The Role of Leadership in Shaping Culture

In my last column, I showed that American hospitals are characterized by a culture of blame: one that is antithetical to the pursuit of patient safety and high reliability via organizational learning.

Leaders are responsible for shaping organizational culture, even if their own behavior may be a product of the existing culture. In many cases, they may not have the commitment, skill or supports to fulfill that responsibility. This may explain much of the variability in results when adopting practices used elsewhere with success. For example, Rotteau and colleagues recently reported dysfunctional behaviors among senior leaders participating in patient safety walkrounds at two major teaching hospitals ( ).

Such observations prove the point made by former MIT professor Edgar Schein in Organizational Culture and Leadership that leaders don’t have a choice about whether or how to communicate. All they can control is how to manage what they do communicate - both verbally and non-verbally. Schein advised that the best way to understand a system is to try to change it. From this perspective, the kind of results reported by Rotteau should not be considered failure unless the leaders fail to learn from their experience and try again.

Schein also noted that the manner in which an organization responds to a crisis, such as a serious reportable patient safety event, tends to reveal the latent and largely unconscious assumptions of the culture. At the same time, the crisis itself offers an opportunity for positive change.

In Schein’s view, a learning organization requires Theory Y management based on the belief that humans are fundamentally self-motivated and need only challenge and direction to achieve excellence, rather than Theory X, which assumes that people are intrinsically lazy and need close supervision and control to be productive. Nevertheless, Americans value individualism, a value which potentially conflicts with the assumption that the best learning organization relationships are cooperative and collaborative. This means that group work for quality is counter-cultural and that leadership will be more likely to generate quality improvement through a pragmatic appeal than through a push to convert individualistic Westerners to communal values.

This brief analysis takes us full circle. The ability to learn from mistakes is essential to progress both individually and collectively. In a learning organization, learning must occur at all levels. Thus, leaders must learn in whatever ways they can, including trial and error, how to be better leaders and foster organizational improvement. Staff must be engaged to learn how to translate their experiences into improvements in patient care. This won’t happen if leaders don’t consciously address the system of blame of which they are a part.

Coming Next: Requirements for High Reliability

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Marc T. Edwards, MD, MBA

President & CEO

QA to QI

An AHRQ Listed Patient Safety Organization