Lessons from a hospital: Improving culture, fixing systems

August 12th, 2020

A few months ago, I joined the board of our local hospital. It’s a small facility in a rural town, boasting remarkably high quality of care. Part of my interest in joining the board was to see how a hospital system operates, and what I might learn for my work, both in higher education and the church. I’ve long believed that other sectors can teach the church about what it means to lead vital systems without sacrificing our theological convictions. Hospitals are highly technical environments with immensely high stakes — literally life and death. In a setting like that, what space exists for adaptive leadership?

Perhaps unsurprisingly, our hospital administrators pay a great deal of attention to organizational systems and culture. When it comes to patient care, for instance, our facility has adopted something called “Just Culture,” a patient safety system widely endorsed in health care, including by the American Nurses Association. In a Just Culture system, when a mistake happens, the first discussion is not necessarily about blame. Instead, the staff analyzes what happened and how the system could be improved to prevent it. 

Imagine this fictitious scenario: A nurse gives a patient the wrong dosage of medicine. The knee-jerk reaction would be to blame the nurse. In the analysis that follows, you might learn that the nurse had trouble reading the doctor’s handwriting, and that particular doctor was known to be unapproachable. Some changes in the system are implemented: Doctors are personally required to type their prescriptions into the system. The entire team is reminded of the importance of asking clarification, and the doctor is coached to be more approachable, so as to create a culture of trust. To immediately blame the nurse is to fail to notice the system that guides everyone’s decisions, and fails to understand how such a mistake could happen again. 

There’s a reason why health care systems pay attention to all of these details. A small mistake can be a detriment to the entire hospital. A patient could die or be hurt. Even if that doesn’t happen, the hospital could face financial consequences, like lost money from insurance payments. Or, the hospital could simply lose the trust of the community, which would be adverse to the health of everyone. 

The “Just Culture” model remembers that people respond to their environment. In the above scenario, even a strong-willed nurse who’s unafraid of the unapproachable doctor would eventually become exasperated with the lack of communication, leading to other harm. Move the pieces around all you want, but eventually, the system produces a mistake. 

The “Just Culture” system works, with numerous studies showing that it leads to improved patient outcomes. [1] By asking everyone to be accountable, the whole system is improved and lives are saved. When the “Just Culture” system doesn’t work, it’s reasonable to assume that there are larger systems issues within the hospital, where leaders do not want to take responsibility for the culture they have created. [2]

Theologically, this makes a great deal of sense. In his book Creation and Fall, Dietrich Bonhoeffer writes that all of humanity bears in the burden of one another’s sin. Bonhoeffer reminds us that, because of the nature of sin, “No one can absolve himself or herself from it … inasmuch as no one commits the deed in isolation, but each bears guilt for what the other has done.” [3] For Bonhoeffer, sin is not just about individual actions. It’s about the nature of the world. It’s about the organizational system that we create and perpetuate. 

This raises an honest question: Do we who are leaders in the church think deeply enough about the ways in which our systems are harmful to our work and to our communities? Do we foster a culture where the sins of the system and culture are regularly reviewed and reorganized? 

A friend of mine shared their frustration with a particular church system. They were working with a committee where everyone could name the desired outcome, and yet time and again, the committee operated in such a way that inhibited collaboration and progress toward the goal. 

Whenever this was pointed out to the members of the committee, the individual members would begin to blame others for the failures. This person had not communicated effectively, the chair had rushed an important section of the meeting, and another person was absent from a pivotal meeting. Eventually, the members of the committee arrived at a common refrain: Give us grace, we’re all working on the same mission, and no one had bad intentions. 

As I observe the culture of the hospital, I am reminded that intentions are not excuses, that actions have consequences and that real grace demands change. The stakes are too high for anything else. 

I’ve wondered why we in the church do not hold ourselves to the same standard. Why do we not pay attention to the sins of the organizational cultures that we create? Can those of us in leadership positions create cultures where feedback is valued and shared? Or, will we infantilize grace so as to accept pardon without sanctification?

We can learn something about applying theology to our organizations from the health care field. Perhaps it’s time that the church creates its own “Just Culture” system. When there is a mistake made, when we see a harm in the community, or when we fail to meet our objectives and our mission gets sidelined, our first question should not be “Who is at fault?” but rather, “How did the culture that I as a leader help create lead to this failure?” The “Just Culture” system works because it demands the community grow together, from the most senior leader down. It’s an image of discipleship, really, and the church would do well to emulate it.

[1] Dicuccio, Margaret Hardt. “The Relationship Between Patient Safety Culture and Patient Outcomes.” Journal of Patient Safety 11, no. 3 (2015): 135–42. 

[2] David, Donald Scott. “The Association Between Organizational Culture and the Ability to Benefit From ‘Just Culture’ Training.” Journal of Patient Safety 15, no. 1 (2019). 

[3] Bonhoeffer, Dietrich. Creation and Fall: A Theological Exposition of Genesis 1-3 Fortress Press, 1997. 119-120

comments powered by Disqus