Culture Change with guest Mahesh Polavarapu and our hosts Andy Little and Drew Kalnow.

Post by Spencer Willette, OMS-II 

Change is hard; implementing successful and sustainable change is even harder. In this episode of EM Over Easy, the guys explore quality improvement and culture change within your residency program and working environment. 

When change is implemented and it doesn’t get the results we hoped for, the tendency is to view that change as a failure. But it may not be. In fact, the change you get is usually a reflection of the way your system was built. For example, at Mahesh’s institution, residents are responsible for maintaining adequate airway supplies within the department. This is done by pre-shift checks by the 2nd or 3rd-year residents that are not formally tracked. While this has traditionally worked overall, there are still instances when the airway supplies needed are not readily available, the equipment (like the VL blades) is damaged without any way to track source error, or things aren’t where they are designated to be. Just before the start of his fellowship, it was decided by the residency and administrative team that the process needed to be changed because it ‘wasn’t working’. When he started looking at potential changes, he quickly realized that the process was actually working. It was getting the results it was designed to get, these just weren’t the ones they hoped for. So, he worked backward. He started with figuring out what we wanted the results to look like and then built a system designed to get those results. 

Implementing Change:

Starting change: Figure out where you want to go and work backwards to figure out where to start. 

Set expectations: If you were to look back on your project in 12 months, what would you consider a success? Then consider, what pieces of that success are already in place? 

Evolution over Revolution: Implementing change can be difficult since the founders of the original systems in place may still be involved. Additionally, it’s not always necessary to reinvent the wheel, many of the processes in place work well but could use some tweaking. Evolutionary ideas tend to be more successful than those that are revolutionary.

Culture Change: Change without purpose is temporary. But, creating and cultivating a culture that stands for a way of being and performing can have long term effects. 

If you try to implement change that’s completely different from the current state, that’s going to be very hard for people to adjust to. Like it or not, we are creatures of habit, regardless of how bad that habit may be. So don’t take something that you ‘don’t think is working’ and throw it in the trash. Instead, dissect it and preserve the good parts. Then make some modifications and see what happens. Going back to the airway supplies example: the process of having residents do airway checks was a good one and the residents felt that the way equipment was stocked worked well, no need to change. So, Mahesh kept those core principles. It allowed for whatever changes he made to have some familiarity, so the culture change wasn’t revolutionary. 

Striving for perfection can be admirable, but not always attainable and sustainable. For example, instead of having all airway boxes checked three times a day, he set the goal of having a 75% check rate. Given the busy and unpredictable environment of the ED, 100% is not always feasible. Additionally, implementing this standard and change was from less of an authoritative measure on residents, but rather a “let’s hold each other accountable” standpoint. 

Lastly, you have to believe in human fallibility. You may think your change is ‘fool proof’, but mistakes will be made. Using a punitive system is usually not productive. You have to take time to figure out why mistakes are made and see if they can be mitigated for when, not if, they happen again. Sometimes it’s human error. Sometimes it’s a barrier the individual has that you didn’t think of when creating the system. And sometimes, it’s the system that’s unwittingly set up to allow those mistakes to occur. Taking the time to understand these factors and the people involved is imperative. At times it can be arduous, but still way more efficient than calling your change unsuccessful and starting from scratch. 

Take-home points:

○  Every system is built to yield the results that it gets. Don’t blame the individuals, look to improve the system.

○  Work to implement a culture change. It’s long and sometimes tedious, but it’s also resilient and sustainable.

○  Take the time to investigate why you may not be getting the results you anticipated. The reasons may surprise you.

○  Successful change is about creating a culture where individuals embrace change.



If Disney Ran Your Hospital

Just culture

Just Culture: The Key to Quality and Safety

Just culture: It’s more than policy


Dr. Mahesh Polavarapu – EM Administrative Fellow and Attending Physician, ChristianaCare Health System & Doctors For Emergency Services

EM Over Easy · Episode 91: Culture Change

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Culture Change
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