Stories for Cultural Change

Listening to and learning from your organizational stories

Written by Elizabeth K. Briody, Ph.D

There are many ways in which people learn–some by reading, some by experiencing, some by listening, or some a combination of them all. Sometimes people tell stories–even in organizations! When they do, listeners can learn a lot about what is going on culturally.

As a business anthropologist, I’ve heard a good many stories over the years. While some might consider stories an occupational hazard, I think about their potential in strengthening organizations. Whether a story sheds light on an organizational success or a perennial problem, it can be a valuable source of cultural insight.

Let’s take a look at the Patient Flow Story to understand how one can learn from organizational stories, particularly how they can be collected, analyzed, and validated.

The Flow Story

When people arrive at a hospital needing care, they become part of “patient flow”–a term referring to a sequence of steps in the diagnosis and treatment, ending at discharge.

Flow can be a tough issue for hospitals. Bottlenecks frequently occur as staff try to balance the often-unpredictable influx of patients with the appropriate number of staff and available beds. When wait times are long, patient satisfaction plummets.

By looking at the story told through comments, discussions and interviews, we can get a better grasp of what is actually happening and where problems (and solutions) might be identified.

A Consensus View of Flow

But how do staff understand flow? In one hospital I studied, staff shared a consensus view of patient flow. The way they arrived at that consensus reflected the frustrating environment in which they worked. As one nurse stated:

“I mean we all hear stories, like the bed was clean three hours ago and it hasn’t been changed in the computer!’ or ‘You have to wait until after the change of shift. We can’t take report now.’”

Staff perceptions were based on experiences in their own unit. Sometime, a powerful upstream unit such as the Emergency Room (ER) was said to be responsible:

…if people said they couldn’t handle it and were running around like chickens with their heads cut off, the charge (nurse) would say, ‘My nurses are saying they just can’t handle that patient.’ And the response we would get from the ER was, ‘It doesn’t matter. The patient has to come (to you) in 15 minutes and you are taking the patient anyway, regardless of what your feelings are….’

Yet, criticism traveled freely across all hospital units:

“An admitting physician will come down here. It could be 20 minutes. It could be two hours…The patient just sits here…and we can’t explain what’s going on. It’s an uncomfortable position for the (ER) staff….”

or

“I don’t think the floors understand…that when they have five patients that are set for discharge and they put all five patients in the computer minutes after each other, how that really affects the flow from (the patient transport department) standpoint.”

Staff’s view seemed to relate generally to an inability to control the amount and pace of work:

“As a bedside person, you are put in the vise of doing more work and then being criticized for the patient experience and … you have proportionately less time to pay attention to all the patients you already have!”

Staff Strategies to Handle Flow

Staff took actions to level the patient flow through their units. In some cases it simply meant resistance. Here is a relatively common strategy of slowing down the work:

“…a nurses station hold(s) off on a discharge, or delay(s) a discharge, in order to prevent a new patient from coming to their floor because it’s almost change of shift…” Otherwise, a nurse would have to complete all the necessary processing of the new patient before going home.

Other staff attempted to problem solve on their own, often pitching in to assist when it was not an assigned job duty:

“Yesterday, I’m walking down the hallway and I see a patient…(who asks) ‘Can somebody take me? Where’s my ride?’ And I’m like, ‘Oh no. We can’t have that.’ So I made sure to cancel the transportation request and we took the patient down. A lot of times that’s what we’ll do.”

Summing Up the Current Culture

The Flow Story points to differentiation, dissatisfaction, and dysfunction.

The Flow Story reveals that hospital staff and units optimized for themselves rather than for the hospital as a whole. We see that the Flow Story is emblematic of a silo-based organizational culture:

• “The rules are, ‘Stay in your own lanes until you are asked in.’”
• “Some say, ‘My area did just fine and that’s all I care about.’”
• “If you can get that patient off my floor, I can take care of my patients.”

Of course, in any research project, data must be confirmed and validated. Guess which terms and phrases were heard frequently at this hospital?

