Assessing and Changing Work Culture

Most healthcare employees readily agree that every healthcare organization has its own unique culture. However, culture as a concept is difficult to define. You can’t see or touch a healthcare organization’s culture. It’s hard to describe succinctly what a culture is and isn’t. And you and your employees may experience your organization’s culture in significantly different ways. That’s because any organization’s culture is likely to be interpreted differently by diverse individuals. Unique events in people’s lives affect how they act and interact with information, policies, and one another. Edgar H. Schein(1) suggests, “We recognize cultural differences at the ethnic or national level but find them puzzling at the group, organizational, or occupational level.”

Nonetheless, you can and probably do see many physical manifestations of your healthcare organization’s culture every day. In some ways, culture can be described as the overall environment that surrounds you in your healthcare organization. But more than that, and whether you realize it or not, your healthcare organization’s culture powerfully shapes your employees’ work enjoyment, experiences, relationships, and processes.

Think of your healthcare organization’s culture as its unique personality. In a person, the personality is composed of the values, beliefs, underlying assumptions, interests, experiences, upbringing, and habits that shape and influence behavior. Likewise, in a healthcare organization, culture is made up of the values, beliefs, underlying assumptions, attitudes, and behaviors shared by the people who work in the organization. The result of a healthcare organization’s culture is a set of behaviors that is motivated by rules for working together. Many of these are usually unspoken and unwritten.

Your healthcare organization’s culture comprises all of the life experiences each member of the team brings to the organization. However, your organizational culture probably was influenced most by the people in your organization who are or were in leadership positions — your organization’s founder, physicians, and key administrators — because they most likely shaped your healthcare organization’s mission, vision, decision-making, policies, and planning strategies. Nevertheless, each member of the healthcare team contributes positively or negatively to your healthcare organization’s culture and is in a position to deviate from or perpetuate the status quo.

HOW CULTURE IS EXPRESSED IN A HEALTHCARE ORGANIZATION

A healthcare organization’s culture is not expressed as a hard number or a line item on the bottom of a report. However, it is a key ingredient that influences patient retention figures, collection ratios, production reports, and other important healthcare organization management data. Kim S. Cameron and Robert E. Quinn(2) suggest, “Most organizational scholars and observers now recognize that organizational culture has a powerful effect on the performance and long-term effectiveness of organizations.”

Perhaps the best way to understand a healthcare organization’s culture is to look at the ways that it may be expressing itself in the organization. For example, a healthcare organization’s culture may be expressed through the employees’ language, decision-making, symbols, stories and legends, uniforms, posture, facial expressions, meetings, and daily work practices. The objects chosen to grace a desk can tell you a lot about how employees view and participate in a healthcare organization’s culture. Likewise, a healthcare organization’s bulletin board content, patient newsletter, brochures, website, e-mail, and voice mail; the interaction among employees at staff meetings; and the way in which people do or do not collaborate speak volumes about a healthcare organization’s culture. So, too, do the apportionment of space within the organization, wall décor, wall and flooring colors, furniture styles, magazines in the reception area(s), lighting, cleanliness, hours, salaries, bonuses, and even the assignment of staff parking spaces in the parking lot.

When healthcare organizations are examined from a cultural viewpoint, attention is drawn to various aspects of daily life that historically have been ignored or understudied. Joanne Martin(3) suggests, these include, “ . . . the stories people tell to newcomers to explain ‘how things are done around here,’ the ways in which offices are arranged and personal items are or are not displayed, jokes people tell, the working atmosphere (hushed and luxurious or dirty and noisy), the relations among people (affectionate in some areas of an office and obviously angry and perhaps competitive in another place), and so on.”

Your healthcare organization’s culture may be strong or weak. If it is strong, chances are that most of the people working in your organization agree on its culture. If it is weak, the employees probably don’t agree. Sometimes, a weak healthcare organization culture can be the result of many subcultures, or the shared values, assumptions, and behaviors of a subset of the organization. In other words, each department in your organization may have its own subculture. Within departments, the staff and the managers may each have their own culture. These departmental cultures may or may not support your overall organizational culture.

Ideally, your healthcare organization culture should support a positive, productive environment for you and the members of your team. However, it is important to remember that happy healthcare organization employees are not necessarily productive employees. From a leadership point of view, it is important to focus on those aspects of healthcare organization culture that will create a happy and positive work environment and will support and increase the organization’s productivity and quality of care.

