There are two definitions of culture I especially like, because they directionally define an organization. The clearest definition of culture for a service organization is from Forrester Research: “A system of shared values and behaviors that focus employee activity on improving the customer experience.”6 Substitute “patient” for “customer,” and you have a definition of culture for any healthcare organization that not only states why it exists but also states who exists at the center and is most important. My other preferred definition is from Edgar Schein, professor emeritus at the Sloan School of Management at the Massachusetts Institute of Technology: “A pattern of shared basic assumptions learned by a group as it solved its problems of external adaptation and internal integration.”7
These definitions allow practical flexibility in grappling with an intellectually challenging and complicated topic. Our goal as healthcare leaders is to get our people focused on what is right for patients: creating a Patients First culture. Who can argue with defining the culture as the need to keep patients central?
Applying Cleveland Clinic’s definition of the patient experience (safe care, high-quality care, maximum patient satisfaction, and high value), we can revise Forrester’s definition as follows: Healthcare culture is a system of shared values and behaviors that focus caregiver activity on improving the patient experience. Taking a lesson from Schein about adaptation and internal integration, we can move forward to build on our foundation.
We aligned our culture around the patient. We believed that if people understood that the real reason for coming to work every day was taking care of people, we would improve the patient experience and the culture. We then determined what components were necessary to drive toward this ultimate goal.
Culture Starts with the Right People
How well an organization hires and manages its talent will determine its degree of success. Hospitals traditionally have implemented a rather transactional human resources strategy. HR departments advertise job openings, screen applicants, assist with hiring, administer timekeeping and payroll, facilitate performance reviews, and conduct other transactions necessary to manage a workforce. Strategic talent management, popularized by a 1997 McKinsey & Company study,8 is something very different from transactional HR management. Talent management transforms HR from a strictly transactional function to a strategic function that impacts how organizations “source, attract, select, train, develop, retain, promote, and move employees through the organization.”9 Talent management links strategy with the HR process so that an organization acquires people predisposed to alignment with organizational goals and objectives. It wraps the HR function around the mission, vision, values, and goals of the organization. This is very different from ensuring people get paid.
Great companies spend a lot of time making sure they have the right people in their culture. Zappos, for instance, offers every new employee a $4,000 quitting bonus. Its leaders’ belief is that if new employees take the money, then they are not committed to what the company is about and they are not wanted. Jenn Lim, who cofounded a company called Delivering Happiness with Zappos founder Tony Hsieh, describes their philosophy about “hiring slow and firing fast”10 to ensure that the culture the company is trying to create is protected.
Most people choose a healthcare career from a genuine desire to help care for their fellow humans. While the following has no statistical backing, I estimate that roughly 85 percent of our employees come every day completely dedicated to what they do. Ten percent may not be quite so motivated but probably are aligned with our mission and what’s important. Five percent likely don’t care whether they work for a hospital or a fast-food chain. The 10-percent group needs to be motivated or probably shouldn’t work in healthcare, and the 5-percent group needs to go. This 15-percent club has missed the reason for working in healthcare; the people in this group consider it just a job, don’t like or aren’t committed to taking care of patients, and probably don’t belong. As leaders and managers, our job is to try and elevate the 10 percent and outplace the 5 percent. The scholarship on employee engagement by and large suggests that one important point: one badly disengaged, nonproductive, or disruptive employee can contaminate a big chunk of the workforce.
Cleveland Clinic’s HR strategy formerly focused on transactional management of people. When Cosgrove became CEO, he recognized the need to significantly improve our management of human capital. He conducted a national search for a new chief HR officer and found the perfect candidate in Joseph Patrnchak, who had extensive experience in the industry, most recently with Blue Cross Blue Shield of Massachusetts. His primary responsibility was to transform Cleveland Clinic’s HR from a very transactionally focused operation to a strategically aligned one.
Patrnchak started by defining key components of our talent management life cycle and realigning the HR organization around our functional areas. He created a talent acquisition department and rebuilt a learning and development organization that had been eliminated. He recruited and hired team members with extensive HR experience.
