5 November 2013

 I wonder if there is a term for an allergy to certain phrases? My metaphorical histamine levels are being triggered at the moment by two: delivering ‘at pace’ (which seems to have replaced the equally irritating ‘quick wins’ in meaning (well you know what it means) lots of frenetic activity and little real impact, and ‘culture eats strategy for breakfast’ .

Originally coined by Peter Drucker, the latter is of course true – we’ve watched culture defeat strategy time and again; and a healthy culture supports good day-to-day decision-making in a way that the most brilliant strategy simply cannot.

 No, it’s where it takes us that is the problem. What do the people telling us this want us to do next? Surely they can’t want us to introduce a strategy to change the culture?!  (One that will be eaten by that culture?). My fear is that they do.

 But if some of us see that for the conundrum that it is,  what is our solution?  I suggest we will only find one if we try to understand both culture and strategy much better, and  before we rush into implementing (at pace!) a raft of well-intentioned but misguided attempts at change – that will at best irritate and at worst alienate.

 So what do we know about culture?

 We know that culture strongly influences (even determines) many of the default decisions we all make everyday, the ones beneath our awareness, the ones we make on autopilot.  Another (related) suggestion is that culture is those default decisions that members of a group share. In other words, default decisions are both effect and cause of a group’s culture. Personally I find that one of the most useful ways of seeing culture, but we need to explore it further before we can think about how any of us can influence it.

 If we do so, if we think about those decisions we make on autopilot,  we realise that they form the  overwhelming majority of decisions we make every day. Buddhists and neuroscientists tell us that we make these based on instantaneous judgments equally underneath our radar in which we  rate everything we are exposed to as something we like,  don’t like, or something  we can ignore. It is these instinctive reactions that lead to actual thoughts, and these thoughts prompt others and others, in a rapid sequence. We know too that these sequences have a familiar pattern, a pattern of thinking and reacting that is distinctive to ourselves. And that we only become aware of these patterns when we pay explicit attention to the behaviours our mind (without asking our permission!) engages in.

 If we are going to change a culture we need to change some of these patterns, but how? Well we know how to do that on an individual basis, and perhaps there are lessons there for influencing the culture that (as we have seen is both a cause and effect of these.

 This observing of our patterns of thinking is one of the fundamental roles of meditation. Or rather, this is the role of one of the three fundamental forms of meditation, the three being:

1.       ‘losing our minds and coming to our senses’: by focusing on the moment by moment experiences within our body as we breathe, stilling our mind’s propensity to jump from thought to thought like a monkey jumping from branch to branch, without our intention, permission or awareness, developing our ability to stay in the here and now.

2.   ‘showing up for what comes up’: simply noticing, without trying to change them, the thoughts and feelings that arise, noticing patterns, sometimes labelling some of these thoughts, but always allowing them to come, accepting them,  and letting them go wherever they do without any interference, simply staying aware of them. We can describe this as developing the observing self

3. fostering healthier patterns of reaction (including compassion) by practising them.

 All three can be helpful in considering how to influence culture but it is developing that ability to go into the ‘observing self’, whether on the meditation cushion or in the middle of the hurlyburly of everyday life, that allows us to come to recognise some thought patterns as old friends, see how unhelpful they are, and in that recognition give ourselves choices.

 ‘Oh this is me judging and blaming again, how else could I react to this?’. ‘Oh yes, I’m taking this personally again, is that really reasonable?’. ‘I want to be right again, I’m arguing to prove I’m right, is that the most important thing here?’.

 Over time the observing self becomes more able, more skilled at interrupting some of these unhelpful patterns. But our ability to move into it is of course influenced, and often  opposed, by the culture we are working or living in.

 In  a world in which our media headlines delight in labelling this person or that group as blameworthy (as wicked, or stupid, or both), it is more difficult for us to resist that temptation ourselves and instead of seeking the underlying causes of an action, or being prepared to accept that sometimes things that are bad or sad just do happen, we angrily and self righteously join in the calls for retribution.

 Brene Brown’s research shows clearly the impact of this fear and blame and subsequent shame, on our enjoyment of our lives, and it is this that so often drives the culture on wards and in departments or surgeries, the culture that we want to change. So we do need to find ways of  doing so, but in ways that do not themselves induce fear, blame or shame. it would be tragic if in our quest for a healthier culture we instead increase those levels, and I can’t  help wondering whether a duty of candour will do just that.

