Doctors: A More Egalitarian Hospital Culture Is Better for Everyone

“Leadership Saves Lives” requires that each hospital create a “Guiding Coalition,” a group of more than a dozen staff members, ranging from high-ranking administrators to clinicians, nurses and technicians from across the entire institution. The coalition members participate in regular workshops, discussions and national forums on ways hospitals might improve, then help their respective hospital translate newfound ideas and information into clinical practice.

To assess the clinical effect of the intervention, the researchers decided to look at heart attack patients, individuals whose care depends on the staff in several departments in a hospital. The researchers implemented “Leadership Saves Lives” in 10 hospitals of varying size and from different regions that all treated large numbers of heart attack victims but shared below average patient outcomes. Over the course of two years, the researchers regularly surveyed and interviewed all the guiding coalition members using the research tools they had developed specifically to measure cultural change.

The researchers found that all 10 hospitals changed significantly, but six hospitals experienced particularly profound cultural transformations. The staff of these hospitals spoke of an institutional shift from “because I said so” to “focusing on the why’s.” Instead of accepting that every heart attack patient had to undergo certain testing or take specific drugs because the chief of the department or administrator had previously established such clinical protocols, for example, it became more important to provide the data that proved such rituals were actually helpful. Staff members in these hospitals also said they received, and appreciated, increased support from senior management and a newfound freedom to voice opinions in “more of an equal role, no matter what position you are.”

In contrast, providers who worked in hospitals without such profound changes described a persistent expectation of deference to authority, a tendency to blame and make promises without follow-through, and a work environment “so squarely in the box that we can’t even see the edge,” in the words of one provider interviewed.

One hospital in the study, for example, had been struggling for years with poor outcomes because patients often had long wait times between the onset of heart attack symptoms and the initiation of appropriate in-hospital care. Many of the hospital’s administrators and clinicians assumed that little could be done because of their rural location. But the hospital’s EKG technicians knew of a new and relatively inexpensive transmitter that could immediately relay EKG results to the hospital.

“But the EKG technicians never felt empowered to speak up,” Dr. Bradley recounted. “The hospital C.E.O. never even knew that the problem of relaying EKG results existed but could be solved until he came together with the technicians in their hospital’s Guiding Coalition.”

The researchers discovered that the degree of an institution’s cultural change was directly linked to how patients did. Hospitals that made more substantial changes in their work culture realized larger and more sustained drops in heart attack mortality rates. Among the four hospitals in the study that experienced less dramatic cultural changes, there were improvements in patient outcomes, but the improvements were not sustained.

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