1. Leadership is the source of the beliefs and values and the most central issue for leaders to understand the deeper levels of culture
2. References
   1. References culture project .pdf
3. Organizational Culture
   1. Culture Definition
      1. Theory Definition
         1. Set of solutions devised by a group of people to meet specific problems
         2. A pattern of shared basic assumptions learned by a group using external adaptation and internal integration
            1. Characteristics
            2. assumptions- fair treatment is important for everyone; 3 levels external adaptation, managing internal integration, deeper cultural assumptions
            3. Reference: Schein
            4. value- respect/accountability
            5. Reference: Schein
            6. artifacts- policies and standards
            7. Reference: Schein
            8. symbols- mark, sign, word representing an idea, object, relationship; process of interpretation
            9. Reference: Hatch
            10. ecological context- physical, temporal, social coordinates
            11. Reference: Van Maanen/Barley
         3. Perceptions, thoughts, feelings that are intangible
      2. Theory based assessment of a culture
         1. Characteristics
            1. Schein- assumptions, values, artifacts
            2. Example OSU unit- hard working, value patient standards, policies change based on evidence based practice
            3. education, process improvement, patient needs
            4. Hatch- symbols; builds off Schein
            5. Example OSU unit- EKG, star board for performance, heart
            6. symbolize performance improvement
            7. Gagliardi- subculture, revolutionary cultural change
            8. Example OSU unit- bringing in new staff to replace old, new leadership hired
            9. recognize change is needed
            10. Van Maanen- ecological context
            11. Example OSU unit- patients population, low economical status
            12. surrounding neighborhood
            13. Trice and Beyer- substance/ideologies and forms
            14. Example OSU unit- substance- management in not working; forms- team meetings, metrics posted for staff
            15. SWOT analysis with staff to create unit goals
   2. Cultural Characteristics and Behaviors
      1. Unique Healthcare Characteristics
         1. Safety
            1. Artifacts: signs, footies, side rails on beds, bed alarms, paper consent for treatment
            2. Values: fall prevention, Dr/RN education, well being of patient, error prevention
            3. Assumptions: patient won't fall, understand protection requirements, follow commands
            4. Examples
            5. All patients receive fall prevention assessment
            6. Consent is signed before procedure and opportunity for questions and explanations
            7. cross check for medication administration with another RN
         2. Privacy
            1. Artifacts: HIPPA form, curtains in rooms, closed door, gown/clothing given
            2. Values: patient information, patient identity, patient body
            3. Assumptions: not sharing information, limiting level of voice, confidentiality, security
            4. Examples
            5. Keep voice lower when discussing health history
            6. log off of computer chart when not in use
            7. use code word for patients requesting information
         3. Advocacy
            1. Artifacts: disclosure form, white board in rooms with patients able to ask questions
            2. Values: patient rights, quality of acre, respect
            3. Assumptions: support patient, patient s have fair access, patients may be frightened/vulnerable
            4. Example
            5. exoress and explain treatment choice
            6. have interpreter available with language barrier
            7. assess ability to sign consent
      2. Loop learning
         1. SIngle loop learning
            1. error occurs without questioning
            2. Example
            3. Outcome
            4. What describes the information
            5. no questioning occurred; in the future all patients were given a pregnancy test; took policy as truth and just
            6. policy states anyone under the age of 55 without a hysterectomy must take a pregnancy test; refusal is not an option
            7. patient wanted to refuse pregnancy test before procedure; signed papaer claiming she was not pregnant
         2. Double loop learning
            1. challenged to ask why
            2. Example
            3. Outcome
            4. What describes the information
            5. How did/should we solve the problem
            6. full department met and provided examples of options; vote was conducted with majority rule; schedule changed=fair and consistent
            7. new staff asking questions and seeking reasoning behind schedule; want more of a set schedule without rotation
            8. call and holiday schedule have an option to be changed and modified
            9. new staff hired on do not understand the call and holiday schedule; requesting more information
