I was a panellist at an improvement event last week, which was nice to do, (by Zoom, so much easier than trekking all the way to London btw). The topic under discussion was that of the research and evidence for improvement in healthcare. Case studies and learning about improvement over the last 18 months during COVID-19 were presented.
One of the questions asked after the two main speakers was related to culture, and the questioner pointed out that no one has mentioned the word ‘culture’ in the talks so far, which from their perspective was odd, as surely that was sentinel. I thought this was an interesting point, as it is sentinel, especially for sustaining new ways of working and associated improvements in quality and performance. So, why hadn’t it been mentioned specifically?
I reflect now that the point is interesting to me for three main reasons: 1) I hadn’t noticed that, but the questioner was right, yet in my biased head in a way generating a culture in which improvement thrives is precisely what was being discussed. So, why was the word culture not used? 2) how can ‘we’ as improvement practitioners make that link between culture and improvement more explicit, if we don’t have a habit of talking about improvement culture explicitly, and finally 3) what are the practical steps leaders could take to influence culture through improvement practice?
Taking each in turn. First, that word ‘culture’ why hadn’t it been used. I’m really wondering about that. I suppose from my perspective, it is a bit of a catch all, weaselly word, to me. It can mean different things to different people and, well it can be used as the cause, or the effect, of pretty much anything if we want it to. “Why do we think [X] happened?… well you know, it’s just what happens here… it’s the culture in’ it [shrug]”. Which I suppose I really struggle with because it kind of says to me that maybe nothing can be done about things because “it’s the culture, init”; it is “how we do things round here”. I just don’t like to think that nothing can be done about stuff.
So I suppose I avoid the word ‘culture’ because it is so broad and non specific, and to me anyway, sometimes a bit meaningless because of that. I reflect also that I really do think that we all have agency to change things, so this “it’s the culture” indirectly says to all the biases in my head that maybe people think nothing can be done, so “why bother trying, nowt to learn here”. I am also not convinced there is “a culture”… lots of different ones maybe? And I’m not an expert on culture in any way, so it makes me nervous to talk about it. (I guess lots of you might disagree with me on this, I’m curious to hear others views on this).
Second, why when we talk about improvement is the word culture often not mentioned? I think this is interesting, for me (recognising but moving past the above), there is something about if culture is so big and foundational to organisations, then why do we think improvement projects could have any hope in changing culture, how arrogant would we need to be? Often we are talking about much smaller pieces of improvement work (not always), so for me it would seem an over claim to say “this improvement project has changed culture” and anyway how would I know? What would my measures be? So I don’t say it, I don’t feel I know enough about culture to say anything. However, I do feel that the improvement research literature, especially the more recent evidence, suggests that lots and lots on ongoing projects and practice can build up overtime and modify culture, in some circumstances.
If we think about Edgar Shein’s work on culture, he talks about culture being a bit of a layer of assumptions and beliefs, espoused values and then the artefacts of the things we do everyday. Which I have seen interpreted often and used in leadership development approaches as a strong reason why leaders really need to think about their own biases and motivations and do that inward reflection of their own views and beliefs and personal “whys” to improve their leadership. Because this bit can then be compared and/or aligned with exposed values, for strengths and gaps, reflection, influence and stronger arguments to inspire and develop actions can take place, leading to the artefacts such as policies, actions and documents etc. This to me kind of says there is an assumption you can “think your way into acting”, through examining your thoughts, feelings, beliefs etc. Change starts with me.
I’m not sure that this approach has always held out for me, at least not in isolation. I feel there is another assumption in play in improvement work, that of culture changing all the time in response to acts taken by all of us, all the time. I also have a bias in my head saying… but what if you feel ‘it’ can’t be done (whatever that is, eg changing an organisational culture rapidly”), what then? If ‘it’ needs to be done, how will we “act our way into thinking”? By making a gesture everyday and hoping for new patterns of response and learning? Perhaps this is exactly what we had to do during our response to COVID-19?
In this sense, I feel that leadership routines and habits and deliberate, practiced behaviours can help to changing thinking patterns and beliefs even if they feel uncomfortable and clunky to begin with and even if it feels like “it won’t work, and is too trivial to change something as important as culture”. And I feel this is the space where improvement practitioners talk about culture, but often (not always) without using the word. Every time a leader of a team tries out something like a safety huddle or a visual management board or tests a new idea in a experiment, for me is a gesture and a change to the “way things have always been done round here”, where we can learn. So for me these types of planned deliberate improvement routines can help to modify culture in that way, especially when scaled. Unfortunately much improvement practice is rarely scaled and exists in pockets or easily withers out when leaders get promoted or move on. It’s hard to change a habit in a scaled and sustained way; and leadership attention to support is often needed long after we have moved on to our next crisis or priority unfortunately.