HOW TO ASSESS YOUR HEALTHCARE ORGANIZATION’S CULTURE

While you may admire and learn from the culture of another healthcare organization or another organization, you cannot duplicate that culture 100% in your healthcare organization. Ann Rhodes and Nancy Shepherdson(4) suggest, “Great cultures can’t be replicated or copied; you must launch your own based on values you and your people determine are best for your organization.” Therefore, while your healthcare organization’s culture may share some of the qualities of other organizations, it will have its own distinct flavor and be uniquely yours.

You can obtain a picture of your current healthcare organization culture in several ways. However, before venturing forward, be sure that you’re ready to take a long hard look at your culture. Your assessment may make you happy, puzzled, sad, or disappointed. However, whatever you learn from your culture assessment, your culture is what it is. To change your culture, your first step is to understand the culture that already exists.

It is generally a lot easier to assess another organization’s culture than your own. When you work in an organization daily, many of the manifestations of your culture are likely to become invisible to you. You must be willing to take yourself out of the equation and look at your organization objectively. That means that you must become an impartial observer of your culture. Look at everything and everyone with the eye of an outsider. Pretend that you are a cultural anthropologist observing a group you’ve never seen before. Observe and make note of emotions, objects, artifacts, and interactions among people. Pay particular attention to:

• How space is allocated.

• What is posted or displayed on the walls.

• Other signage both inside and outside the organization.

• Objects displayed on desks or in other work areas.

• How common areas are furnished, decorated, and used.

• The tone and frequency of emails and other written messages.

• The tone, frequency, and volume of telephone calls.

• How staff members interact with one another and with patients.

• Sensory observations such as smells, sound volume, and textures.

• The general atmosphere of the reception area(s).

• Employee dress, hygiene, age, diversity, and other characteristics.

• Employee behaviors such as posture, facial expressions, and pace.

• Office location.

• Neatness and cleanliness.

Also notice what is not being said or done. For example, if no one in your organization smiles or mentions something that you think is important, that’s an observation worth noting. Finally, try one or more of these three effective techniques for assessing organizational culture:

1. Culture walk: Step out of your usual role and literally take a walk around your healthcare organization as an observer. Look for the physical signs of your culture. You may have to take repeated walks, on different days and at different times, to get the most complete picture of your culture.

2. Culture interviews: Interview your employees individually or in small groups to get their insights about your healthcare organization’s culture. Use indirect questions such as those suggested in the bonus feature at the end of this chapter. Observe and make note of your staff’s behaviors and patterns of interaction throughout the interviews. Who speaks the most? Who speaks the least? Are you noticing any communication patterns?

3. Culture surveys: Craft your survey after you have completed your culture walk and/or interviews to get more detailed information. Provide space on your surveys for your employees to elaborate on their responses.

IDENTIFY YOUR DESIRED HEALTHCARE ORGANIZATION CULTURE

With a clear assessment of your current culture, you are now ready to identify your culture strengths and where you may be falling short. Examine your organization’s mission, vision, and values. What vision does your healthcare organization have for its future, and how must your culture change to achieve that vision? Work with your colleagues to answer these questions:

• Where do we see our healthcare organization in 10 years? Who will be our patients? How does this vision mesh with the overall demographic trends predicted for our community?

• What are the five most important values we would like to see represented in our healthcare organization culture, now and in the future?

• Are these values compatible with our current healthcare organization culture? Do they exist now? If so, where? If not, why not?

• What needs to happen so that we can create a culture that supports where our organization wants to be?

• Do we have support for creating cultural change? Will our organization’s leadership support the change both verbally and behaviorally? Do we have the funds and other resources we will need to change our culture?

• Do we have sufficient training to achieve the desired culture change? Are we able to provide training to communicate new expectations and to teach new behaviors?

WHY CHANGING CULTURE IS SO DIFFICULT

Before forging ahead, keep in mind that a culture change may be one of the toughest challenges a healthcare organization will ever take on.

Culture change requires people to be uncomfortable, to break out of long-established routines, and to change their behaviors. It often is difficult for employees to unlearn their old way of doing things, embrace the new ways, and consistently behave differently.