         3. Triple loop learning
            1. concerned with the underlying ideas/principles
            2. Example
            3. Outcome
            4. What describes the information
            5. How did/should we solve the problem
            6. Is this the right problem and approach? Another option?
            7. the approach is correct but follow through must be completed for success and to continually met standards
            8. research evidence from the last 5 years on proper removal care of the TR band post cath; take into consideration company guidelines and document a new written policy; educate all staff on new policy with support from studies
            9. one piece of paper given to staff by terumo company; OSU did not have any formal written policy
            10. policy never really existed; took papers from vendor as policy and did not have any evidence based practice associated
            11. TR band removal policy is outdated and needs updated and education given to all staff
      3. Decision making in an ICAS
         1. Decision Description: Implement new process change for the post procedure care of patients with intra aortic balloon pump therapy following cardiac catherization procedure
            1. Stakeholder: patients
            2. Neutral: quality care obtained
            3. Negative: more training for staff; not as experienced
            4. Positive: no transfer needed
            5. Positive: no double charge
         2. Characteristic: Shared purpose: ability to utilize resources already established at OSU East instead of transferring to the Ross Heart Hospital.
            1. Stakeholder: cath lab staff
            2. Negative: responsible for increased care of IABP and training
            3. Positive: no needed for transfer for med flight
            4. Positive: more available for emergency cases
         3. Characteristic: Flow: change flow from the cath lab and then straight to OSU East ICU. Eliminate transfer by med flight and wait times.
         4. Characteristic: Multidimensionality: meet with all areas involved to get full perspective. Establish guidelines and ownership.
            1. Stakeholder: administration
            2. Neutral: patient care gets completed
            3. Negative: compliance needs established with more perfusion hired
            4. Positive: keeps reimbursement within OSU
            5. Positive: increase patient satisfaction
            6. Negative: increase cost of staffing needed
         5. Characteristic: Organizational Intelligence: realizing a process change needs to occur when multiple transfers occur per month and increased wait times for the transfer with the utilization of cath lab staff
            1. Stakeholder: ICU staff
            2. Negative: more training needed with ongoing yearly compliance measures
            3. Positive: increase experience level
            4. Positive: integral part of patient quality care experience
         6. Characteristic: Permeable boundaries: openness to exchange the new process; unsure of limitations
   3. Measurement of Organizational Culture
      1. Name and description of organizational culture survey
         1. Denison Organizational Culture Survey
         2. provide practitioners with a tool that will offer a simple, yet comprehensive look at four aspects of organizational culture that influence business performance
         3. 60 item instrument that evaluates underlying cultural traits/management practices and gives results in a summary report giving levers for change
      2. History
         1. Developed for 20 years by Dr. Daniel Denison at the University of Michigan business school
         2. completed a number of studies examining the relationship between organizational culture and effectiveness
         3. Identifies four traits: involvement, consistency, adaptability, mission
      3. Purpose
         1. powerful tool that enables leaders, key stakeholders, and employees to understand the impact their culture has on the organization's performance
         2. learn how to redirect culture to improve organizational effectiveness
      4. Usage in Organizations
         1. general business, merger, facing industry restructuring, start up venture, a new CEO, restructuring an organization in decline, new strategic initiative, customer service challenges
      5. Outcomes identified from the use of the survey
         1. baseline of cultural strengths/weaknesses
            1. development of leaders
         2. understanding of culture relative to high performing organizations
            1. shared expectations concerning culture
         3. target change efforts
            1. identification of immediate areas of focus which will support the organization and its members in attaining rapid results
         4. understanding of bottom line performance
