Building a Culture of Quality with Wendy Nicklin

Summary

A new CEO arrived at an organization that had a strong vision & mission to contribute to improving
the quality of healthcare. The quality improvement business of the organization seemed
reasonably strong and well regarded. However, within days of assuming the new responsibilities,
the CEO realized that there were symptoms of a less than desirable culture, the product was
becoming less relevant to clients and it was evident that external stakeholder relationships
required strengthening.

The Problem

The culture of the organization was such that staff were afraid to speak up, that they would ‘get in
trouble’ or ‘lose their job’ if they offered suggestions for improvement. Teams were not working
well together. Communication was poor. Meetings were not well organized, for example, there
was no set agenda and no minutes were taken. The Board and board members were not
effectively utilized. The primary quality improvement product was becoming ‘out of touch’ with
reality and client needs. Some clients were questioning the value of using the product. External
stakeholder relationships were adequate, but not strong, and there were non-existent linkages
with some obvious potential partners in the quality sphere of healthcare. For example, a
representative of the organization was not invited to important meetings. They were not
deliberately excluded, they were just not thought about.

The Consequences

Internally, staff turnover was high (in the region of 20-25%). Teams were not working well
together. Senior management was not committed to attending senior management meetings –
they attended if they wanted to or often missed the meetings. There were senior meetings where
there was no agenda and no minutes taken. While the Board met at the defined quarterly
intervals, the expertise of the Board was poorly utilized.

Externally, while the organization was well regarded by its clients, key stakeholders and others
were minimally engaged. The organization was excluded from external discussions on key
healthcare issues where, if involved, it could have provided valuable input. Clearly action was
necessary to :

1) Develop a strong internal culture of quality, one within which staff knew they were valued and
respected;

2) Improve the relevance of the product;

3) Strengthen external stakeholder relationships.

Barriers / Obstacles

The main barrier was that the culture was entrenched. Many coordinated steps had to be taken to
begin to turn the culture around. Several senior staff who contributed to the negative culture
were still within the organization. Addressing their behaviours and approach was a sensitive issue
and challenging.

Actions

Internally (staff):

• Actions were taken to prove to staff they were valued – we were all partners.
• The staff developed new values for the organization – these were presented to the Board
for input & acceptance.
• The values were converted into ‘expected behaviours’ – an exercise undertaken by the
staff – and then assessed twice/year.
• All-staff sessions were held at minimum every few weeks – with an agenda and time for
open dialogue within which anything could be raised.
• The CEO had informal sessions with staff on a monthly basis. There was no set agenda and
any issue could be raised.
• A fitness room was installed.
• A policy was developed such that all staff members, from clerical through to senior staff,
must be ‘on the road’ with the product at least once every 3 years.

Product:

• Extensive steps were taken to upgrade the product over a period of several years.
• Short term / immediate changes (easy wins) were made while the medium to long term
changes were underway.
• The name of the organization was changed in order to better reflect its mandate.
• Feedback mechanisms were strengthened to obtain product feedback from all stakeholder
groups on a regular basis.

Board:

• A strong partnership between the CEO and board was cultivated.

• Location of Board meetings began to be held across the country – to facilitate engagement
with key stakeholders.
• The Board members were consulted and involved between meetings and attended
conferences and other meetings with stakeholders.
External stakeholders:

• Deliberate steps were taken to meet with existing external partners – mutually identifying
where the partnership could be strengthened.
• New partners were identified and relationships initiated.
• External communication was strengthened.
• All staff and stakeholders were involved with appropriate initiatives. Partnerships and
collaboration were key.

What Worked?

All actions worked, however it took time. The inter-relationship between the internal culture,
productivity, relationships with the Board, quality of the work, product changes and external
relationships wove an integrated picture. It took at least 2 years to truly shift the internal culture
and measure the impact.

The external relationships were significantly stronger, such that we were invited to meetings and
conferences with such frequency that it was difficult to keep up with the requests. It took about 3
years to effectively shift those external relationships to the extent that the input of our
organization became a ‘given’ and valued.

Outcome

The internal culture turned around markedly. Staff turnover dropped significantly, to about 2%
rather than in the region of 20-25%. Staff engagement surveys improved.

The Board was better engaged and convening the Board meetings in other cities and liaising with
stakeholders of that region was an extremely positive change with positive feedback.

Positive feedback on the improvements to the product was obtained, with regular feedback
mechanisms in place. There were ‘bumps on the road’, however the areas of concern were
respected and resulted in modifications as necessary.

