A culture of engagement and accountability is essential for health systems to succeed in an era of population health management and accountable care. Strong organizational cultures enable and nurture the new behaviors, actions and investments required to navigate the many changes affecting the healthcare industry, particularly the transition to value-based care. But driving cultural improvement is not easy, and it does not happen overnight.
To the contrary, efforts to change culture must take into account the history, heritage and attitudes of an organization's past. And they must be carefully and continually assessed, developed and nurtured at all levels of the organization.
This roundtable, sponsored by Gallagher Integrated, includes responses from three recognized leaders from renowned health systems across the U.S.
Participants include:
John Chessare, MD, President and CEO, GBMC HealthCare System, Greater Baltimore Medical Center
Howard Grant, JD, MD, President and CEO, Lahey Health (Burlington, Mass.)
William Pryor, Chief Human Resources Officer, Cape Fear Valley Health System (Fayetteville, N.C.)
Note: Gallagher Integrated did not influence the responses provided in this roundtable in any way.
Question: How do organizational cultures need to evolve in the new era of healthcare?
Dr. Grant: Organizations must create a safe environment for evolutionary behavior, thereby encouraging staff to embrace change while recognizing that it is not always easy. As reimbursement diminishes while costs of care delivery rise, the most successful organizations will be the ones that are the most nimble. Healthcare organizations must be quicker to adapt than they have been historically, and celebrate innovation to create an environment that welcomes reengineering and value-based reimbursement.
Dr. Chessare: The new era of healthcare is about change. Most of us agree that this change is moving us toward the national triple aim of improving the patient experience, improving the health of populations and lowering the cost of healthcare. At GBMC we've added a fourth aim: To increase joy among those providing the care.
Historically, many physicians — even though they didn't realize or believe they were doing this — acted as if they were trying to maintain the status quo. But now we really need to be more introspective and focus on what it is that our communities, patients and country needs us to do. To get from where we are today to realizing the triple aim, an organization must have a culture of change.
Mr. Pryor: As chief of HR, I've had a tremendous amount of discussion about this over the last several years. As a leader, you have to explain to employees what needs to change and why. You make the case for those changes at every level you can — town hall meetings, staff meetings, videos, emails, etc... At this point, the Affordable Care Act isn't new, but it is still effecting change. You can sit back and wait for things to happen, or you can be proactive. We've decided to be proactive.
Q: How can organizational culture guide individual behavior?
HG: A healthy organizational culture should define expectations for individual caregivers' performance in critical areas like quality of care, patient safety, patient experience and operational efficiency. When an organization's culture expects leaders to embrace defined goals, and gives individuals the tools and guidance they need to realize that performance, the results tend to fall in line with the desired outcomes. The strongest cultures thrive, even during periods of the greatest stress, because their caregivers have the confidence to navigate whatever challenges are placed in front of them.
JC: Leaders must have two-way conversations with employees and clearly define the organization's vision so they understand and buy-in to it. We tell new folks the expectation is they will do every time what they would want done to their own loved ones. And underlining that vision is the idea that we are always striving for continuous improvement. The best way to influence behavior is to thank and celebrate people who exhibit this culture, and for those who don't, we have direct, discrete conversations with them. The literature suggests you get more out of celebrating successes than highlighting failure, but you're not a great manager if you don't have a conversation with someone whose behaviors are at odds with the vision.
WP: We have to get our folks to understand where we are going and how they can contribute to our goals. If employees do not see the connection to the larger mission, they will wonder why they are there.
Under the ACA, each organization has to figure out where they need to be and develop actions that everyone can take to drive change. Take the patient experience. Everyone in the health system plays a role in that. No matter what role someone has, they need to take a positive approach and have a smile on their face.
Q: What are the ways that engagement can impact organizational success?
HG: Engagement is the most critical ingredient of an organization's success because a committed workforce is far more likely to deliver the highest quality, most compassionate and most efficient care. And clear communication is a key driver to realize a high level of engagement initially and then to sustain it. Consistent expression of goals, expectations and aspirations to both internal and external audiences solidifies engagement, which in turn increases the likelihood of enhanced performance in all facets of the organization. It takes a concerted and protracted effort to establish a high level of engagement and persistent focus to sustain it.
JC: Engagement is essential because without an engaged workforce, there isn't a way to improve and meet the goals of the triple aim. As CEO, I often say I'm the No. 1 cheerleader of the organization. I make sure people have what they need to get the job done. But if people only rely on senior leaders to change the organization, that's silly. The engagement of people who are doing the work is what will generate continuous improvement.
WP: Employees do better in terms of providing quality healthcare and a great patient experience when they are engaged. Engagement really drives every facet of a health system. And it is contagious. If there are employees who are resistant and disengaged, those negative headwinds will pull you away from where you're trying to go. We want peer pressure to be positive.
At the same time, we clearly define our culture at new employee orientation. If an employee doesn't want to buy into our culture, then they should not come here. We want everyone to want to be here.
Q: How are healthcare organization cultures impacted by the shifts toward population health management?
HG: We are in the midst of profound changes in cultural perspectives on our priorities for healthcare delivery systems. The hospital-centric healthcare world is rapidly morphing into a systemic approach to enhancing the health of a population. The organizations that will thrive in this new arena will demonstrate flexibility in all aspects of their operations as they migrate away from the way we have managed our business for decades. The critical balancing act is figuring out how to preserve the most cherished components of your culture — like the commitment to deliver compassionate patient care or colleagues' respect for each other — while radically changing care models and how caregivers are rewarded for their performance. It will take a delicate touch.
JC: It's not really that organizations' cultures are impacted by population health management, but that in order to make such efforts successful, you really need to have a culture of action and improvement. If employees have the mindset that they will just come into work, do what they're told and go home, there is no way you can transform your organization. Population health management requires a massive redesign and a culture of performance improvement.
WP: The approach has to be more patient-centered and effective. Organizationally, you have to be able to look at your patients not only episodically, but as a whole. For some patients, it is necessary to ask, what keeps this patient coming back to the emergency room? We have a paramedic program where we return to patients' homes to make sure they have the right medications, they are making their doctor appointments and have the care they need so that they can get well sooner. The organizational culture has to continue to evolve to meet the patient’s need on their turf.
Q: How can organizations leverage culture to not only embrace but encourage transformation?
HG: It starts with trust and respect. If a healthcare organization's mission is clear, and it enjoys a commitment from its staff and other community stakeholders to that mission, it is much more likely to adopt transformation more smoothly. The strongest healthcare organizations have an engaged workforce that will recognize that the transformation will be in the best interest of everyone — their patients, their organization, their workforce and the communities they serve. Celebrate that the innovative successes are achieved in large part because of the strong culture and trust; and subsequent transformations will reinforce the notion that creative innovation is the norm as opposed to the exception.
JC: If you get your people to adopt the mindset that it's their right and duty to suggest ways to improve, they will have a greater sense of ownership over the change. Once in that mindset, they will start running with the ball and they will want to transform.
Our opportunity to do the right thing in healthcare is here. In Maryland, we have global hospital budgets that allow us to experiment and create more value for our patients and communities. Shame on any leader who doesn't take steps to transform the organization to get us to the triple aim.
WP: At the end of the day, you have to make the case to every employee, physician, nurse, environmental services worker — whomever — that they play a part in achieving the organization's goals. You must be able to break it down and explain the case at every level so each employee sees how they contribute to the big picture.