            1. cultural factors that link to decline
      6. Validity History
         1. developed to overcome problems existing approaches and measure culture in ways that predict performance
         2. can predict revenue generation and profitability
         3. fast and east to implement, applicable to all levels of the organization
      7. Reliability History
         1. return on assests and sales growth
         2. correlation between culture and perception of performance, satisfaction and quality
         3. partnership project surveyed 960 individuals to help debug the process
         4. future research will help to descibe and understand between industries, levels, and functions
      8. Innovation Behaviors Measurement
         1. Identified Innovation Behavior
            1. Tenacity/perseverance
            2. Create purposeful, focused change in an enterprise's economic or social potential
            3. Rationale- commitment to seeing vision through; endure journey to implement innovation; persist in efforts
            4. Creativity problem solving/imaginative
            5. Rationale- engage in process of creative imagination; ideas and opportunities and ideas are developed
            6. Ability to maintain focus yet adapt
            7. Challenge the status qup
            8. Rationale- adapt while also maintaining a sense of direction and focus
            9. Resilience
            10. Rationale- cope with stressful, adverse, and devastating situations; able to recover and continue to pursue goals
            11. Design thinking
            12. improve organizational effectiveness
            13. Rationale- value creation with new products; ability to question, observe, and experiment
            14. Self-efficacy/confidence
            15. Rationale- self assurance about ability to take on challenges; perform certain tasks as expected ot needed
            16. Change management
            17. improve adoption
            18. Rationale- ability to help stakeholders accept and embrace changes in work environment
            19. Teamwork/Collaboration
            20. Rationale- communication and work with different professions and disciplines; understand cultures and equality
            21. Evidence/compatibility practice efficacy
            22. encourage organizations to more quickly adopt evidence based treatments and practices
            23. Rationale- adaptability of innovation with existing practices, norms, beliefs, values, efficacy, and reinventions
            24. Building/using networks
            25. Rationale- establish, maintain, and structure networks that foster relationships, enhance access/potentially lead to realization of objectives
      9. Guidelines for Assessment
         1. Identify survery questions that reflect innovation
            1. risk taking, exploration, facilitation
            2. Rationale- disciplined process with multiple words representing innovation
         2. Explore innovation language with key concepts
            1. considers out of the box, boundary spanning ideas
            2. Rationale- Variety of words/questions involved; take into consideration all questions
         3. Understand questions that mirror and foster growth and development
            1. continuously adapt while staying focused on task
            2. Rationale- innovation is continuous; constantly thinking about the future and vision
         4. Recognize with examples innovation behaviors
            1. Ask the best questions and think differently
            2. Rationale- Seeing an opportunity and communicate and experiment the idea
         5. Look for creativity and design thinking to help problem solve
            1. creates an environement and culture for innovation to take place
            2. Rationale- Utilizes resources and deep dive experiements
      10. Psychometric Analysis of Organizational Culture Survey
          1. Dension Organizational Culture Survey
             1. Description
             2. Reference: Denison, D., Neale, W. (2017)
             3. Strengths: survey of 60 item instrument; simple, yet comprehensive analysis of the culture of an organization by evaluating the underlying cultural traits and management practices that influence business performance; data returned to scoring center results include graphic profile, line item report, and levers for change
             4. Weaknesses: behavior based, rather than focusing on general emotional climate
             5. Underlying Theory
             6. reference: Denison consulting. (2017)
             7. Strengths: Developed to operationalize a theory of cultural effectiveness that focused on four key traits as drivers of organizational performance: involvement, consistency, adaptability, and mission. Tool used to understand impact culture has on performance and learn how to redirect culture to improve effectiveness.
