Overcoming 'tribal' culture wars to improve patient safety

January 12th, 2015

Improving patient safety cultures in health care requires involvement and action at the local level by leaders committed to replacing a “tribal” mentality with a shared vision of a health care team, says Peter Pronovost, MD, PhD, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore.

“In too many places it’s still an ‘us versus them’ mentality, whether it is doctors versus nurses or nurses versus administrators or doctor vs doctor, or the staff on the floor vs the staff in the ICU,” he says. “We have these tribal cultures. What we have seen work is when leaders align everyone with a common purpose, create clear ways of behaving and then monitor and improve performance.”

In working with clinical colleagues and system engineers at Hopkins, Pronovost came up with three overarching goals and the key characteristics needed to fulfill them.

“We spent a lot of time soul searching and what we came up with is to partner with patients, their loved ones and others to do three things in order of importance: eliminate preventable harm, continuously improve patient outcomes and experience, and eliminate waste,” he says. “What do we need to drive toward those goals? We came up with three surprisingly simple behaviors.”

Simple, but indeed surprising when contrasted with the high pressure traditional hierarchy seen in health care cultures. The core principles underlying the patient safety goals at the Armstrong Center are:

• I act humbly.
• I respect and appreciate others.
• I am accountable to continuously improve myself, my team and my organization.

“What helped in our work to get the doctors and nurses to overcome these culture barriers or really battles, was aligning them to say that patient harm is unacceptable,” Pronovost says. “What we learned in our CLABSI [prevention] work was a small scale of what it takes to drive this culture change. But it fundamentally is about vision and values. If you get those right then you can cascade all these other things underneath it.“

The values expressed in this idea of culture were not exactly what one would expect in health care, where humility has not been a defining feature.

“For us to say I will act humbly in an academic medical center – that was a shocker,” Pronovost says. “That may not be what many people at academic medical centers have as their strong suit. But unless you are humble you can’t learn and improve.”

An expression of this humility was a willingness to visit other businesses and industries to see if aspects of their work culture could be applied to health care. Respecting and appreciating others includes recognizing co-workers for a job well done. “The point is that culture doesn’t happen by chance,” he says. “As Ritz Carlton says, the system is behind the smiles.“