“kingdom” “fiefdom” “blaming” “turf” “territorial” “handoff” “hurdle”

Organizational inconsistencies were particularly noticeable at unit boundaries–such as between ER and any one of the floors; work rules, practices, and processes routinely varied in the different units. The Flow Story points to differentiation, dissatisfaction, and dysfunction.

Solutions Proposed by Staff

The Flow Story offers perceptions of the general experience of flow and insights into problem solving.

The Flow Story offers perceptions of the general experience of flow and insights into problem solving from those directly affected by the bottlenecks and shortages. Several themes emerge portraying what this hospital’s culture might be in some future state.

Accountability: “I think it’s getting on the same sheet and measuring and monitoring and holding accountable every part of the system where there is a flow problem. You identify it. You drill down…”

Empowerment: “The flow issues…really can get fixed by the people at the bottom if somebody gives them the vision, gives them the mandate to get the job done, and gives them the opportunity to do it. But we try to drive change from the top.”

Collaboration: Staff pulled together particularly during stressful times, say, during a patient “surge,” or a combined patient surge and trauma incident:

Nurse: “Holler at me if you need me. I can do Triage or Unit-3 or whatever.”
Charge Nurse: “Have you eaten yet?”
Nurse: “No.”
Charge Nurse: “What can I do for you so you can?”

Despite being short-staffed, the nurses worked well together, though no one wants to be routinely short-staffed.

How Can the Flow Story Help Change the Culture?

Stories perform multiple functions, raising awareness, furnishing explanations, solving problems, and reinforcing ideals. If we listen and learn from them, they can point us in helpful directions.

First, we validate the Flow Story against specialized language describing how other hospital processes operate. If terms like “handoffs,” “blaming,” and “kingdoms” ring true with a particular hospital story (like the Flow Story), then that story can be considered broadly reflective of hospital culture.

Stories perform multiple functions, raising awareness, furnishing explanations, solving problems, and reinforcing ideals.

Second, we identify which concerns seem to matter most to staff when patient capacity is high, and where the bottlenecks are said to occur. We learn that patient admissions, transfers, and discharges are problematic and that the bottlenecks appear at the boundaries between hospital units–such as between the ER and a particular floor.

Third, we examine the cultural themes linked with staff’s proposed solutions: more accountability, greater staff empowerment, and higher levels of collaboration. We find that staff want a different way of working together–on a regular basis–not just when a crisis hits.

Finally, we turn to the scholarly and business literature for additional insight on organizational culture and change issues. There are many articles and books on the topic of improving the functioning of siloed organizations, a good place to begin might be the reference list at the end of the chapter my colleague Ken Erickson and I wrote for the book Collaborative Ethnography in Business Environments. In it, we identify five elements one must have in place so that changes made in a siloed organization endure over time.

Among them is collaboration across siloed organizational units–for instance, between the ER and a particular hospital floor. To change the way in which organizations work requires other simultaneous changes. For example, our expectations for how work should be done and who should be doing it need to be altered. No more handoffs! So, staff from ER and the particular floor work together to transfer the patient. Incentives and recognition encourage greater teamwork rather than the old form of individualized work.

One takeaway from the Flow Story is that none of us has all the answers to the organizational issues we face. However, by systematically exploring the stories we hear, and learning from what they tell us, we are well on our way to understanding what needs fixing and how to do it.

A second takeaway is that those closest to the issue (or bottlenecks) can describe their experiences and working conditions. Their knowledge is readily available if we will only listen. Listening, of course, necessitates attending to those around us, building relationships with them, and recognizing that their ideas should be taken seriously.

The Bigger Picture

Organizational stories provide employees and their leaders with critical insights to improve the organization’s effectiveness and assist with organizational-culture change. Stories are a medium of exchange that can help the organization evolve and mature in ways that benefit organizational members.

I will leave you with this last example to ponder: how one story had a sustained impact on manufacturing culture within General Motors. Think about what your stories might do for your organization’s future!

Originally published at We Seek — Presented by e180.

e180 is a social business from Montreal that seeks to unlock human greatness by helping people learn from each other. We are the inventors of braindates — intentional knowledge sharing conversations between people, face-to-face. Since 2011, e180 has helped thousands of humans in harnessing the potential of the people around them, and we won’t stop until we reach millions.