January 2021, Volume XXXIV, Number 10

Cover story two

The Science of Culture

A look inside health systems

et’s look at the “science of culture” in the embedded physician services organization of health systems. While trustees of  health systems cannot be expected to understand all there is to know about the management and complexities of health services delivery, they can be expected to understand and be accountable for the culture of the organization served. But why are boards accountable for the culture of the health system? Isn’t that the job of management? Trustees of health systems are the keepers of the culture of the organization they serve. Our research demonstrates that the people of organizations (physicians and staff) believe “the culture of the organization is what the leaders want it to be.” The board is viewed as the ultimate authority of the organization, and by extension are the “leaders”.  As such it is reasonable for the people of the organization to assume that the culture they experience is what the trustees’ want it to be.

The balance of this article is presented as a “summary of the science”, our observations derived  from the study of culture of physician services organizations. Observations will refer physicians in independent practices and to employed physician groups operated by health systems, with key comparisons to independent physicians affiliated with  hospitals and health systems. Understandings derived from such comparisons are important, since most health systems in the U.S. are staffed by physicians who fit into three categories; employed, contracted or independent. The scope of the definition of organizational culture is narrowed to “leadership culture”. The observations, and related support provided here derive  from administration of the CulturePulse; a proprietary evaluation tool developed by D.K. Zismer and B.J. Utecht. This tool evaluates the leadership culture of organizations based on the assumption that the principal job of leaders is to define, design, deploy and direct the cultures of the organizations they lead. The format provides boards and senior leadership teams an agenda for discussions regarding the leadership culture of their organizations, including how leadership culture affects organizational performance.

There is no unified culture in most organizations.

Culture in organizations is a product of the human condition at work. Leaders are the principal factor in the curation of how that human condition forms individual and collective beliefs and attitudes toward the organization. Attitudes and beliefs affect the behaviors of individuals and teams in organizations, and attitudes and beliefs direct the energy that drives performance. For healthcare organizations performance translates to clinical quality, the patient experience, economic and financial productivity, employee turnover rates, and it affects the quality of the talent the organization attracts.

Employees bring basic human needs and wants to the work setting, along with their personalities, personal and professional work histories, and their hopes, aspirations and expectations for their prospects as a member of an organization. These prospects manifest as expectations for extrinsic and intrinsic rewards. Leadership’s delivery on the expectations for the extrinsic rewards are the easier parts of the equation; extrinsic rewards come in the forms of money, advancement, accolades and recognition. Delivery on the intrinsic rewards is typically more challenging for leadership, but can have the greater influence on the culture of organizations; intrinsic rewards such as trust, fairness, equity, security, predictability, appreciation and fidelity to the implied promises of missions and values. Individual perceptions of the leadership culture of organizations are profoundly affected by the expectations for a spectrum of rewards, extrinsic and intrinsic, available as a member of the organization.

Taxonomy of leadership culture

Through administration of the CulturePulse to physicians, other clinicians and support staff in physician service organizations, evaluations of leadership culture observations may be drawn that help evaluate and define leadership culture. Some of these observations include the following points.

There is no unified culture in most organizations; especially not in health care, including physician services organizations. Healthcare organizations are a tapestry of specialization of personnel and function. Consequently there are multiple sub-cultures within healthcare organizations. The state and status of these sub-cultures is the product of the leadership. Scores on our evaluations of culture in medical groups demonstrate that while staff may have clear perspectives on how the culture of the organization “should be” (and they will freely share their views and perspectives in our survey instrument), their perspectives on the culture of the organization overall is heavily influenced by where they work in the organization, department or division. So, while healthcare organizations are, in fact, collections of multiple subcultures, patients expect to be cared for by a unified team of professionals. Performance of the whole is a product of the multiple sub-cultures cooperating and collaborating together at consistently high levels of performance.

Sub-cultures in organizations are susceptible to situational shocks and shifts. Shocks and shifts can come in a number of forms; examples include changes in leadership, internal consolidations of operating divisions and departments, budgetary performance shifts, and introductions of changes in clinical processes and programming. Shocks to one sub-culture can reverberate through others. No sub-culture operates in isolation of the others in healthcare organizations, and no sub-culture should be presumed to be stable, or impervious to shocks and shifts. Boards need to remain in-tune with how organization decisions may affect culture and performance.

Physicians may overestimate the health of the culture of the staff in the trenches. Physicians who have viewed CulturePulse scores  of the staff in their own organizations, as compared with those of the physicians, have said things like “I guess we’re out of touch”  and “we’re in LaLa land”. It is important to remember that while patients’ perspectives of their encounters with their physicians matter, the status of other subcultures encountered by patients matter as well. Inasmuch as patients will believe the physicians in clinical settings are leaders of the organization, including all clinical programming and related services, they will attribute the condition of the full culture they encounter to the physicians; i.e., “it must be what they want it to be, they’re in charge.”

