Analysis of the NEJM Catalyst Insights Council Survey on Organizational Culture. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
By Stephen Swensen and Namita Seth Mohta
Organizational culture is the essential element in meeting health care goals, according to Stephen Swensen, MD, Professor Emeritus at the Mayo Clinic College of Medicine and Senior Fellow at the Institute for Healthcare Improvement. “Culture, more than anything else, drives performance,” he says.
In that context, it is notable that culture at many health care organizations is changing — and in the right direction, say nearly 60% of respondents to our latest NEJM Catalyst Insights Council survey. Three-quarters of respondents — who are clinical leaders, clinicians, and executives from organizations directly involved in health care delivery — label culture change a high or moderate priority in their organization.
“Culture is the way in which organizations make decisions about what they are and aren’t going to do, and the cumulative way in which employees experience their jobs and lives at the organization. Both of these directly influence the types of care that patients experience. Simply put: Change your organizational culture and you change the patient experience,” says Namita Seth Mohta, MD, Clinical Editor at NEJM Catalyst.
The survey results show that a lot of work on organizational culture remains to be done, says Swensen, who heads NEJM Catalyst’s Leadership Theme. He points to how respondents roughly balance the importance of the bottom line and patient care, with a score of 45% and 55%, respectively. The ideal culture, he says, would tip the scales heavily toward patient-centered care (keeping in mind the fiscal responsibility to keep the doors open).
In written responses, Council members comment that a commitment to quality, an emphasis on patient care, and a focus on each individual’s impact have resulted in positive culture change at their organizations, whereas concentrating too heavily on the bottom line and productivity has had negative repercussions.
A physician from a health system in New England says, “A strong group of mid-level administrators who are regional medical directors gives the organization a semblance of structure and culture that is physician-driven. But that group is not adequately resourced or powered to really drive change. Administrative leadership tied to finance and payer contracts drives too much.”
Survey respondents say the CEO is most accountable for culture change (chosen by 33%). While Mohta agrees, she stresses that responsibility lies with everyone. A productive and impactful culture is embedded in the ethos of the organization. “There shouldn’t be a case where the CEO leaves and ‘takes the culture’ with him or her.”
Senior leadership should assist the CEO in fostering culture change by co-creating the vision and strategy for change, Swensen says. Methods by which clinical leaders can have a hand in changing culture include instituting daily huddles that allow everyone on a care team to voice their opinion, enforcing a mission of patient-centered care, and emphasizing the well-being of physicians.
Although a practicing physician herself, Mohta is an outlier on the question of whether culture change must be led by a physician. While two-thirds of Council members indicate it is extremely or very important that culture change be led by a physician, as does Swensen, Mohta disagrees. “The skills necessary to establish, lead, and scale culture change can effectively be possessed by a non-physician,” she says. “Physician champions, however, are a requirement.” While 36% of clinicians responding to the survey say culture change should be led by a physician, 44% of clinical leaders agree, compared to 30% of executives.
With over half of respondents (55%) reporting that their organization relies on top-down command-and-control strategy to bring about culture change, Swensen says this is a sign that “they are doing culture change poorly.” Organizations should be hiring people who support cultural objectives (selected by 33% of respondents) and firing people who clash with the culture (20%), he says. They also should invest in training new and current employees (50%) and be open to bottom-up decision making (20%).
A higher incidence of clinicians (61%) than executives (47%) list top-down command-andcontrol as one of the top strategies used for changing their organization’s culture. One clinician respondent says a negative aspect of the top-down atmosphere is “rules dictated/enforced by corporate offices out of state.” Another clinician respondent says, “Decisions are handed down after they have been made with little input from staff before the announcement.”
Swensen’s view is that “All discussions need to be done with the people doing the real work. If culture change is done properly, physicians and nurses shouldn’t feel that decisions are being made from the top.” He encourages organizations to keep their stated goals simple when defining culture change, pointing to the Mayo Clinic’s primary value statement, “the needs of the patient come first.”
That declaration “is simple, elegant, and gets to the core,” Swensen says, adding that such simplicity makes it easy to keep everyone aligned and to understand the value in such a culture.
Health care organizations will know their ongoing culture change efforts are successful, Mohta says, when there is an environment in which employees are empowered to ask new and different questions and to answer old questions differently in the service of continuously improving patient care.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
What is the single most positive aspect of your organization’s culture? What is the most negative aspect?
“Positive: Growth of patient and family centered care as an increasingly visible enterprise-level strategy for approaching the triple aim.
Negative: Always leading with, What can we get by with? rather than, What’s possible?”
“Positive: Accepts all regardless of race, sex, culture.
“Positive: Committed to high quality care.
“Positive: Belief in developing staff.
Negative: Lack of transparency, lack of accountability.”
“Positive: We are acutely aware that we are in an environment of intense change and executive leadership is aligned in understanding and meeting the challenges to succeed in our new environment.
Negative: Fear of change, specifically that it may mean job loss, among our 400 nonprescribing provider clinicians and some support staff.”
Download the full report for additional verbatim comments from Insights Council members.
Charts and Commentary
by NEJM Catalyst
We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about organizational culture. The survey explores the current state and the priority of organizational culture change, the effectiveness of creating and sustaining culture, patient care versus the bottom line, the amount of culture change necessary, strategies for changing organizational culture and accountability for culture change, and the importance of culture change being led by a physician. Completed surveys from 710 respondents are included in the analysis.
While a majority of Council members indicate their organizational culture is changing and headed in the right direction, it’s important to note that more than half of clinicians indicate their organizational culture is changing in the wrong direction (23%) or maintaining the status quo (31%).
Nearly all respondents (94%) say culture change is a priority, but to varying degrees. Culture change is rated as a higher priority for more executives (41%) than clinicians (23%).
Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.