Culture eats strategy for lunch

The title of this post refers to an oft quoted piece in business and change literature; to paraphrase, you can have a great plan but if it doesn't take into account the culture of the organization, you will fail. This I think is the crux around which healthcare reform and quality improvement specifically will succeed or fail. This is the great intangible that must be isolated and measured, so that we can truly begin to determine how healthcare providers differ from one another in terms of the quality of the service they deliver. As doctors we believe that the keys to a great service are world class doctors, state of the art facilities, the latest in IT; basically the best that money can buy.

However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.

Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.