The factors (individual items on the CulturePulse) that most influence the opinions of the state and status of the people affiliated with one sub-culture may not be influential for others. Here again, the leaders of organizations should presume there is no unified or commonly held perspectives of the state and status of culture in organizations, nor is there a uniform approach to how leaders should address the cultures of the groups they lead.

There is a somewhat pervasive assumption held by students of culture that if the people of the organization understand the mission of the organization and know how they fit with and contribute to the mission, individuals are more likely to hold the status of the culture in high regard. Our results demonstrate that while important, these two can operate independently of individuals’ perceptions of the culture; i.e., one’s understanding the mission and their belief that they contribute meaningfully to that mission may have little bearing on their perceptions of the culture they work in every day. So, when the people of the organization reflect an understanding and belief in the mission, and they understand how they make meaningful contributions to the mission, leaders should not presume that all is well with the individuals’ perceptions of the culture and “where they live” in the organization.

Physician organizations are keen observers of how leaders interact.

Other repeating patterns of culture in healthcare organizations

Leaders’ abilities and inclinations to hold all to high levels of performance accountability are meaningful to the people of organizations. We typically see a stark “downdraft” in survey scores, across the board on this factor. “Holding all physicians to the same high standards of patient care quality” can be a very strong predictor of how physicians rate the quality of hospital leadership and the overall culture of health system leadership.

Staff in physician organizations are keen observers of how leaders interact to cooperate and collaborate with their peers (other leaders) for the good of the organization, and staff will routinely hold opinions of whether individual leaders behave in the best interests’ of the organization or self interest. The people of the organizations will also hold strong opinions on the whether leaders reflect the values of the organization in their decision-making, and leadership behaviors. A common mistake of leaders is creation of a “silo culture”. Extremes here can make those they lead feel stifled and even trapped by their leaders. Healthier cultures foster and encourage cooperation, collaboration and problem solving between departments, and division or clinical specialties.

The people of the organization will hold strong opinions on whether leaders work to ensure “an environment that can be trusted to be fair”. Most individuals in organizations understand that not every decision made by leaders will  be pleasing to them, but they do expect leaders will make every decision based upon values of fairness and equity. The predictability of perceived trust, fairness and equity can be strong predictors of individuals’ motivation to perform at the highest levels on behalf of a mission.

How individuals rate the last item on the CulturePulse; i.e., “I believe the culture of the organization is as good as it should be” will predict their response levels to all other items on the evaluation tool. For example, if a respondent rates the state of the culture of the organization at the lowest level on the scale, it is probable they will rate all other items at low levels. Likewise those who rate the last item at high levels will tend to rate all others at high levels on the scale. While such findings may seem to be a statement of the obvious, the key point for trustees here is the breadth of the effect an individuals’ perceptions of the leadership culture can have. To be specific, if an individual rates the leadership culture at a low level they are likely to rate another 20 key leadership culture factors presented in the evaluation tool at low levels. To put this observation in the practical, if 15% of the work force in the physician services organization rate the overall leadership culture as  a “1” (lowest score on the 1-7 scale) this class of respondents is also likely to rate 20 other key contributors to leadership culture at similarly low levels.

Relevance to a Governing Board

Let’s return to a foundational, going-in premise of the article; “trustees own the cultures of the organizations they govern.” To repeat, while trustees of healthcare organizations can’t be expected to understand all the complexities and intricacies of operating a hospital or health system, they can be expected to understand, in-depth, the state and status of the cultures of the organizations they govern. Why? Because, the culture of the organization will affect the mission performance of the organization, and mission performance is job #1 of governance.

For trustees who accept the premise that a governing board owns organizational culture, the question of “what to do next” follows. The answer to the question lies with the right relationship with the CEO. The CEO is directly responsible to the board. Boards have responsibility and accountability for one employee; the CEO. Boards should engage with the CEO directly and routinely, on the state and status of the leadership culture of the organization, including its ongoing assessment and evaluation, and plans for its ongoing development. The state and status of the leadership culture should also represent an area of performance evaluation, and ongoing development for members of the senior leadership team. The governing board and the senior leadership team are viewed by the people of the organization as the guardians and keepers of the corporate culture.

As physicians gain more insight into the science of culture they become more able to effect positive change within their health systems, no matter how large or small.  Better understanding of the business dynamics that drive corporate decision-making allows them to be more active partners in that process.

Daniel K. Zismer, Ph.D. is Co-Chair and CEO of Associated Eye Care Partners, LLC, Also, Endowed Scholar, Professor Emeritus and Chair, School of Public Health, University of Minnesota. 

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Daniel K. Zismer, Ph.D. is Co-Chair and CEO of Associated Eye Care Partners, LLC, Also, Endowed Scholar, Professor Emeritus and Chair, School of Public Health, University of Minnesota.