I reflect now, that I can be more explicit in my practice when I am espousing and advocating the use of improvement artefacts – my improvement gestures if you like. Artefacts such as PDSA, visual management boards, fishbone diagrams, leadership walk rounds or standard work and many other improvement tools that help teams to solve problems together. For me improvement methods like these, when used well, help set out my values and beliefs because they can help to provide spaces and frameworks to support people to speak up and problems, to take a scientific thinking approach to test out changes using PDSA, to think and consider the views of the customer/patient (and even include them in the process), to ensure we learn everyday, and to support working together across disciplines. So, when I advocate the use of improvement approaches, my visible artefacts if you like, these are my improvement gestures to influence culture. My assumptions are that if lots of teams start to use these practices and artefacts we can start to spread and scale these improvement routines into the development of improvement capability and thence into habits and the “way we do things around here”, a culture where improvement thrives. What I have noticed where there is sustained effort by a team in improvement practice, is that beliefs and values can start to change, the acting, can change the thinking; (as well as self reflection) and this can lead to different ways of working round here.
Third, if this can be so, what is it that leaders and practitioners can practically to support the development and sustainability of cultures in which improvement can thrive? How can we develop that kind of sustained habitual improvement capability? What gestures can leaders at all levels take to help cultivate improvement cultures? What will it take to sustain such a cultural transformation?
For me, drawing from my research, improvement capability can be argued to be made up of a bundle of routines that dynamically change over time in response to context. And routines can be deliberately developed, so for me we can focus deliberately on leadership routines, as an intentional gesture to build improvement capability and support the development of new ways of working around here, our culture.
How can we disrupt existing routines and build new habits and routines instead to help us have new thinking and acting patterns everyday, to help us to learn and improve everyday?
Two practical approaches spring to mind immediately for new routines and gestures that can start right now. 1) the intentional, sustained and rigorous use of PDSA e.g. through the application of Toyota Kata style improvement coaching habits, which have clear and explicit coaching roles for leaders (which I have written about elsewhere in this blog) and 2) leadership walkrounds.
Leadership walk round, gemba walks, safety walkrounds… whatever you want to call them. They can be an intentional leadership routines, that when completed rigourously and frequently can help to develop the kinds of improvement routines and gestures at scale that might modify culture. There is rarely an celebrity improvement case study organisation in the literature that doesn’t talk about these kinds of routines in one way or another. David Mann’s book on “Building a Lean culture” (2004) or Mike Rother et al’s book on “Toyota Kata Culture” (2018) in particular are full of practical help on leadership routines to support improvement.
Leadership routines for improvement can be bespoke or general. They can include a checklist, an audit, or items to talk about or then can incorporate questions to ask staff or patients. They can incorporate assurance and safety checks or a coaching cycle for a test of change. They can be done within a framework for all leaders at all levels. They can be flexible and tailored to you, your organisation and your challenges. They might be uncomfortable to start with, it might be hard to find the time to do them, and they might need some practice and incremental improvement. I guess changing culture is going to have a few obstacles, else it would be easy. We will really have to want to change it.. And there are lots of reasons that hold us back…. What might we need to unlearn as leaders?
Where I have seen leadership walks (of any kind) done well, they can really make a difference imho. Examples include at HMRC in the North East, they have a 30 min team leader ‘walk’ using visual management and standard work every shift, which filters to a 30 min supervisor walk with his/her 5/6 team leaders, every shift, which filters to a departmental 30 min and so on, to a bi-weekly senior leaders walk for 45 mins with direct, manually collected data cascade both up and down in real time.
At Unipart, standardised leadership boards were used so that even the board member who has to visit an area of work once a quarter, had their own standard work and visual management counter to turn green when complete (a manual process enforced by the magnet only able to be turned if physically present). This process had a focus on the PSDA approach in the area, with questions for the leader to ask about the improvement work and how they can support its progress.
Similarly at Mercy Health in Michigan, the Toyota Kata approach has been used by the executive nurse to create a new weekly executive leadership routine to support the sustainability of problem solving practices at scale across the whole hospital to improve the patient and staff experience. The first obstacle to solve was that of making executive diary space to do it.
This last year, across healthcare, we have used safety walk rounds by team leaders and senior leaders across workplaces have been used frequently in healthcare to support Infection control compliance and problem solving to great effect.
So my next steps…
1) try to talk about improvement and culture more explicitly and less implicitly (hence this blog),
2) think about daily habits and routines that can be developed everyday no matter how small, and persist and expect them to keep needing focus and sustained attention… (this is culture change after all.. those trying to kick a smoking habit know how hard it can be to change a habit).
3) all of us can take action now, what new leadership routine can you try tomorrow at work? A leadership walk round might be quickest and easiest next step, though getting over diary commitments might be tough. What might I expect to happen? Could I sustain something like that everyday or every week for a month? Could I get into a leadership walking habit? How many leadership walkround steps can I see on my imaginary improvement pedometer?
Let’s see what we can learn about improvement culture as we change leadership and improvement artefacts, routines and habits.
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