More Than Medicine: Changing Culture Doesn’t have to be Chaotic

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An honest evaluation can reveal why previous results weren’t cutting it.

Change is hard; implementing successful and sustainable change is even harder. When change is implemented and doesn’t get the results we hoped for, the tendency is to view that change as a failure. But it may not be. The change you get is usually a reflection of the way your system was built.


For example, a department recently looked at their process for checking critical equipment in the resus bay. The residents were responsible for maintaining adequate airway supplies within the department. This is done by pre-shift checks from the second- or third-year residents and they are not formally tracked.

While this has worked overall, when the airway supplies needed are not readily available, the equipment (like the VL blades) is damaged without any way to track source error, or things aren’t in their designated location. At this site, it was decided by the residency and administrative team that the process needed to be changed because it “wasn’t working.”

When looking at potential changes, they quickly realized that the process was actually working. It was getting the results it was designed to get. These just weren’t the ones they wanted. So, they worked backward, starting by determining the desired results and then building a system designed to get those results.


Implementing Change

Starting change: Figure out where you want to go and work backward to figure out where to start.

Set expectations: If you were to look back on your project in 12 months, what would you consider a success? Then consider what pieces of that success are already in place?

Evolution over Revolution: Implementing change can be difficult since the founders of the original systems in place may still be involved. Additionally, it’s not always necessary to reinvent the wheel. Many of the processes in place work well, but could use some tweaking. Evolutionary ideas tend to be more successful than those that are revolutionary.


Culture Change: Change without purpose is temporary. Creating and cultivating a culture that stands for a way of being and performing can have long-term effects.

If you try to implement change that’s completely different from the current state, that’s going to be very hard for people to adjust to easily. Like it or not, we are creatures of habit, regardless of the negative nature of that habit. Don’t take something that you “don’t think is working” and throw it in the trash.

Instead, dissect it and preserve the good parts. Then make some modifications and see what happens. Going back to the airway supplies example: the process of having residents do airway checks was a good one, and the residents felt that the way equipment was stocked worked well and there was no need to change.

Mahesh kept those core principles. It allowed for whatever changes he made to have some familiarity, so the culture change wasn’t revolutionary.

Striving for perfection can be admirable, but not always attainable and sustainable. Instead of having all airway boxes checked three times a day, set the goal of having a 75% check rate.

Given the busy and unpredictable environment of the ED, 100% is not always feasible. Additionally, implementing this standard and change was from less of an authoritative measure on residents, but rather a “let’s hold each other accountable” standpoint.

Lastly, you have to believe in human fallibility. You may think your change is “foolproof,” but mistakes will be made. Using a punitive system is usually not productive. You have to figure out why mistakes are made and see if they can be mitigated for when, not if, they happen again.

Sometimes it’s human error. Sometimes it’s a barrier the individual has that you didn’t think of when creating the system. And sometimes, it’s the system that’s unwittingly set up to allow those mistakes to occur.

Taking the time to understand these factors and the people involved is imperative. It can be arduous, but still way more efficient than calling your change unsuccessful and starting from scratch.

Take-home points:

○  Every system is built to yield the results that it gets. Don’t blame the individuals — look to improve the system.

○  Work to implement a culture change. It’s long and sometimes tedious, but it’s also resilient and sustainable.

○  Take the time to investigate why you may not be getting the results you anticipated. The reasons may surprise you.

○  Successful change is about creating a culture where individuals embrace change.


EM OVER EASY is a podcast by three EM physicians, Andy Little, Tanner Gronoowski and Drew Kalnow, with a focus on #MoreThanMedicine. The podcast can be found on Apple Podcasts, Stitcher and more. For more about the content and hosts, visit and follow them on twitter @emovereasy.

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