The Critical Role of "Culture" in Quality and Patient Safety

Dr. Lucien Leape and his colleagues, in the July issue of Academic Medicine, decry the slow pace of improvements in patient safety in our healthcare system. After considering the various causes, they conclude “that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change.” The authors delve into the different forms of disrespect that negatively affect the culture of healthcare organizations, resulting in conditions that threaten patient safety. Although the article draws many of its examples from academic institutions, I believe the underlying theme of the importance of culture on patient safety and quality is relevant to all provider organizations, large or small, academic or community-based. I have spent more than 40 years in healthcare, mostly in leadership positions. I know how my own behavior has contributed to a positive environment that promotes teamwork and motivates individuals to focus on patient safety and how, more times than I care to admit, it has had the opposite effect.

As I reflect on my experience, I know that many people in healthcare are suspicious of leadership and tend to think of us as primarily focused on financial outcomes. They think that we have a different value system. They see themselves as genuinely caring about the patients and perceive that leadership is focused on productivity and the bottom line. That disconnect can lead to a sense that people’s contributions to the care of patients are not respected or valued. This feeling can be exacerbated when those departments that make greater contributions to the financial well-being of the organization, often for historical reimbursement reasons, are held up as paradigms for everyone else and are perceived to have more influence with leadership. I call it the “you give them everything” syndrome. The point is that leadership has a big impact on culture and historically we have not provided the right emphasis. This point was driven home in a meeting with our hospital medicine group where one of the members complained that all they hear from me is how expensive their department is, not what they contribute to our 98 to 100 percent scores on best practice for heart attacks, congestive heart failure and stroke. Unfortunately, he was right.

My experiences have led me to take a different approach to my communication with hospital staff and physicians. Now when I present updates on how we are doing, I talk about quality and patient safety first, the patient experience second, and the finances last. I emphasize that we’re here for the patients, not to make money. The financial performance is the enabler for the first two. Obviously, I haven’t stopped being concerned about the dollars, but I recognize that most people in our organization relate first to quality and the patient experience. They want to know that leaders

hip really is concerned about the care being provided. They also want to know that we listen when concerns are raised about impediments to providing the level of care and service patients deserve. When we’re genuinely aligned, it’s easier to have dialog around some of the other challenges faced by the organization.

Many factors go into in creating an organizational culture that focuses on patient safety and quality, but leadership can make a big difference by recognizing and communicating its importance.

I look forward to your comments. —Lou Giancola