Chances are that your healthcare organization was formed some time back and that it grew and developed over a period of many years. Your healthcare organization culture also was formed during this time, and it probably grew in response to particular needs and values. For example, your current healthcare organization culture may match the style and comfort zone of your organization’s founder who may or may not still be working in the organization today. Perhaps your organization’s culture meshed well with the expectations of the patients you served at one time in the past. Or perhaps your culture was established and perpetuated by the management style that at one time prevailed in your organization. The organization of your past may be quite different from your organization today, and the individuals who formed the culture may no longer be involved. Nonetheless, the old patterns of thinking and behaving that started long ago may have become cemented in your organization and may be difficult to change today.

In general, employees resist a culture change for one or more of these reasons:

• They see no need to change. If your employees don’t see the organization as broken, they probably won’t see a need to fix it. People usually want and need a compelling reason to undertake a culture change. Financial hardship, the threat of legal action, or other threats to the well-being of the organization and its employees usually get people’s attention.

• The timing seems bad. Employees may feel that there’s too much going on right now for them to step out of their day-to-day concerns to think about larger issues like healthcare organization culture.

• The change appears to be too costly. It may seem to employees that it will take too much time, money, or both to justify changing the culture.

• They don’t know how. The employees in the organization may think that a culture change is a good idea but not know how to change the culture, what to do, in what order, or when.

• They mistrust the new direction. The organization’s employees may perceive the culture change as too risky, likely to cause a backlash, and fraught with too many problems. They may feel that changing the culture of the organization could threaten their job security or that more will be expected of them without reward.

When the healthcare organization employees feel secure, realize and recognize that their current culture needs to transform, and understand what to do, they generally will be in support of the culture change. Therefore, it will be important to know what employees are worried about, what they need to move forward, and what feels unclear, murky, frightening, or overwhelming. Then with a combination of persistence, employee involvement, kindness, understanding, and training, it will be possible to change the culture of your healthcare organization.

HOW TO CHANGE CULTURE: 12 FUNDAMENTAL CHANGES

Conventional wisdom suggests that it can take up to seven years to change a work culture. However, it is possible to change a culture more quickly. The key is to change fundamentally the basic work systems and processes that created the organization that you have now. As you measure your success in changing your healthcare organization culture, look at what you accomplish one person at a time. Focus your attention on the success of individuals. By doing so, you will see a wave of optimism unfold as these individuals begin to build your new healthcare organization culture and bring others into the fold.

Below are 12 fundamental changes that can ultimately lead to a more significant change in your healthcare organization culture. Use them to develop and implement your culture change plan.

1. Make your expectations clear. Talk with your employees without using threats or coercion. Simply identify what has to change and why, and what is expected of the employees in the organization. Put the emphasis on individuals and on departments in each step. That may mean that what is expected of individuals may vary. However, each employee should understand their unique role and how they fit into a larger collaborative effort to change your culture.

2. Stop doing things that run counter to your desired culture. Every day, your existing culture is moving either closer to or further from the type of culture that you want it to be. Identify systems and behaviors that are clearly moving you in the wrong direction. Make those your priority and focus on them first.

3. Provide incentives for hard work and performance improvements. Letting employees know that their behavior is noticed and appreciated can boost morale and change work culture. Establish performance recognition awards and give bonuses to deserving employees to reinforce behaviors that lead to the desired culture change.

4. Change your compensation system. Is your existing compensation system perpetuating your existing culture? For example, does the way you make decisions about salaries and raises affect the degree to which staff members bring up problems to their administrator, assist with putting improvements in place, provide service to your patients, and detect and correct deficiencies? Employees are constantly evaluating what they and others are earning against the daily efforts they are making. Change your compensation system to reward the employees who support your desired work culture.

5. Reward success in other ways. Title changes, parking spaces, office locations, and other perks linked closely to culture change successes also can ensure the long-term success of your culture change.

6. Align work systems with the desired culture. Review your systems for promotions, staff scheduling, and task assignments to be sure that they support your desired culture. For example, don’t reward individual performance if the requirements of your desired organizational culture specify teamwork.

7. Practice effective communication. Keep employees informed about the culture change process. Be explicit about what is expected. Be sure your employees see meetings, postings, and other communications as valuable.

