Mar 25, 2016

Announcer: These are the conversations happening inside health care that are going to transform health care. The Health Care Insider is on The Scope.

Wendy: We hear a lot about culture change and how important it is, but how do you actually change culture? What are some steps you can follow? Nancy Lorenzi is Assistant Vice Chancellor for Health Affairs and Professor of Biomedical Informatics and Clinical Professor of Nursing at Vanderbilt University. Nancy, but how do you do it? It seems like an impossible job.

Nancy: Yes, it is, but if you take one step at a time, then you can do it. First of all, you have to figure out what on earth your culture is. What is it that's out there? Without knowing what it is, you will never know how it can be.

Wendy: And how do you do that?

Nancy: One of the ways we do that is we have to listen. I'd start asking people, "What seems to be some of the issues that you are facing? Tell me stories from the heart that seem to be problems with culture." And once I got that from a number of different people, I would get a converging algorithm on what some of the issues were. Then, I would go out because I'm the boots on the ground person. I would go out to the clinics. I'd ask you to identify the place, which may not be your worst place, but it would be one that would be easier to work with. I would go out and I would observe the patients, I would talk to the patients, I would observe the staff. I would see their behaviors and then I would look at what kinds of things we might do based upon what I saw and experienced.

And I think that you can do this in a lot of different ways. One way that I did with one of our PhD students is we did a mirroring technique. So she followed a patient and I followed a clinician until that patient and that clinician met and we saw how they interacted with the check-in system. I saw how the physician interacted with the nurses and then, actually, one of the two of us had permission to go in the room with the patient and we saw how the physician and the patient interacted. And there were some issues with culture there that needed to really be changed.

I could give you a specific example, but I'm going to make it general. This young man had traveled quite a distance to come in because, in his area, he did not have the quality of care he needed. Then, I saw this physician do something that would never fit with this young man, meaning he gave up probably a $10 an hour job to drive in for like five or six hours for care. He was criticized for not showing up to talk to a nurse practitioner at one other time. He was given another appointment with the clinician and another appointment with the nurse practitioner on a different day.

So we actually went in and talked to some of the people in that particular clinic about how to deal with this. This is where organizations sometimes get reluctant to pay for this because it's like you just talking to people, people are gathering data, gathering rich data to see how things are happening in their area and what they can do to make things better for that particular patient or make that clinic better.

I've just thought of something funny I'm going to tell you. I was doing observation in a primary care unit and what happened was the physician was finished with the patient and the physician came out of the office and the patient said, "What should I do now?" And the physician yelled in, not yelled loud, "Get dressed and leave." That's not a very good culture.

So with the outtake person coming in, stepping in for just a few minutes, you're anchoring the patient as to what happened. You're anchoring the patient as to if they had any questions that they were not wanting to ask the physician. And sometimes for culture, you have to do workflow redesign. It's not all people stuff and how we talk to each other. Those are the kinds of changes that we're starting to make and, as I said, we started that in September two years ago. And is it all over because we see 2 million outpatient visits a year? No. Will it take time? Yes. Are we staying with it? Definitely, yes.

Wendy: So you mentioned that first you need to examine the culture you have and look for the issues that are there. And then, you try to work toward the culture that you want to have. What kinds of steps do you take for that?

Nancy: If you're out there and you really want to do this and you aren't sure what to do, my first steps would be to look at writing a plan of what you want to do first. Talk to the senior leaders to say, "We think this needs done because of this this and this." With that is your umbrella and your direction, teams of people can come in and I can do strategy for what we could do. So we do a lot of brainstorming. The outtake was an idea that came up from one of these sessions and it's made a major difference.

I'm big on piloting things. We've piloted a lot of different ways to go in and change and some don't work and some work well, in which case we would spread them throughout others. But try it. Try and see. You've got to find a place that is malleable enough that you can actually make some change. Don't go for the hardest place. I always argue this one point.

If you're going to do something to get people on a team, don't go to the place where everybody has a strong emotion because you'll be dealing with that forever. Go to a place that is more neutral and you can get people to converge on that neutrality and make a difference. If so, then it's sort of like of concentric circle from that where they agree. They work as a team, they see what's happening, then you can go out and eventually you'll get to that really hard one where everyone is so emotionally attached.

And each place is different. I think organizations are like people. So I'm an organizational doctor. This organization's is going to have different vital signs. Its heart rate's is going to be different. Its blood pressure is going to be different. You have to know what those are before you can change them. That's what I argue with everybody is if we don't know, don't make a change because it might be wrong. Let's figure out what's happening and then go for the right at the beginning.

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