A Culture of Continuous Improvement

The word culture gets tossed around quite a bit in healthcare settings and its use can be somewhat ambiguous. Culture has many definitions and when applied to discussions of the workplace, can take many different meanings. For clarity, when I advocate for building a culture of continuous improvement, I mean specifically building a normative work environment where all members of the team have no fear of questioning the work and sharing ideas. Seems simple, right? Unfortunately, there are many barriers to creating and maintaining such a work environment. It takes time, practice, and a commitment from leadership to be inclusive and supportive. Team members will learn from experience. If the experience of expressing ideas, asking questions, or making suggestions is received poorly, they will respond accordingly. Employees afraid to or uncomfortable raising their hand simply won’t. Alternately, if staff are met with curiosity, inclusion, and encouragement, their positive experiences will help facilitate shared learning and growth. If you are leading a unit or service, challenge yourself to do a quick assessment of the area(s) you are leading. How do staff react to problems that make their work more difficult? Think of workflows, processes, equipment issues, etc. See the below examples. Where do you think the majority of your staff fall?

1. They say nothing unless asked directly, and provide cautious answers

2. Express frustration and complain but hesitant to participate further

3. Share feedback, make recommendations, ask to be involved

   
   

Doing a self-assessment is not a pass or fail test of your leadership, there are no bad findings here. It’s important to objectively understand what the norm is and not make assumptions. Don’t assume staff are comfortable escalating concerns. Don’t assume you have a good working relationship with all team members. Make it your goal to better understand the working relationship that is real and currently exists. It’s not likely that all or even most of your team fit into just one bucket. You might have a few outspoken persons who love the job, a few who strongly dislike the job, and many quiet unknowns either on the fence or leaning in one direction or the other. If you want to build a culture of continuous improvement, you need a workforce of engaged problem solvers and to do that, you’ll need to evaluate where the team is. It can be good, bad, or terrible. Whatever you find, remember that this is just a starting point and not an indictment of your ability to lead a team. Do they like, love, or loathe the workplace? Do they feel supported by your leadership? Do they have the necessary skills, tools, and support to do the work you ask of them? There are many important factors to consider in assessing the health of a dynamic team of working professionals in the healthcare setting. Here are a few habits I recommend building into your leadership that will help you gain valuable insight and develop a clearer understanding of how your team views your leadership and their workplace. Consider the many different ways to regularly get direct feedback from individuals. Establish a non-punitive, collaborative space for all team members to feel good about participating with and helping to create solutions. At the top of my list, be honest, accurate, and transparent about what and why.

Leader rounding

The human connection is powerful. Use it. For best practice I’d recommend looking at published articles and journals regarding stay interviews. I had the opportunity to partner with a Studer coach early in my leadership years. I learned how valuable these personal leader rounds can be. They are simple but effective. Don’t overthink the exercise. I’ve tagged a link to a Quint Studer article on stay interviews for you. The important takeaway in any stay interview or leader rounding (call it what you’d like) is talk to individuals and give them privacy and space to share what’s working, and as importantly what isn’t. Demonstrate a willingness to hear difficult feedback and find opportunities to improve the overall work experience. Those quiet employees who only share important information about the job when asked are going to thrive here. You will uncover important barriers hiding in the workplace that likely aren’t on your radar...including that piece of equipment that hasn’t functioned properly in weeks which really frustrates your crew. If you practice this consistently you will build trust with those individuals who are less comfortable sharing the good and bad of what you need to know. You have an opportunity to build trust and create a healthy, positive work experience that will open the door to better communication with your team.

Survey your team

Healthy work environment? Another survey? Well, yes but hear me out. Survey anonymously for honest answers. If staff are hesitant to participate it’s likely because they 1) don’t believe the surveys are anonymous and 2) they’ve completed a million surveys before and see very little relevant change made after. Be mindful and engage your staff a bit differently. Create a process of ‘survey to action’ that keeps you as the leader on the hook for follow up and applying meaningful action to the survey results. Don’t be afraid to literally show staff your view of survey data being collected. Prove that it is in fact anonymous. I’m going to make another recommendation here based on lived experience and please note there is no perfect survey or program, so please review and research options and decide what is best for you and the organization you belong to. The AACN’s healthy Work Environment initiative has an incredible survey for nurses and non-nurses that is free to use. You can create an anonymous survey that allows you to share a link in an email and send out to your workforce. You can set how long the survey will be active, and once the survey closes you will get an excellent summary report of the results. This report includes a useful breakdown of your top and lowest scores, as well as where you compared to other like areas nationally. The AACN HWE survey also allows you to track the number of surveys completed to see overall participation as you go. I’ve tagged the AACN healthy work environment page below for ease of access. I encourage you to take a look. Again, there are many surveys, and you can also consider developing your own questionnaire to get feedback that is specific to the issues you are exploring. Regardless of what type of survey, don’t underestimate its value if used properly. Used properly meaning don’t push for participation and then fail to follow through...You will need to have an action plan that includes addressing the information gleaned from the survey. Normalize having honest conversations about the survey results, especially items that score poorly. This is where you get to shine.  

Publish the survey results and schedule open discussion

Reviewing the survey results with your team is an important follow-up item and can be a great conversation with participants including those who often complain or escalate concerns. The persons on your team who are vocal and tend to complain – use the survey results to better understand the prevalence of their frustration. Is their experience widespread or unique to them? Transparency matters. Treat this like an open dialogue with no constraints on staff who have chosen to participate. Respect their input and ask clarifying questions to better understand it. This is your opportunity to help individuals validate their concerns or drill down to better understand them. Be inclusive. Show them something different. Be inclusive and make them a part of your coalition to make a better work environment. This is a great exercise to help every person be heard and made an important key stakeholder in improving the quality of their work experience. Try this and be consistent with follow-up. Use this engagement to identify important opportunities, build an action plan to address them, and provide regular updates. You will teach those who are vocal about their frustrations that a process exists for each individual to be heard and be a part of addressing issues most important to them. For those quiet employees, you will demonstrate in good faith that sharing feedback and participating in the governance of the work environment is a healthy and productive exercise. Of course, those champions who are already in a good place and your outspoken advocates – you prove them right and make them proud. Prove to your team that you are willing to listen, willing to hear difficult feedback, and that you are willing to partner with them to make good changes.

Continuous is as it implies

The concept of a culture of continuous improvement is not a one and done exercise. It’s not an in-service or a staff meeting, it’s not a flyer on a huddle board. Going back to the specific use of the word culture which in this example is intended to mean what is normal in practice. Normalize a work environment where each member of the team is able to raise their hand, question their work, and share important ideas. The patient care landscape changes, the environment changes, as do the tools and technology we use to do the job. If you as a leader can provide a work experience that allows team members to comfortably acknowledge when change is needed, you will create a team of dynamic content experts and highly engaged problem solvers able to tackle any barriers getting between them and the highest quality, safest patient care outcomes. Invest the time and energy needed to understand your team and the job you are asking them to do. Be patient and play the long game. This takes time and good practice. If your team(s) are hesitant to trust you and participate, understand their lived experience may have taught them to be cautious. Appreciate that experience and meet them where they are. Imagine how this can impact your ability to retain great staff. Get to it.

Steven Corey RN MSN MBA

Experienced healthcare leader

Advocate of Lean Strategy

Butwhythoughpi.org

April 6, 2025

AACN. (2025). Healthy Work Environments. Retrieved from AACN.org. https://www.aacn.org/nursing-excellence/healthy-work-environments

Studer, Q. (2022). The Power of the Stay Interview. Retrieved from Quintstuder.com https://quintstuder.com/the-power-of-the-stay-interview/