management theorists and

practioners have promoted the importance of culture and

its impact on organisational performance.

“Culture not official rules or policies ultimately

dictate what you can and can’t do” (Deal &

Kennedy 1999, p. 40).


Can you change culture?How is culture learned? ‘Socialization’ is a key part of learning a

culture not ‘taught’ with the recipient as a passive

receiver but is learnt by the new staff members through active learning

Includes observation, making mistakes/being punished and being rewarded often in subtle ways by earning approval or inclusion for behavior in-line with the culture. (Schein 1992)


Can you change culture?

Much of the Literature shows culture is very difficult to change and happens over a long period.

Deal & Kennedy (1999) …2 of the original gurus of change:

“There must be a million consultants promising to help “change the cultures” of companies. What a lot of bollocks. Cultures change only when they need to and are damned well ready to change”


What’s so special about hospital culture? Allegiance to Professional culture History - class, gender, power

influences “strong’ cultures evident - oaths,

professional association, registration, training/education

Resistance to being ‘managed’


A Case Study of Deciphering Culture RWH - Division -Identified concerns and problems in

a particular Division and asked for assistance Recent history - increased activity, through-put &

acuity, nursing staff shortages, high levels of tension & conflict between staff

Absence rate - 12.8% Casual staffing - $0.7 million 17 nurse vacancies - staff turnover rates increasing Zero applicants for advertised jobs


Wider Internal & External ClimateInternal Amalgamation Change of CEO Changes to senior

management Change to structure Budget reduction Quality measurement

priorities Targets priority

External Major political &

economic reform in 1990s

Casemix funding model Restructure of hospitals

in Melbourne Redundancies Competitive Neutrality Budget reduction


Deciphering the climate and culture Read the history, listen to the stories Interviews & Focus groups with staff -

‘outsider’ view important Report on findings - acknowledge the

positives, identify concerns, make recommendations for change

Reference Group - multidisciplinary, cross-sectional, open to learning not ‘fixing’


Cultural Mapping - Schein’s Model of Organisational Culture

Artifacts

Espoused Values

Basic Assumptions

History…...

Surface Level - systems, processes, buildings, org structure (hard to decipher)

What the organisation says its about - written documents, speeches, strategic plan

“Unwritten rules” - unconscious, undiscussed values, beliefs & philosophies

Schein, E, 1992 Organizational Culture and Leadership, Jossey-Bass


Organisational Defensive Mechanism

Argyris - (Argyris, C. 1997 Initiating change that perseveres, The American

Behavioral Scientist, Thousand Oaks, Vol. 40, Iss. 3; pg. 299-310)

beliefs become embedded in org culture tacit, unconscious, ‘undiscussable’ if challenged - threaten or embarrass

beliefs= defensive or attacking response

Impact - hard to change, ‘anti-learning’


Findings - Artifacts Environment Hospital structure Quality & measurement Budget reduction New managerial focus Clinical workloads Staff shortages Research


Respect for staff openness

Privilege to work with the staff Cultural mapping requires identifying

beliefs and “unwritten rules” - some of these could be judged as ‘wrong’ or ‘outdated’ but need to be understood within the cultural history and context

Never denigrate the past Breaking “dirty laundry” rule...


Findings - Espoused Values Quality - Highest standard of patient care Integrity - Honest and open communication Valuing staff - Contribution of all individuals is

encouraged & recognised Unity - Team approach Diversity & equity - respect for difference Teaching & training important Customer focus Excellence & Innovation


Findings - Basic Assumptions

Existence of Sub-cultures evident from process

This lead to additional facilitation of cultural mapping sessions with various professional groups from the Division


Basic Assumption - Nurses

“Don’t rock the boat” Cope…no matter what Credibility equals expertise & length of

service Our way is best Know your place Don’t air the dirty laundry


Basic Assumptions - New Graduate NursesPrior to starting: Question everything Nurses will be respected for asking questions Nurses have a voice Nurses can make decisions Nurses are valued as part of the

multidisciplinary team New staff are like ‘gold’ Nurses should advocate for their patient


Basic Assumptions - New Graduate NursesPost starting: New staff know nothing New staff are a burden Power equals how long you have been here Don’t question This hospital’s way is the best and it can’t be

done better You have to prove yourself by conforming to

the group


Basic Assumptions - Doctors Don’t make mistakes Have good clinical skills Please the consultant Adopt a similar practice Learn quickly Always cope and “get through it” Manage all workloads - can’t say ‘no’ Don’t stint on cost/care Don’t stick rigidly to rules - individual

professional judgement important


…Some implications Professional subcultures Beliefs are strong, traditional beliefs aligned

to professional groups Does not appear to have shifted by recent

economic & political reforms May be that structure and system change has

not necessarily meant cultural change Incongruency may exist btwn management

and clinical professional cultures - Lit shows this = staff satisfaction & turnover


A final optimistic noteWithout setting out to ‘change culture’ the

project did deliver good outcomes over 18 month timeframe:

Absence rate decreased to 4% (from 12%) Staff turnover decreased, 100% of new graduates

stayed on for first time in years Zero vacancies Waiting list of new applicants Increased staff satisfaction (Best Practice Survey results)

No. of nurses “at risk of leaving nursing or the organisation decreased by 58%” (Best Practice Survey results)


Acknowledgements

Thanks to RWH management for supporting & resourcing the project

Thanks to RWH Division staff for being so open and honest..and trusting an ‘outsider’

Thanks to Rosalie Holian & Ian Woodruff, RMIT supervisors


More information…...

For further details please contact: Linda Betts

[email protected]

or phone 0409 420 991

linda betts & associates 2004 rmit health service leaders: how is the role changing? counting...

Documents

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culture n alvesson

n allegiance

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hospital culture

linda betts associates

importance of culture

people behavior n