In May the American College of Healthcare Executives (ACHE) and the NPSF Lucian Leape Institute released a white paper titled Leading a Culture of Safety: A Blueprint for Success. Most white papers on patient safety call for culture change, but offer little advice as to how. The Blueprint for Success paper is different: it provides a clear framework and practical, actionable steps. It offers examples, advice on assessing readiness and means for monitoring progress implementing culture change. We hope leaders throughout the health care industry study this paper closely and discuss it with their boards and senior-most leaders. The time has come to end the two-fold public health crises of medical error and health-worker safety. But be forewarned: true culture change is hard. Most efforts fail; some find limited success; only a few create breakthroughs. We’ve consulted to large organizations engaged in culture change for two decades. In our experience, breakthrough successes have three things in common — three pre-requisites that must be in place in order for a culture change to have even a chance of success: Leaders’ relationship to the challenge: The leaders of successful culture change efforts — leaders who create breakthroughs in their organization — share a specific mindset; a particular “relationship to” the challenge at hand:
  • They believe the change is possible, despite evidence that it is unlikely or improbable.
  • They are personally committed to the change, despite not knowing how they’ll make it happen.
  • They accept responsibility for the way things are currently and for bringing about the change. They see themselves as “at cause” and “able to respond”, rather than “at effect” or “victims.”
Reality check: imagine standing in front of a roomful of your bosses, peers, employees and family and saying, “This organization hurts people – both patients and staff members.  I am responsible for that. I commit to eliminating these injuries — not reduce; not mitigate; eliminate.  I can’t do it alone. I need your help. But that’s what we’re going to do. If you ever see me failing to live up to this commitment, I want you to remind me of what I said here today.” What does imagining this reveal about your relationship to the challenge? A mindset of possibility, commitment and personal responsibility will be required to lead this change. Relationship between leaders: Organizations that achieve breakthroughs are led by highly effective teams. One person can make a difference, but until the team at the top is fully engaged, change will be slow. The most-effective teams have a few things in common:
  • They are aligned in support of a challenging goal and shared approach. (Note: alignment is not the same as consensus. Team members will disagree, but effective teams talk through conflicting opinions and then move on.)
  • They have clear expectations of each other, and hold each other accountable.
  • They have frequent, candid conversations. Sitting around a table to review performance data is not conversation; the best leadership teams allow time for dialogue and thought-partnership; they offer one another feedback, ask for and offer support, and acknowledge each others successes.
  • They work through failures and setbacks together, without assigning blame or saying “I told you so.”
Reality check: at your next staff meeting, ask each person to share a frustration they have about the performance of another department — then check: was the leader of that department aware of the frustrations? When was the last time the two leaders discussed it? Better yet, ask each manager to describe the performance of a department other than their own — ask them to discuss the challenges, successes and needs of the other team. Can they do it? Are the relationships within your leadership team strong enough to ensure coordinated, sustained effort across the whole organization? A collaborative, collegial, well-aligned team will be needed to implement this change. Team members’ relationship to leaders: Change begins at the top, but breakthroughs occur when folks at the front-line act / think / feel differently. Our team members’ perceptions of us — their relationship to us — determine our ability to influence their thinking and behavior. Every breakthrough we’ve seen has come in places where teams perceive their leaders as worthy of following:
  • Leaders are visible, felt, and present. The best leaders are seen by and known to the workforce.
  • Leaders are seen as authentic and genuine. Folks can smell insincerity a mile off — the best leaders are willing to be themselves, tell it like it is, and encourage others to do the same.
  • People feel valued by their leaders. By asking people to change, we’re asking them to invest discretionary effort. The best leaders get that effort because their teams know they care.
Reality check: show up, unannounced and unescorted, at unexpected time, in an unusual place — come in on the night shift and sit down in the cleaning staff’s break room. Do people know your name? Do you know any of their names? Tell them they can ask you anything they want — are they willing to risk asking you a tough question? Ask the folks to help you out by giving you some straight, direct, no-holds-barred feedback: what do they think your biggest concerns are… and what should you be concerned about? Are people open to you? Are they willing to share and to listen? Are able to listen more than you talk? Do you follow-through and follow-up in what you hear? Authentic relationships based on care and respect are vital to creating a breakthrough. Summary Our relationships with people, and to situations, determine our capacity for action. Before setting out to implement the ACHE/NPSF’s Blueprint for Success, leaders should examine their relationship to the challenge, the relationships between leaders on their team, and their followers’ relationship to leaders.   The absence of any of these prerequisites is not fatal — but the gaps must be addressed as part of the change effort. The good news here is also the bad news: these capacities cannot be purchased, hired or delegated — no program or best-practice will address these gaps; but the power to change is within us — within you, the person sitting in your chair. Interested in learning more? Ready to lead a breakthrough for patient- and worker-safety in your organization? We’re ready to help. About the author: Andy Erickson is a principal and CTO at Humanus Solutions, a consulting firm specializing in people-centric leadership. He can be reached at