This is about an organizational culture. Culture is a function of the language we use to create our culture. If we want to have different permanent outcomes, we need to use different language. If we think about how we think, and begin to think differently about the language we use and change that language, we will change our culture. When we change our culture we will change how we communicate, we will change how we do things, and we will ultimately achieve different outcomes (Figure 1). For example, if we didn't have reporting systems but rather had information communication systems — or we no longer conducted investigations but rather built knowledge — we would have a less punitive and more preventive environment from which to learn more from what we do right every day and not only from what we do wrong occasionally.

Figure 1. Systems Thinking Starts with the End in Mind
Figure courtesy of CRG Medical, Inc.

In April, the National Nurses Organizing Committee (NNOC) Texas succeeded in unionizing Tenet's Cypress Fairbanks Medical Center Hospital. The initial order of business was to move toward getting a contract for the union's newest members and also to sign-up other nurses who work for health care facilities in Houston and around Texas. The big message is for improving nurse-patient ratios, adding whistle-blower protections, and providing a voice at work.

More interesting to me is that the NNOC campaign is not just centered on nurse-to-patient staffing ratios but also is related to less-than-ideal communications between management and staff. This communications gap between what management thinks and what the staff is doing and how it is done is huge. Management-designed policies, protocols, and procedures are often not aligned with the actual processes used to perform the task. For leaders to take the action to align management's expectations with the caregivers' actions a communications mechanism must be in place. This mechanism must be available to all staff — from those in housekeeping and the operating room to those in the executive suite and the boardroom.

The system should capture and analyze what people think, why people do things, how they do them — plus provide the mechanism for management to know what the organization knows 24/7, without actually being present. Management that provides the means to communicate can act on the knowledge created by the staff input. Subsequently, the organization begins to learn from itself. It becomes a "Learning Organization." Hospitals committed to move from a reactive, corrective, and punitive culture become proactive, preventive, and predictive communities that naturally improve patient communication and safety outcomes.

If the leaders in our healthcare community implement communication systems without delay, the results will be immediate and dramatic, changing the negative combative relationship that is now rapidly emerging with the creation of the NNOC Texas success to unionize our nurses. We can now see the light at the end of the tunnel — it is a freight train heading toward us. If hospital CEOs adopt The Baldrige National Quality Program's Health Care Criteria for Performance Excellence, we may be able to divert the ultimate process of unionization of our nurses that is gaining steam. Unionization is usually a last resort when communication between management and staff is not aligned and when the channels are in disarray and off-track.

Douglas B. Dotan, MA, CQIA
Healthcare Division Chair
ddotan@crgmedical.com

Qualifications in Quality:
A Perception Survey and Results

Our division's leadership council approved a survey to assess and define appropriate educational qualifications in quality methodology for various levels within the healthcare job hierarchy. From backgrounds spanning both healthcare and other industries, 67 people responded. On the first round of exploration using the Delphi Process, this group volunteered their identification of pertinent formal qualifications. Discussion of results and personal introductions revealed important distinctions between perspectives of those from different sectors. On the second round, they rank-ordered these credentials. With few exceptions, we were able to confirm comfort within the group with results summaries thus far, identified a few important points of residual conflict, and then attempted to match levels of progressive responsibility in healthcare roles with progressive levels of credentials or curriculum. At this point, it became clear that no more than one third of the group felt sufficiently familiar with all pertinent credentials to continue the matching process.

Lessons learned from this exercise include the fact that many members consider this question to be important and overdue for discussion; our members' perception of the relative value of various credentials differs from perceptions within ASQ about its offerings; many of us are not sufficiently familiar with distinctions between educational offerings to make an informed choice; and ASQ needs to do a better job of providing simple guides to curriculum content within various credentials thereby explaining their relative value for different occupational groups within the healthcare sector, all of which are concerned about quality improvement. Our Division is now deciding whether to continue trying to match progressive credential or curriculum content levels with the progressive responsibility in different healthcare job roles by using the smaller cadre of member volunteers as an authoring group (whose work would be vetted by the rest of the 67 participants), or whether some other approach should be taken to continue this exploration.

David Birnbaum, PhD, MPH
School of Nursing, Univ. of British Columbia
Principal, Applied Epidemiology
British Columbia, Canada
brnbaum@interchange.ubc.ca

Correction

Sue Kozlowski, CSBB (ASQ), is the author of the article, "Is a Wait Always a Waste," printed in the March/April 2008 issue.