8. Create value statements for each employee. Have employees put your mission, vision, and values into words that state their impact on each of their particular jobs. For example, a front-desk receptionist’s value statement might be: “I live the value of quality patient care by listening attentively whenever a patient speaks to me in person or on the telephone.” This exercise gives employees a way to relate your desired culture to their specific job duties.

9. Review your physical structure. Does the way you apportion and use your physical space support your desired culture? For example, if your desired culture is one of trust and confidentiality for every patient, then your space must support that. Can your receptionist speak to patients in confidence without being overheard by others in your reception area? If not, you will need to change your structure to support your desired culture.

10. Change your hiring process. Is your current hiring process designed to help you attract, identify, and retain people who think and behave in a manner that is consistent with your desired culture? If not, you are moving further from your change goals with each new hire. Change the way you recruit, interview, and hire your employees so you can employ individuals who will support your desired culture.

11. Acknowledge and celebrate success. As a leader, culture change will be dependent upon your acknowledgement of success. Even a brief moment of one-on-one acknowledgment from you will ensure that your employees know that you noticed what they did and that it was important to you and your organization.

12. Engage in ongoing constructive dialogue. Everyone in your healthcare organization should feel that their input matters. Establish regular opportunities for your employees to share complaints and suggestions with you and with one another, without fear of reprisal.

HOW HEALTHCARE ORGANIZATION CULTURES ARE FORMED AND PERPETUATED

Before it is possible to change a healthcare organization’s culture, it will be helpful for you to understand how any organization’s culture is typically formed and perpetuated. Here are three ways:

1. People shape the culture. The personalities and experiences of the staff create the culture. For example, if most of the people working in your organization are outgoing, the culture is likely to be open and sociable. If employees display photos depicting your organization’s history, your culture is one that values history. If doors are kept open, and few closed-door meetings are held, your culture is unguarded. If negativity about your organization or its administrator is widespread and your employees complain often, a culture of negativity will take hold.

2. Culture is negotiated. One person working alone in a vacuum cannot create a culture, and a culture cannot be handed down from on high. The entire staff must work collaboratively to change the environment, the way work is performed, and the manner in which decisions are made in the organization. That means that culture change must be a process of give and take by all members of the healthcare organization team.

3. Culture is learned through interaction. Employees learn to behave in particular ways through rewards and negative consequences that follow their behavior. They learn culture by interacting with one another. Even a job applicant experiences a sense of culture during the interview process. An initial opinion of your culture can be formed as early as the first phone call or visit to your website.

BONUS FEATURE: GREAT QUESTIONS TO ASK IN A CULTURE INTERVIEW OR SURVEY

It is usually difficult for most employees to put their healthcare organization culture into words. Indirect questions will help you elicit the most useful information. Below are examples of indirect questions you can ask during a culture interview or in a culture survey.

• How would you describe the employees who fail in your healthcare organization?

• What is a good question to ask a candidate seeking a job in our healthcare organization?

• Who is a hero in our healthcare organization? Why?

• What is one thing you would most like to change about our healthcare organization?

• What would you tell a friend about our healthcare organization if they were about to start working here?

• How would you describe your relationship with your coworkers?

• What kind of a boss is your boss?

• What television program reminds you most of our healthcare organization? Why?

• Who does most of the talking in our healthcare organization?

• How, if at all, does seniority play a role in our healthcare organization?

• How are decisions made in our healthcare organization?

• On a scale of 1 to 10, with 10 being the highest, what is the stress level in our healthcare organization on most days? What is the stress level on the most challenging days?

• What five adjectives would you use to describe our healthcare organization?

Excerpted from NEXT-LEVEL Healthcare Leadership Advanced Topics for Healthcare Administrators, Leaders, and Managers , American Association for Physician Leadership, 2025.

References

1. Schein EH. Organizational Culture and Leadership, 4th ed. San Francisco: Jossey-Bass, 2010.

2. Cameron KS & Quinn RE. Diagnosing and Changing Organizational Culture. San Francisco: Jossey-Bass, 2006.

3. Martin J. Organizational Culture: Mapping the Terrain. Thousand Oaks, CA: Sage, 2002.

4. Rhodes A & Shepherdson N. Built on Values: Creating an Enviable Culture that Outperforms the Competition. San Francisco: Jossey-Bass, 2011.