Humans are a tribal species. Throughout our history, we have formed groups to help ourselves compete for resources, defend against threats and provide a social milieu. In modern society, one of our tribes is inevitably the people we work with. Bonds form and norms develop that become important to the people in the workplace. A culture develops that differentiates one organization from another.
This is especially true for groups of people who work together in challenging environments where the stakes are high, including most hospitals. Because healthcare workers know people’s lives are in their hands, they take organizational culture seriously. They identify with it and guard it fiercely.
My colleague, Charlotte Hovet, MD, is a family physician with years of expertise in helping hospitals with physician leadership and culture issues. She offers a pretty good description of organizational culture and why it is important: “Culture is made up of individual and collective values, attitudes and beliefs that translate into unwritten rules of behavior. These rules, or norms, clue us in to what others in the organization expect of us, and they allow us to predict behavior. Thus, culture has a significant impact on how people in an organization relate to one another and communicate.”
Once a culture is established, it doesn't easily change because people learn to behave in ways that allow them to fit into the culture. (If they don’t fit in, often they either leave or are let go). Changing workplace culture means changing the way that people think and behave, which is never easy.
The issue of organizational culture is an important question for healthcare leaders for two reasons. First, mergers and acquisitions have become common, and the melding of two organizations inevitably requires reconciling two cultures that may be different, sometimes significantly different, from each other.
Secondly, a larger sea change — the move from fee-for-service reimbursement to value-based payments — will also require a culture change.
Mergers and acquisitions pose a culture challenge that will take patience and thoughtfulness to overcome. The temptation, if you are part of a larger organization that is acquiring a smaller organization, is to be The Borg.
Fans of the Star Trek TV series will remember that The Borg was a culture comprised of cyborgs that subsumed other cultures into it whether they wanted to be or not. As The Borg told its hapless victims, “Resistance is futile.” And while The Borg was a powerful culture, it brought chaos to the galaxy and spawned active resistance everywhere. They were hated and feared.
So you won’t make any friends and you will possibly create quite a few enemies if you try to impose your organizational culture on a smaller organization.
Dr. Hovet suggests that the key to effective, and peaceful, culture melding is to first understand the culture of the organization you are acquiring.
“If you understand how they do things, and even more importantly, why they do things the way they do, you’ll have a better chance of a smooth transition,” Dr. Hovet says. “Get the most important stakeholders at the table and listen to them. Don’t tell them how things are going to change. Instead, listen to how they do things and what things they want to change. Once you have heard everyone’s voice, you will have a much clearer picture of where and how to adopt the culture to fit your own.
“Also, if you let the stakeholders be a part of the decision and planning process, you’ll have champions on the ground where you need them when things get sticky or difficult. And you might find that this smaller organization has some really good ideas that you could learn from. But if you don’t listen first, you may never hear those good ideas,” she adds.
I’ll add another thought here: Remember why you merged with or acquired the other organization. If you are intent on enlarging your geographic territory, remember that you have to win the patients in the new area, just like you won your current patients. That means that you want to tread lightly and respect the culture and values of the organization, seeking to enhance the existing trust between the organization and its patients/customers in the community you are embracing.
If you acquired an organization that had specific strengths, focus on nurturing those strengths. Too often, organizations get tunnel vision and force changes that erode the very strengths that attracted them to the smaller organization in the first place. They forget what the ultimate goals are, especially when faced with the details of merging cultures and technologies. Keep your eyes on the prize, whatever that might be for your individual situation.
The same basic principles apply to helping physicians and other clinical staff adopt a new organizational culture to meet the challenge of value-based reimbursement.
Chances are your organization has depended on filling beds and filling the schedule in surgery, cath lab and other procedure-based areas in order to succeed financially. Administrators may have courted physicians based on their ability to fill beds and schedule procedures, and physicians have been rewarded for volume.
In a value-based reimbursement environment, the attitudes and behaviors that maximized revenue will become a liability. Hospital leaders will be challenged to help change the thinking and behaviors of their physicians, a group not excessively fond of being told how to do their clinical work. As a physician, I know just how hard it can be to change practice patterns, especially when the changes are forced upon me.
It’s going to be a difficult challenge, and patience is your best tool for meeting that challenge.
Start by getting the right stakeholders at the table and talk about the challenges. Pose questions instead of presenting answers. Brainstorm with your stakeholders on ways to create the effects you are looking for. Listen first, and remember that better patient outcomes at lower cost is your ultimate goal. Don’t let yourself get sidetracked into exciting new technology that isn’t what your specific situation calls for, or set up complex systems that get in the way of efficient and effective patient care.
And make sure that the solutions you and your team propose are sustainable. If you work with all stakeholders and listen to their needs, you’ll be more likely to find solutions that will be easy for the organization to embrace.
Finally, remember that there will be skeptics, naysayers and foot-draggers with any important changes in organizational culture. And that’s a good thing. You need to listen to the grumblers as well as the cheering section if you want to get a really clear view of the situation. Those grumblers, if treated with respect and if their concerns are addressed, can ultimately be your best champions.
You don’t want to be The Borg, forcing your will on those less powerful. You want to discover new galaxies of good healthcare, and you’ll need everyone’s help to do it. Be like Guinan on Star Trek, the El-Aurian character played by Whoopi Goldberg who ran the ship’s lounge, 10 Forward, and listened to everyone’s troubles. She rarely gave advice. Instead, she asked questions that focused each person on solving their own problems. So, like Guinan, listen and include people, and ask questions instead of giving answers. It takes patience and thoughtfulness, but it is more effective in the long run.
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