Contributors: Jennifer Tomasik, SM, FACHE, and Barry Dornfeld, PhD,
To learn more about Jennifer and Barry, click here.
A high performing academic health center that acquired several community hospitals had publicly unified under a shared brand, yet internally the remnants of an older culture of silos and divisions prevailed. The cultural clash made it nearly impossible to unify the system, weakening both the public brand and the patient experience across its different parts.
A new Chief Learning Officer organized a diverse set of medical educational offerings under one organizational structure to promote a common language across the health system, and common frameworks of learning and development. Yet professional groups within the system — nurses, physicians, advanced practitioners — still flocked to their own “tribe’s” courses and followed their own curriculum rather than opting to participate in classes together.
These vignettes provide examples of how culture can impact healthcare organizations in pursuit of their mission and strategic priorities. As consultants working across the healthcare ecology, we increasingly hear more and more stories about culture and are aware of its increasing importance in moving healthcare organizations forward. We have seen how culture can get in the way of progress, impacting the delivery of care, the collaboration between researchers and clinicians, the move to service lines, the creation of centers and institutes, and the performance of the enterprise as a whole. While healthcare leaders once saw culture as “soft” or even inconsequential, they are now coming to appreciate its central role in driving the changes they want to see happen.
Seeing Culture as an Asset in a Changing World
We know culture is a great asset for organizations navigating turbulent change. We saw it at work in one medical center where a unit developed its own team-based approach to coordinate quality efforts, bringing together physicians, nurses, and quality experts to work collaboratively. When the Chief Medical Officer took note of how this team was operating and the progress they made in increasing quality metrics, she asked them to teach these practices to other units, thereby spreading this culture of quality more broadly.
As the business of healthcare evolves in ways both progressive and disruptive, we are encouraged by the increasing attention to culture as a resource. More organizations are working to preserve a unified culture as they grow, struggling to improve a particular department’s toxic culture, trying to understand the “hidden curriculum” in a medical school, or getting stuck around a strategic change in which culture creates a critical barrier. Along with this increasing awareness, culture exists as a kind of black box for organizations. Leaders recognize they have cultural challenges, yet have difficulty defining what they are and what to do about them. Given the complexities of healthcare organizations and systems — multiple “loosely coupled” units with highly trained professionals embodying different identities and working with different incentives — cultural alignment can be a challenge.
Given this elusiveness, where can an organization get started when it wants to work on its culture? We have developed a few guidelines:
- Start with a good enough definition of culture. While there are several definitions we find helpful, including Edgar Schein’s three-layer model of behaviors, language, and beliefs,1 we use this simple formulation: culture is made up of “the rules and assumptions for getting work done — the beliefs, working agreements, and tangible behaviors that people demonstrate at work.” Still somewhat broad, but a starting definition can help identify how culture shows up in your organization, and how you can think about working on it.
- Assess where culture — these “rules and assumptions” — might be getting in the way of productive work and where it may be helpful. You can do this through a combination of observing and asking, the basis of an ethnographic approach, or through a cultural assessment survey. We used ethnography when we trained a group of nurses at a high-ranking academic center to “shadow” each other in working pairs to better understand their current care practices and what they could change and improve.
- Look for found pilots for change. Any organization has examples of the culture it wants to create already operating in the present — what we call “found pilots.” These found pilots are powerful tools for cultural change, as you can learn from them and understand what practices and supports are working to drive cultural change in the direction you are trying to move.
- Build a coalition for cultural change. The leaders of these “found pilots” are already valuable innovators, and people you will want to pull into your organizational change effort. This informal group can be leveraged as a coalition for change.
In response to the challenge laid out in the first vignette above, a fragmented system brand identity, we worked with the organization’s academic, clinical, and business leadership to do a deep dive into its culture. Through interviews and focus groups, we identified areas of cultural alignment and tension, where ways of working were supporting the mission and strategy and where they were getting in the way. We brought a large group of leaders together to share our findings and agree on a set of projects that would move the organization forward.
We have learned important lessons about working with culture in partnership with healthcare leaders:
- Culture is critical to business success — ignore it at your peril. Overlooking the importance of culture can undo a great strategy and stymie the best intentions for implementation.
- Culture is never one-size-fits-all. Your organization’s desired impact needs to direct your culture — where to keep differences intact and where to look for commonalities. It’s about what you need to share to make you successful, and where differences are healthy.
- And culture is a strategic asset you can build on. The future you want to see already exists. Found pilots — examples of that future you aspire to — already exist in your organization. Your job as a leader is to locate and amplify them, and create the culture you need to be successful.
- Schein EH. The Corporate Culture Survival Guide. Jossey-Bass Publishers: San Francisco, 1999.