There is little argument that culture is key to a successful enterprise. Many of the objectives, particularly in healthcare, cannot be achieved with prescriptive management approaches, they require engagement, understanding, and, yes, a “good” culture throughout the organization.

As an example, safety and quality, both key to being a provider of choice, are ultimately reliant on cultural dimensions. Rules attempting to force either one of these deliverables will only lead to surface compliance, but truly sustainable, world class performance will come from “within”, by having developed the 6th sense, by having a culture of safety and quality, supported by the appropriate organizational structures, processes and tools. So which comes first, the culture, or the structures, processes and tools? Can culture be fundamentally be created, or is it the result, or outcome of other activities?

The Harvard Business Review in its April Edition discusses the issue, leading with the headline of “You Can’t Fix Culture”. It explains and elaborates on this question with 4 examples of cultural transformation in various organizations. In reading the article, our work with organizations ranging across industries from manufacturing to healthcare, and geographical diversity from Europe to South America and the US mirrors the findings of the articles. Culture cannot be changed directly, and an isolated initiative to embark on this objective will not be successful. Certainly, many attempts are made to do so, and these attempts usually spend inordinate amounts of time and money on “making the workforce happy”, usually through work and mission unrelated activity. When culture is built on anything other than the core reason for being, it will most likely not be deeply embedded. Requiring managers to write monthly thank you cards to employees may be justified under the banner of doing the right thing, or maybe habit forming, but all too often they lead to resentment after having gotten ‘another thing to do’. Culture change aligned with the core purpose on the other hand will ultimately free up resourcing by enabling all levels of the organization, and thus run much deeper.

Culture can be changed, “designed” and created successfully. Culture is really an outcome of deploying the mission, values, designing sound processes, organizational structures, leadership behaviors and performance and change management methods.  And, maybe most importantly, these elements must be authentic, lived by the organization every day. Authenticity at all levels and across all activity is key in driving a true high performance culture.

In 20 years of working across diverse organizations, below are a few drivers we have been able to isolate as culture shaping:

1. Make Each Persons Impact on Mission Performance Clear

Every organization, no matter what kind, has a purpose beyond Dollars and Cents, and each individual should be able to clearly understand how their efforts relate to this overall purpose or mission. Unfortunately, two barriers can prevent this from happening. The first one is an unclear grasp and communication of the “key reason for being”. This is rare, most leadership teams are clear on the purpose of the organization beyond economics. The second is lackluster deployment to the associate level, and a lack of translation particularly with the supporting roles in the organization. This can be amplified in healthcare, where a strong hierarchy often exists, and entire areas of the organization feel somewhat disenfranchised as “lower class citizens”. A point in case we regularly discuss in detail are employees in the revenue cycle, as one example, where full engagement is critical to process quality, and the motivation to perform has to be created by creating a different paradigm. There may be a lot of discussion about “no money no mission”, but it is often not until associates realize just how much money they are entrusted with (take the annual cash receipts of the organization and divide it by the PFS FTEs as one measure of “entrusted” levels). This simple math creates a solid perception of self-worth and confidence, and the understanding of importance of their individual, personal role becomes apparent. This can be done for each and every role in the organization, and creates the pride employees of high performing organizations carry with them, on the job, to their family, into the community.

2. Design the Organizational Structure – Preferably Aligned with Processes

Organizational structure drives most everything in terms of how an organization is able to execute and deliver to the mission. Organizational Design is often times not really designed at all, but the result of evolution based on available resources and other factors. Organizational design is called design for a reason, and the foundation of the design should be process alignment when possible, not functional alignment. Process alignment (or value stream alignment, swim lane alignment, etc) creates line of sight to customers, enables cross training and cross pollination, easier metrics alignment, and a host of other benefits. All of these elements then impact culture, and we have found that process aligned high performance work teams are the express lane to impacting culture quickly, and in a meaningful way.

3. Provide the Freedom to Act with Accountability Via Structured Performance Management

Performance management consists of measures designed to quantify the performance level of the organization regarding its purpose and mission, linked to a clear performance improvement and accountability mechanism (daily/weekly/monthly performance reviews following a standard), with pay for performance linked to these metrics. In theory, most organizations have some form of performance management, however, the devil lies in the details as with so many things. Measures are often relics of long gone days or convenience measures (things we can easily measure) versus truly meaningful (much harder to do). Other issues are related to having too many measures, we recommend 7+/- 2 per organizational unit (fewer is better to maintain focus). Performance reviews should be focused, standardized and data driven, with a clear mechanism of getting to root cause, and should entail briefings on successful execution of action items along with trending of outcomes. Pay for performance, for many healthcare organizations, is one of the last bastions of the past. With payers now driving reimbursement based on performance, it is past time to employ these methods into the organization as well, and establish a deliverables versus attendance culture. (The quote attributed to Jack Welsh comes to mind: “When the rate of change on the outside exceeds the rate of change on the inside, the end is near”)

4. Provide Practical, Meaningful and Embedded Improvement and Change Management Methods

Exclusively, all organizations have a tremendous talent at the ready to drive efficiency, effectiveness and in general improve the cost, quality and delivery speed equation. The key to unlocking this potential is a sound method of improvement, without violating established policy or venturing into anarchy. There are two keys to doing this well, and the industry that has led all others, from which many lessons can be learned, are automotive or manufacturing in general. The first key is to equip the entire organization with the tools and methods that have been proven to drive true system wide improvement (versus sub optimization). The second, is an organizational structure, and associated governance, that allows the lower levels of the organization to remove barriers without needing excessive levels of approval. The issue becomes that this interplay of governance, improvement and decision making authority is dynamic, and has to be matched to organizational maturity, which will change dramatically over time. As a result, governance at the lower levels of the organization needs to be modified as you go along.

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