Leveraging Culture
“The most dangerous phrase in the language is: We’ve always done it this way.“- Rear Admiral Grace Hopper
Culture is Everything, Everything is Culture.
If you want to adopt a new peds regional centered program, changing culture is the single most important force you must attend to. If anyone tells you otherwise, they are wrong. With a healthy culture, one can move mountains, create miracles, literally catch lightning in a bottle.
One of the hardest things to overcome about our specialty is the fact that we all tend to work in silos. While we may occasionally see each other in the PACU or in the holding area as we prep our next patient, by and large we spend the bulk of our day stuck in a room with the other perioperative staff. If you also factor in ever increasing production pressure and the day-to-day hustle to “keep the OR’s humming,” it becomes fairly easy to work alone and feel isolated and alone.
While I had adopted a growth mindset and set about trying to change the way I practiced, in order to make institutional change I needed to convince those around me to change as well.
To many, change was disorienting and threatening. However, I happened to be in the right place at the right time. We were in the midst of a hiring spree, recruiting as many talented peds people as we could. Changing culture is much easier when you are working with people with similar experiences, skill sets, and visions of where the future of clinical practice might lie.
How can you change culture and make your culture strong? An agreement about and adherence to a set of core values by everyone. Here are the core values that we adopted.
Communication. One of the first things we did to enact change was to increase the “on the ground” lines of communication. We created a “peds anesthesia” text group consisting of the roughly 15-20 junior peds anesthesiology attendings. With this, we could bounce ideas off each other for upcoming cases, call for help if we had a difficult airway or an impossible IV stick, ask for a quick “GU break,” or just have a safe place to vent. Breaking down the barriers of communication helped solidify our sense of community and collaboration. It made us feel like we were a part of something special, and that we were all in it together, almost like we were a family. You could always feel the small wave of understanding when new hires realized that they were a part of something special and that we were really there to take care of each other. While they might certainly be thrown into the clinical deep end early in their acclimation period, they were never truly alone.
Creativity. We were always looking for ways to improve our technique. Whether it was scouring recently published articles or case reports, posters from recent conferences, hearsay from colleagues at other institutions—we took it all in and tried to make something of our own. Not just to imitate, but also to synthesize and take new steps forward.
Individuality. We all brought something unique to the table, and it is well known that diversity fuels innovation. My mind works a specific way, while yours works in an entirely different way. There were countless times when someone would make a connection or come up with an idea that would never come in our individual vacuums. Every voice brought something of value; every voice fueled innovation.
Quality. We were each a sounding board for one another, helping to clarify and refine one’s ideas. We also spent considerable time teaching everyone, to ensure a consistent technique was used. While there was certainly variability in the way that we practiced, we marched more in step than out.
Leadership. While over time most people came around to what we were trying to do, there were some that were intimidated by new technology and technique. To help educate everyone on our techniques, I collected folders of digitized articles, sorted by ease of understanding and technique descriptions. If I had time between cases, I would give impromptu lectures on abdominal or chest wall blocks on tegaderm wrappers or any other piece of scrap paper I could find.
Historically, there was very little mentoring for new hires as they transitioned from house staff to full fledged attendings. If the ultimate goal was institutional alignment, there was nothing more paramount than mentoring junior faculty, especially if we wanted to create a sense of community and help foster a growth mentality. It was important to tailor your approach to the individual to achieve a consistent level of baseline competence. And while I took on an oversized role in mentoring junior faculty, I also made in-roads with senior faculty when any opportunity came my way. If our goal was to integrate peds regional techniques into our practice, we had to train juniors and seniors alike, on everything from knobology, terminology, basic sonoanatomy, and ultimately how to perform each new block we rolled out into our clinical repertoire. While everyone had their own learning style and learning curve, within a few years, our culture had shifted from one of isolation and clinical stagnation, to one of community and clinical innovation. Risk-taking and change became the accepted cultural norms. Even the more senior people began taking active roles in learning new blocks or techniques, which in all honesty is what I am most proud of.
Accountability and Trust. For people to feel open about contributing, there was an understanding that these projects were about the benefit of the whole group, not one individual’s gain. While we certainly would divvy up project ideas after brainstorming sessions, we always tried to be fair and equitable. If it was your idea, you had the right of first refusal if someone wanted to take that idea and run with it. Without an environment that reinforces a culture of commitment and respect for each other, you may be hard pressed to achieve lift-off.
We had created an environment where we were all pushing each other to improve, to learn, to try new things. What started out as a kind of hodgepodge of random people had coalesced into a collegial family of practitioners. This sense of community, of trust and respect, and open communication was extraordinarily important as we set out to change the way we practiced. It made it very easy for us to be aligned, consistent and strategic about how we were going to practice. If anyone had a question about what to block for an inguinal hernia, or whether this surgeon was block friendly, or whether someone would be around to spot as they did a pudendal, we were on it. As our culture blossomed, recruiting to the group also became easier. Applicants could feel the energy and camaraderie when they came to interview. It was electric.
It’s vital to continually enforce your core values as a community. If certain colleagues prioritize their own career, take credit for others’ innovation or stifle opportunities for others, you will fundamentally degrade the foundation of your working culture. In order to encourage the greatest possible atmosphere of learning and innovation, all must attend to your core values of community and professionalism. Never forget, culture is a living, breathing organism. It needs to be tended to, cared for, and in some cases weeded. Properly nurtured, there is no telling what amazing fruit it can bear.
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