What do we understand when we talk about culture in a hospitable environment?
We refer to the attitude of each one and in its totality towards the others and toward the environment.
We define as the best culture attitude: fair, horizontalized and transparent.
Maybe the worst culture is that one where people think everything will be the same, no matter what happens, nothing will change or improve, no matter what you do.
We should classify at least two kinds of culture: those ones centered on power and those ones centered on values.
The power-centric ones, that is, very hierarchical or vertical, usually form an atmosphere of fear. People operate with a strong incidence of fear of an authority and its consequences.
The values-centered ones, on the other hand, are more horizontal, as there is not an excessive gradient of authority between one operator and another. Focusing on values, it means that there must be justice acting to support values. Rules are also part of a value system.
Why is it dysfunctional to have a culture of power inside a hospitable environment?
Many authors have defined the hospital environment as a complex system. What is a complex system?
A complex environment is a surrounding area, where there are several actions or “drivers” that promote actions that generate reactions. There is no direct relation of cause and effect between them, neither between them and the reactions or consequences. Sometimes the reactions are disproportionate to the changes in the drivers. It doesn´t mean that there is chaos. There is another kind of order, not direct, not linear.
In a complex system, we have inhibitory factors acting and preserving the system and catalysts, that is, factors that promote change that can be stimulated.
We have drivers that, by the action of others, are positively feed and others that are negatively feed. There is no proportionality of the consequences.
There are also attractors, that is, elements, such as the force of gravity, that always maintain their influence in all situation.
The fact that we do not know how a complex system works does not mean that it is chaotic. It only means that the rule of 1 + 1 = 2 does not work. Linear thinking will not help us. A relational or relative logic, where there is no absolute right, neither absolute wrong, will better guide us.
There will be many cases of paradoxical results. They are simply those whose logic we still do not understand. Not for that, less logical.
A hospital has, for the integration between a human environment, technological environment, private and sick interests, a characteristic of a socio-complex system. But it doesn´t mean that it is not necessary to carry out too many operations with a deterministic sequence of a military operation. This last one must work in logistics, cleaning, production, administration tasks, etc.
For all those operations where is necessary the participation of several people and criteria, when taking decisions, a culture based on values stands out on a culture supported by the power.
The gradient of authority. In the aviation industry, after checking that in some accidents the co-pilot did not have courage to tell the commander that there was an error in the procedure and that led them to a disaster, it began to train the staff together and not separately. The communication skills of the team members were evaluated and they were encouraged to communicate themselves, reducing the authority gradient, what prevented a lower level person within the group from communicating a significant incident to the leader.
A horizontal culture does not mean totally horizontal. It is not a democracy, where a procedure is voted. It is a culture where an assistant can inform a great surgeon that there was a diversion or an error in the procedure. But leaders keep being needed, in those situations where the complex still remains. It is a good culture that the solutions are searched organically in the expert people, with knowledge and skills and not in the chain of command, which means, in the bosses.
A good culture is well-fed by transparency. To have a culture based on values, everyone must have access to information, with great transparency. Transparency is the ethics of the 21st century. Systems are more complex than before and require the participation and collaboration of all, to reduce errors.
Much is said about the culture of guilt, that is, that blames people for mistakes instead of looking for the failures that exist in the system. With few exceptions failures are always caused by a system with errors or unsafe.
The dysfunctionality of power-based culture, within complex systems, is that group decision, in accordance with different specialists and point of views, is necessary for its success. A simple or simplest solution is, by definition, a wrong reply for a complex problem. It is necessary to dig deeper. The solution must consider, at least, the same complexity level of the problem.
Human beings are beings that make mistakes, and the draw of any system must be done keeping it in mind and preventing its consequences, when natural mistakes happen.
It takes too much time to change a culture, once there are many minds and memories surrounded in this change, but it is one of the factors with most results. Technological changes help but it´s not itself enough to create all needed evolution.