The Culture of Your Healthcare Practice: Putting the Pieces Together

Gary Kaplan, MD, Chairman and CEO of Virginia Mason, in a webinar in the fall of 2017, offered a great quote that helps set the tone for the message of this article: “We had to challenge our old paradigms. Physicians are instrumental in setting the tone, and unless the physicians believe we’re on the right path we don’t have the kind of alignment that will help us move forward.”(1) The tone set by leadership, and, as noted by Kaplan, by physicians, is critical, not only in setting the tone for culture, but in all aspects necessary to be successful in the business world.

Let’s start with a definition of the term culture, as defined in Edgar H. Schein’s book, Organization Culture and Leadership. His formal definition is “defined as a pattern of shared basic assumptions learned by a group as it solved its problems of external adaptation and internal integration, which has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.”(2)

Schein, considered by many the authority on culture, suggests a key is the group, since there is some order, and a semblance of common direction, differing from the definition of a crowd. This is critical because a group that has no common mission or direction is more like a crowd, and is destined to break up in a short period of time.

The external adaptation noted in the definition relates to survival, and/or growth, as the group adapts to its environment. The internal integration relates to how the organization functions. The latter is key, and without a solid infrastructure it is impossible to survive in any external environment.

Schein notes that culture is formed over time based upon the direction, or sense, from the founder(s) of the organization. Their initial plan, and direction, is based upon the vision and the discussion that leads to actions consistent with that vision. There are three key aspects of the culture development, and subsequent maintenance:

• Artifacts: external actions, signs, symbols, observed behavior, and words used by members of the group. External in the fact that they can be observed and do assist in framing.

• Espoused beliefs and values: group learning comes from someone’s beliefs and values, typically starting with the founders. These become shared when the group accepts them through actions.

• Basic assumptions: these are solid, difficult to change, and built on the espoused values and beliefs established through group activities and norms of behavior. Focus, attention to details, meaning of actions and words, and emotions in situations form these assumptions. The mental models noted in the learning organization discussion are formed, and defined, by these basic assumptions.

Putting all these aspects together will create a perspective on how the culture works in your organization. In many groups, leadership will talk about one thing, while the artifacts tell a very different story. All groups state that their mission is to provide quality of care and meet the needs of patients. Yet, actions indicate that the real goal is to enhance the bottom line. This is demonstrated through examples such as the compensation formula, decisions made on the treatment plan, human resource management (hire cheap, and fire whenever), and agreement at board meetings to change a policy without follow-up action from all the doctors.

There are also groups that take this seriously and honor the quality-of-care initiative. These groups typically show actions such as Board meeting discussions about effectiveness in compliance with treatment plans, a review of any safety issues last month, and the like. What should be noted here is that leadership from physician owners sets the tone by beliefs and values, which lead to assumptions noted by staff through the artifacts that are observed and experienced.

A recent article in the Harvard Business Review by Groysberg, et al.,(3) identified eight different culture styles. This is a result of a significant review of the literature and the experience of the authors. As you review this list, attempt to identify which one, or which ones, relate to your current organizational culture. There is no right or wrong answer. Instead, simply take an honest look at which style might define your practice:

• Caring: warm, sincere, relational;

• Purpose: idealistic, tolerant, purpose driven;

• Learning: open, inventive, exploring;

• Enjoyment: playful, instinctive, fun loving;

• Results: achievement, driven, goal focused;

• Authority: bold, decisive, dominant;

• Safety: realistic, careful, prepared; and

• Order: rule abiding, respectful, cooperative.

Then, further intersperse each style with a framework that address stability versus flexibility, and interdependence versus independence. Stability reflects authority and safety, while flexibility reflects learning and purpose. Independence fits with enjoyment and results, while interdependence fits with caring and order.

As you read through these, you might think you are all of them, or you might think you’re none of them, or maybe the framework does not fit your model. Their research shows that results and caring are the first two in the ranking. They appear to be opposite, since someone that is driven is not typically also caring. Instead, caring would seem to be perfect for a compassionate medical practice. But to explore this, just ask the simple question of what’s more important at the monthly Board meeting: the financial statement, or quality/ patient satisfaction. It is vital you are honest here.

Given the changing healthcare world with value-based payments and population health in the forefront, which of these styles best fits your practice? Is your purpose, as expressed in your mission statement, reflected in your practice today? Do you have fun at work, or are you facing burnout and too much stress? Is there one dominant personality that controls all decisions? In value-based care, are you safe, or a risk taker? Is everyone compliant?

Reflect on the discussion on your organization chart and your decision-making processes. Now consider the eight styles listed above. Where do you fit?

In our experience, we have seen mission statements that say one thing, yet the practice follows another road. If you look at your practice for culture, a valuable first look is at the compensation formula. A strict production formula, whether RVU, payment, or other base, creates a result-oriented practice. More to the point, if you have 12 physicians, you may have 12 practices. Some may prefer safety (stability), while others prefer learning (flexibility), and still others prefer authority (stability).