             8. Weakness: no specific theory identified, only mention of a model
             9. Beliefs
             10. reference: dension, d., neale, w. (2017)
             11. Strengths: Core 4 traits have impact on organizational performance; items needed action orientation to link to specific managerial impact; build large data base for future research
             12. Weaknesses; Need clear understanding for the need of the survey and end results you hope to achieve
             13. History and Validity and Reliability
             14. reference: denison, d., neale, w. (2017)
             15. refernece: cooke, r., lafferty, c. (2017)
             16. Strengths: 2 decades of research; used by over 500 organizations; research is published in articles and books; published 1995 revised since original date; used qualitative and quantitative methods; used corporate research partners to develop survey
             17. Strengths: most thoroughly researched and widely used assessment for measuring organizational culture; used test and retest
             18. Weaknesses: data measures return on investment, return on sales, strong cultures leads to better financial performers but some effects did not increase over time: job reward, decision making practices, inter unit coordination, emphasis on human resources; need 5 years for drastic change
             19. Usage in Organizations
             20. reference: denison, d., neale, w. (2017)
             21. Strengths: applicable tool to all levels of the organization; developed to over come problems with existing approaches
             22. Weaknesses: No specific mention of use in healthcare setting; very much business based
             23. Advantages
             24. reference; cooke, r., lafferty, c. (2017)
             25. Strengths: fast and easy to implement; can help with many situations in business including companies in decline; produces better financial outcomes; continuous research
             26. Weaknesses: several stages of refinement; cycles of adding new items, collecting even more data, refining the measures; may need a consultant from outside company
             27. Limitations
             28. reference; denison, d., neale, w. (2017)
             29. Strengths: very focused on improvement of culture; provides references; unsure of feedback process
             30. Weaknesses: could be biased information from using manager from inside organization; all information gathered is from developer of survey; unsure of cost
             31. Usefulness of Information Generated
             32. reference: denison, d., neale, w. (2017)
             33. Strengths: lots of research and publications; measures can predict revenue generation profitability
             34. Weaknesses: claims the information is in simple language but may still be difficult to understand; may be outdated with more recent research
   4. Strategies to Advance Innovation in Organizational Culture
      1. Culture is not easily changed and is complex and multifaceted; Create sources of value with a clear mission, vision, and abandon ideas as necessary
      2. Positive Strategies to influence change
         1. Strategy
            1. Rationale: leader self awareness and self confidence; clarify expectations; consistency in language; impact on others; appreciative principle
            2. Engage informal leaders whenever possible to be courageous, resilient, and creative as ambassadors of the desired cultural behaviors and norms
         2. Strategy
            1. rationale: language expectations and obligations; maintaining locus of control; strategically craft questions; appreciative principle
            2. Recognize that friction or conflict is inevitable and must be explored and integrated into culture
         3. Strategy
            1. rationale: performance and the demonstration of impact; specify expectation; understand value work to lead; effort applied; appreciative principle
            2. Less than 30 percent of a group or organization is needed to begin a movement or cultural change
         4. Strategy
            1. rationale: relational capacity to mobilize accountability; expectation engagement and reminders; re evaluation; communication updates; appreciative principle
            2. Culture does not maintain itself, it needs constant attention and reinforcement of values and norms
         5. Strategy
            1. rationale: Integrity/inclusion; way of leading; respect individual voices; understand miscommunication error messages; collaborate patterns of behavior; don't be discouraged; appreciative principle
            2. Individuals can suck the life out of an organization and must be recognized and marginalized. Stay in the appreciative mode
      3. Strategies to overcome resistance to change and innovation in healthcare influence change
         1. Strategy
            1. rationale: identify and ask what is the stated commitment?, behaviors that keep me from my commitment? what is the competing commitments? and what is the big assumption? goal is to understand how to become more effective and research why an individual is resistant to change
            2. Uncover competing commitments
         2. Strategy
            1. rationale: ask the questions what are the consequences of this behavior? what is the opposite of the undermining behavior? is value in gossip evident with assumptions; engage and communicate the value to others
            2. Challenge the competing commitment
         3. Strategy
            1. rationale: provides fresh insights into decision making and leadership; opportunity to identify the problems ; support and follow up
            2. Turn negative Behaviors into Positive action
            3. Use gossip as a resource
         4. Strategy
            1. rationale: failure is not negative but a tool of progress towards innovation; contain a number of causes; can use strategies to avoid failures; be open to flexibility
            2. Understand causes of failure
         5. Strategy
            1. rationale: help to proactively uncover resistance and course correct quickly; driver of change; integrate accountability into the system
            2. Further strengthen success using evidence