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Lessons learned in trying to change
the culture in health care may apply
(Photo: R.I. Education Commissioner
Angelica Infante-Green poses for a photograph in front of a “Promise”
sign at the Rhode Island Foundation “Make It Happen RI” gathering in
December of 2019)
By Lou Giancola for
In 1999 the Institute of Medicine issued a report entitled
“To Err Is Human: Building a Safe Health System.” It estimated that the health
care system was responsible for between 50,000 and 100,000 avoidable deaths per
year and 1 million injuries. Health care professionals initially rejected the
possibility that they could be causing such great harm, despite the fact that
there was undeniable, well-documented proof.
The federal government, through the Medicare program, along with business
groups paying for faulty health care through employer insurance, began to hold
the health care system accountable for better outcomes.
The elementary and secondary education system in Rhode Island seems to be
having its “To Err Is Human” moment, as the performance of students throughout
the state, but particularly in the urban core cities, is significantly lagging
behind students in neighboring states.
Look at the graduation rates. The statewide average in Rhode Island is 84
percent, but falls much lower for the following demographic groups:
• For the economically disadvantaged students, the graduation rate is 77
percent, compared to 92.8 percent for economically advantaged students.
• For Hispanic students, the graduation rate is 76.9 percent.
• For students with limited English proficiency, the graduation rate is
• For students of Native American descent, the graduation rate is 69.2
No surprises here: just as your Zip Code can be correlated to poor health
status, Zip Code is a predictor of educational outcomes.
To change the system
The challenge facing the new R.I. Commissioner of Education, Angélica
Infante-Green, and the superintendents of those districts with large students
from disadvantaged families, is how to change the system to achieve better
Following the principle that you can’t manage what you can’t measure, the R.I.
Department of Education [RIDE] has put together an extensive data bank that is
available to the public. It provides detailed information on every public
school in the state.
Based on the data and a somewhat complicated weighting system, RIDE has used a
“star” system, one to five stars, to differentiate schools. This is another
parallel with the hospital-rating system. The theory is that school
administrators and teachers will strive to improve their ranking.
Schools ranking in the bottom five percent, some 22 schools, have been
identified as needing Comprehensive Support and Improvement [CSI].
Of those 22 schools, there are 13 in Providence, three in Pawtucket, two in
Woonsocket and one in Central Falls, the districts with the most economically
These schools identified as needing Comprehensive Support and Improvement
support have received modest grants from RIDE [derived from a federal grant to
the state] to work on one of more of four areas in what is known as the Rhode
Island Framework for Improvement. They include:
• Turnaround leadership;
• Climate and culture shift;
• High-quality materials and instructional transformation; and
• Talent development and collaboration.
Each of these categories of improvement has multiple criteria against which
schools will be assessed.
For instance, one example under ‘Climate and culture shift, Criterion 2.1.1,’
is: “The school has a process for identifying struggling and at-risk students
and systematically monitors student and program effectiveness.”
The “Every Student Succeeds Act of 2015,” among other things, mandated that
every state develop a system of accountability for schools. As one educator
told me, Rhode Island has been late in putting such a plan in place, but it now
has what appears to be a comprehensive and elaborate plan.
A shift in culture
The Commissioner has publicly declared her intent to shift RIDE’s culture from
that of a regulatory agency to that of a support to the state’s schools. The
plans outlined above have elements of support, but there is also a strong
current related to accountability.
RIDE, along with consultants from a national consulting firm, School Works,
will begin to conduct site visits to those school systems having CSI schools to
determine their progress in the four domains delineated above. A 15-page
monitoring site visit protocol will guide the site visits.
Parallels with health care
The parallels with health care improvement can be seen throughout the plans for
improving Rhode Island schools. Administrators are instructed to use “root
cause analysis” to understand the reasons schools and individual students may
not be succeeding.
CSI schools are also required to form Community Advisory Boards consisting of
parents, and to involve them in the improvement process. The need to listen to
the patient and their relatives or, in the educational context, the student and
their parents, is another similarity in trying to improve outcomes.
I am not an educator. But I have extensive experience in change management in
health care. I have found that the following are essential components to any
successful change management process.
• Leadership. The people who are affected by the process change have to
believe in the change sought by leadership and trust that the leaders are not
out to scapegoat them. In this case, the teachers have to believe that the
Commissioner and the superintendents understand what teachers are up against
and will support them through the change process.
The teachers are like nurses in a hospital. They are naturally suspicious of
leadership, usually because they have not always felt supported by leaders.
Overcoming that mistrust and developing the relationships with the frontline
staff, nurses or teachers, doesn’t happen overnight, especially when it feels
like they are under siege.
Has the Commissioner created those relationships and the trust necessary to
mount a campaign to improve outcomes or does it feel like the pressure to
change is being pushed down from the top without sufficient input from the
teachers? The Commissioner and superintendents are under tremendous
pressure to show immediate results which may work against taking the time to
build a trusting relationship.
• Culture. It has taken years for the relationships, between teachers
and students, between teachers and principals, and between teachers and parents
to evolve. Each school will have evolved differently. These relationships,
influenced by the physical environment, create an atmosphere or culture that is
either supportive of the mission, educating students, or is an impediment.
When I was in a leadership position at a prominent Massachusetts hospital, I
wanted to improve patient/customer service. However, the consultants I hired
found that the effort would fail if we didn’t first fix the toxic relationships
between doctors and the staff.
There is ample evidence, based on third-party assessments, that the culture in
many of our schools is not positive. Culture doesn’t change overnight. It
happens when the participants in the organization see real changes in the way
leaders relate to them and feel supported in their work. Teachers, students and
parents need to believe their voice is being heard and that leaders will engage
them as partners in the change.
Culture change is given prominence in RIDE’s plans. But I don’t know if those
in charge appreciate the time and effort it will take to turn it around.
• Constancy. The people involved or most affected by change want to know
that the most recent plan isn’t the flavor of the month. Many teachers have
seen multiple plans and many leaders come and go. Based on my experience, I
suspect that some teachers are actually sitting back and waiting out this
The teachers need to see real changes in the things that make a difference to
them on a day-to-day basis to give them faith that leaders are serious. Often
these changes seem trivial, such as having the necessary supplies or books
arrive on time.
In the hospital setting it was a thing like making sure there was an adequate
supply of linen on the nursing units. I believe you have to remove the barriers
to people doing their job before you can ask them to change.
• Community support. I have friends who point to the high per pupil
expenditures for public education in Rhode Island and conclude that we don’t
have a resource problem. That attitude may be a barrier to real change. It
leads some to the simplistic conclusion that if it isn’t money, it must be the
teachers. It ignores the fact that resources may not be channeled to the source
of the problem.
More importantly, it draws attention away from the multiple causes of poor
school performance, particularly by students from economically disadvantaged
families. The schools, particularly those in our core urban cities, need
broad-based community support.
Although I have concerns about the way RIDE is approaching school improvement,
I very much want it to succeed. As a concerned citizen, and as someone who has
led change initiatives, I am trying to understand how RIDE is approaching this
My aim is to convey what I have learned to others and to encourage them to
become engaged in this most important endeavor.
Lou Giancola, the former president and CEO of South County Health, is a
frequent contributor to ConvergenceRI.
Richard Asinof is the founder and
editor of ConvergenceRI, an online subscription newsletter offering news and
analysis at the convergence of health, science, technology and innovation in