One thing that should be obvious is if you don’t control your culture, it will control you. Therefore, the key is to understand the culture and then be prepared to change it as necessary to meet the ever-changing external environment. Put simply, if everyone in your practice continues to do things, or act, the way they do today, can you expect to survive, or grow, in the future?

First is an honest assessment of your culture. Evaluate which things are the drivers of your culture, addressing such categories as the following:

• Compensation;

• Decision-making authority and timing;

• Communication between and through all levels;

• Staff accountability to policies and procedures;

• Physician compliance with agreed-upon care plans, risk tolerance, and goals;

• Reporting of data regularly, specifically, and actionable versus simply informational, which does not lead to compliance or appropriate actions;

• Expenditures on facilities, training, and uniforms; and

• Investment and use in and of technology and so much more.

Once this is reviewed, the gaps and roadblocks to achieving desired results will be obvious. The effort, then, should be directed toward fixing those issues and creating a new, or revised, culture. Achieving this new culture will not happen overnight and will require significant resources and time.

Practice leadership must take hold of the effort to revise or refine the culture. After the assessment, acceptance of where the issues are, and where the process should take hold, follows. Leadership must consider each of these related to which style, or styles, represent the best fit. Culture change will take time; therefore, simply looking at the style list and checking off what applies, and what doesn’t, will not work. It is important to have a serious discussion, one that results in 100% leadership buy-in.

How are you going to make the revision happen? What type, and how often will there be communication? It’s not enough to teach and communicate. The leadership must demonstrate commitment, without passive-aggressive behavior.

The key is to hold yourselves, and all members of your team, accountable for actions that occur. Remember that it is the experiences, either observed or impacted, that lead to the change in culture. You will want to work through a model that holds each individual accountable for their actions, as the new or revised culture evolves. The keys to accountability are to see, to own, to solve, and to do the things necessary to comply with the culture change. This will lead to the desired results.

When you, or a team member, sees something that is counter to the desired norm, do you enable them to change? Does TW2ADI (i.e., “the way we’ve always done it”) rule the organization when someone sees something? The excuse that it has always been done that way will no longer work in the new culture. Holding staff accountable, but using these moments as either teachable, or as an encouragement for listening to new ideas, will prove as powerful toward effective culture change.

The team member who sees the action should then own it and accept responsibility to seek ways to improve. A culture must recognize the ability of a team member to identify, but also suggest or develop new ways to do things — or, in the event of a culture change, to identify an issue and come up with a better way to do things. This then solves the problem in concept.

This new idea communicated to leadership, and others on the team, must be to do, or adapt to, the new way of doing things.

As you explore this, consider what the new goals, as well as the desired results, may be:

• Move from fee-for-service to value-based payment, 50% year one, and expect 90% in three years;

• Improve patient satisfaction scores to get at least 95% rating satisfaction as a “5”; and

• Reduce turnover by 50%.

These three goals may seem huge, and distinct, from each other, but if your practice sees the benefit of improved patient and staff engagement leading to reduced turnover and improved satisfaction, the value-based payment move will benefit.

A transition plan is developed based on the goals that have been established. This is done by a champion at the leadership level; teams, both from key departments and cross functional; communication on what the plan is, as well as throughout the process with key milestones expected and achieved; and patience. Culture change will not occur instantly. Remember that it will take time. The staff is enabled, encouraged, informed, and able to openly share what they see through in making the positive changes and successful culture change.

One last thing to explore may be considered the elephant in the room. Are you considering merging, or have you recently merged, with a hospital, health system, or another medical group? What analysis was done related to culture? Where will you fit in? How are decisions made? What control will you have? Do you want control? If you are considering a merger, the above discussion is essential for serious review. If merged, take another look at what happens.

We have seen too many physicians give up, and choose to merge, without thinking through the above discussion. This has resulted in unhappiness, burnout, early retirement, or complacency in action. Obviously, this is not the desired outcome.

REFERENCES

1. MacDonald I. These 6 healthcare leaders say quality improvement is an organizational-wide effort and a cultural imperative. FierceHealthcare.com. January 3, 2018. www.fiercehealthcare.com/healthcare/6-inspiring-quotes-improving-quality-from-6-healthcare-leaders . Accessed December 1, 2018.

2. Schein E. Organizational Culture and Leadership, 4th ed. San Francisco, CA: Josey-Bass; 2010.

3. Groysberg B, et al. The leader’s guide to corporate culture. Harvard Business Review. Jan/Feb 2018. https://hbr.org/2018/01/the-culture-factor .

Excerpted from The High-Performing Medical Practice: Workflow, Practice Finances, and Patient-Centric Care (American Association for Physician Leadership, 2019).