 So what can we do? Let’s think again about strategy

 It helps to remember that there is more than one way of developing and implementing strategy.

 If we look across the strategy literature (the very plentiful strategy literature!) we find at root three distinctly different strategic approaches. There is a planned approach, in which an (often quantitative) analysis is followed by a plan, implemented by project management methods and evaluated accordingly. This is what that most people mean when they talk of strategy, but it is not the only way.

 There is an emergent approach, first described in that language by Henry Mintzberg,  in which the strategists (often insiders with an in-depth understanding of the organisation that is as intuitive as it is analytical) observe the day-to-day decisions that are being made and reflect back to the organisation the pattern that these form (the ‘strategy in action’ that is being followed), and gently but purposefully foster some behaviours and decisions and discourage others.

 And there is a more spontaneous ‘in the moment’ approach, advocated by complexity theorists, who set a strategic  intention and then focus on the quality of the interactions between the elements  of their complex system – and in health care these components are mostly people. So the attention here is on understanding others, empathising with them and their concerns, supporting them when they are behaving in ways that support the intention, and challenging them (gracefully, firmly, effectively) when they are not. This could be summarised as ‘intention, kindness, going towards the difficult’, a phrase that which mindfulness practitioners will recognise.  

 (To read more about these three approaches to strategy click here.)

 It is the first of these (the planned strategy) that is so often eaten for breakfast by culture. The other two are still open to us, indeed in many ways they are the organisational equivalent of mindful meditation. So, how might we use them to  move forward?

 We could certainly encourage personal practices of mindfulness, not by prescription but by example, but we could also examine our routine organisational processes. We could see whether they are encouraging a confident and  energetic ambition to empathise with others and seek to meet their needs or instead promoting fear, blame and shame.  

 Ward handovers for example: do they focus simply on risks to beware of  in the upcoming shift? Or do they:

• reflect on what to celebrate from the shift just ending?
• voice some realistic positive ambitions for patients in the one just starting (of which avoiding risks will be a part but only a part)?
• and take a moment to feel part of a wider team, across different shifts, all under pressure but all caring about the same sort of things.

 I think we all know the answer, and people protest that to do anything different would take too much time. But I’m not convinced that what I’m suggesting would need to take longer than the existing arrangements but even if it did , the extra few minutes would so positively affect the culture on the ward throughout that shift, and over time, on a more permanent basis, that it would be a hugely worthwhile investment. (Part of our current culture is that  we see time as a cost and not as an investment).

 What about other routine processes – at all levels? Performance management processes. Board meetings. Let’s think about the kind of conversations between GP receptionists and patients perhaps,  and the kind of conversations between GPs and receptionists that shape those? Do they concentrate on pressures, on tactics to contain demand, increasing the feelings of helpless embattlement felt by both receptionists and patients? Or do they refer to the ambitions of the practice to support patients and community and meet needs as well and creatively as possible? What kind of conversations between GPs and  those commissioning and contracting them are most likely to encourage the latter rather than replicate the former?

 If we recognise that looking at our routine organisational processes in this way is an organisational form of mindfulness, we will also look for common patterns in those routines, patterns based on fear, blame and shame, and start to challenge these wherever we see them, becoming gradually more skilful in our ability  to do so .

 SO   if culture eats strategy for breakfast, how do we craft a strategy to change culture ?

 Well we start by rejecting the idea of a strategic plan (because that will be well and truly eaten) and we opt for a more emergent approach that recognises complexity, and that recognises deep-seated fears and anxieties. We acknowledge that culture is something each and every one of us contributes to, and we think about  how we ourselves are contributing to a culture of which we do not want to be a part.

 We see all of our interactions with others as a chance to embody a different culture and encourage them to do the same. We look at the organisational processes and systems that we participate in and consider whether they focus on fear, blame and shame or on celebration, positive caring ambitions, and a sense of connection with others.

 Gandhi may not have actually used the words ‘be the change you want to see in the world’ (apparently this is a ‘bumper sticker’ version of a much longer discussion) but that is the spirit we need.

And one implication of that, of course, is that we should actively ignore anyone calling for a change in culture, or insisting on particular ways of changing our culture, who fails to actively demonstrate in their own actions the culture that we want to see.

 We must each start where we are, gently but purposefully,  with ourselves.