External relationships improved substantially, one measure of which was that we were invited to
meetings and conferences with great frequency as noted previously.

The organization went from being seen as a leader of the quality improvement business to a
leader in healthcare, with valuable input to provide on key healthcare issue discussions & debates.
Lessons Learnt

The main lessons learnt were as follows :

• Care for your staff and they will care for the clients.
• As CEO, be present and accessible to the team.
• Building relationships requires the leader to take deliberate steps to meet with
stakeholders and to meet regularly, even if there is not a problem to solve or a topic at
hand.
• Don’t be afraid to bring groups together.
• Remember to evaluate and measure everything you are doing. It is crucial to identify if
progress is being made, or where course correction is required.
• Listen to the clients, truly listen to both the good and the bad. Don’t be afraid to adjust
course if there is unreasonable resistance. A degree of flexibility is important, while also
adhering to your values and direction.
• Don’t sit back once a goal appears to have been achieved. You must continue to nurture
the progress and continue to evolve and improve. If the leader takes his/her eye off the
ball, the organization will slip back into old habits or not evolve. The culture, the product,
the Board and the external relationships must continually be nurtured and addressed.

Questions

1. When a leader/CEO faces challenges internally and externally, how does he/she prioritize
and identify where to begin addressing those challenges? What steps should be taken and
how would you plan to address this situation? (minimum 150 words)

2. What leadership style and approach would be most effective in this circumstance?
(minimum 150 words)

3. What measures / indicators should be identified and tracked to note progress or further
deterioration (internal, product, Board, external stakeholders, etc)? How would you
measure success? What would be the ultimate measures of progress? (minimum 150
words)

4. What should a leader do to ensure an organization does not ‘backslide’ after achievement
of some marked improvements? (minimum 150 words)
About the Author

Wendy Nicklin, R.N., B.N., M.Sc.(A), CHE, FACHE, FISQua, ICD.D

President, International Society for Quality in Health Care (ISQua)

President, ISQua External Evaluation Association

A valued active partner in discussions about improving the quality of health care, Wendy is a
recognized and respected health care leader across Canada and internationally. Obtaining her
academic degrees at McGill University, Wendy has extensive experience as a critical care nurse,
educator, administrator and has held many leadership positions. She has participated in provincial
and national initiatives, such as the National Steering Committee for Patient Safety, and was a
founding Board member of the Canadian Patient Safety Institute for 8 years, working to contribute
to its establishment and success. In 2016, after over 11 years, Wendy stepped down from the
position of President and CEO of Accreditation Canada. She led a significant renewal of the
approach to and value of accreditation. Her global leadership about accreditation is well regarded.

In 2017 Wendy became President (Board Chair) of the International Society for Quality in Health
Care (ISQua), preceded by 7 years on the ISQua Board. She is a previous chair of the ISQua
Accreditation Council for the International Accreditation Program, member of the Innovation and
Systems Change Working Group, an Expert, a Fellow and an ISQua surveyor. In 2018 Wendy was
elected as an inaugural member of the International Academy of Quality and Safety in Health Care.
In 2018, with the initiation of the ISQua External Evaluation Association (IEEA), Wendy was
appointed the IEEA President.

She serves on the board of the Healthcare Insurance Reciprocal of Canada (HIROC), chairing the
Claims and Risk Management Committee. Until March 2019, Wendy was a member of the
Champlain Local Integration Health Network (LHIN), chairing the Quality Committee. She is a
member of the Institute of Corporate Directors (ICD) with her ICD.D designation from the Rotman
School of Management, University of Toronto. An Emeritus member of CHLNet, she is a member
of the Secretariat and co-chairs the CHLNet Health Leadership Exchange and Acceleration Working
Group. Most recently she has been appointed to the Committee on Accreditation of Canadian
Medical Schools.

A past recipient of two Canadian Nurses Foundation awards, Wendy received the Woman of
Distinction Award – Health Services in 1999, the Canadian Nurses Association Centennial Award in
2008, the CCHL Eastern Ontario Chapter Award for Distinguished Service in 2012, the University of
Ottawa Telfer School of Management Preceptor award for 2016 and the 2018 Legacy of
Leadership Award, a lifetime achievement award from HealthCareCAN.

With a strong commitment to effective governance and focusing on quality, safety, accreditation
and leadership, Wendy has numerous publications to her name and has given many presentations
nationally and internationally. She has academic appointments to Queen’s University and the
University of Ottawa.