Cleveland Clinic’s hiring strategy had been to find people to fill jobs, a very transactional approach. Patrnchak introduced the practice of “hiring for fit,” meaning we assessed candidates for organizational alignment. Similar to The Ritz-Carlton, which “selects only the most passionate and skilled hospitality professionals,”11 we wanted to make certain we hired only people in the 85-percent category, passionately committed to healthcare and helping people. HR introduced prehiring screening and began to test applicants for predilection for teamwork, service, and other important organizational competencies. This tactic alone eliminated 20 percent of job applicants.
Patrnchak initiated employee engagement measurement and the development of action plans to improve satisfaction and buy-in. He ardently advocated and ultimately achieved wide-scale adoption of a robust rewards and recognition program called Caregiver Celebrations. He convinced leadership that job satisfaction is not dependent on compensation alone, but that a consistent process of recognizing employees with award certificates, trophies, and gift-purchase points is equally important. These tactics and other major HR initiatives were critical to our work on cultural development. We needed to find the right people, orient them to the organization and their roles, and develop them to high performance. Patrnchak was an early supporter of the concept that everyone is a caregiver, not just an employee.
We Are All in This for the Patient
Adopting the caregiver label for everyone in the organization was an important first step to begin alignment of our culture around our Patients First philosophy. When I first became CXO, I asked one of my patients to keep track of all the caregivers she encountered during her hospital stay. At the end of a five-day, uncomplicated stay for abdominal surgery, she had encountered eight physicians, more than 60 nurses, and so many other people (housekeepers, food deliverers, surgical residents in training, surgical fellows in training, phlebotomists, volunteers, medical students, and so on) that when I walked into her room on discharge day, she apologized, “Yesterday I encountered three new people and forgot to ask their names.”
The number of people “caring” for my patient was eye-opening. Granted, not all of them were directly involved in her medical care, but every one of those employees had an important role in the overall delivery of care. Each could impact not only how she perceived her experience, but how we delivered quality and provided safety.
My patient’s stay was fairly routine. A surgical complication could have extended it, meaning more specialty physician care, more nursing care, more blood draws, perhaps more procedures such as x-rays, more meals, more days the room needed to be cleaned, and, therefore, exposure to yet more people, all playing an important role in care and affecting her stay. My example is limited to the people that the patient encountered. Her family and friends touched places in the hospital that the patient never saw, such as the parking garage, gift shop, hallways, and cafeteria.
; How each of those people defines culture is typically overlooked in healthcare. We’ve all heard similar complaints such as “My hospital stay was great, well, except for the phlebotomist who kept sticking my arm, could not get blood, and never apologized.” Or, “That one nursing assistant was really mean to me.” Or, “Dr. Merlino was great, but every time his resident came to see me, she flicked on the lights at 6 a.m. and scared me awake.” Introducing the concept that everyone is a caregiver was important to begin fostering teamwork and convincing everyone he or she mattered in patient care. Everyone in the organization is important, has a role to play, and must be aligned as a team around patients. This is what Patients First is all about.
The concept of caregiving is not that complicated. If you’re raising children, you’re a caregiver. If you have elderly parents or an ill spouse, you’re a caregiver. Deeming everyone a caregiver is no different from what’s done at a lot of other high-performing service organizations, such as Walt Disney Company, which calls its employees cast members, or The Ritz-Carlton hotel company, which refers to its employees as ladies and gentlemen. Caregiving is also not just about service and patient satisfaction. You don’t have to be a doctor or nurse to help a patient. If a food-service worker delivering a tray sees a patient having a seizure, he or she can help the patient by summoning aid.
Calling everyone a caregiver is not meant to imply that everyone is the same. But it does imply a common purpose. It also implies that we’re in this together, that equality exists, and that everyone should be treated fairly. To foster a highly engaged culture of caregivers, there must be zero tolerance for ill-treatment of patients and each other. Successful implementation also requires that everyone, regardless of role, is held accountable. A healthcare organization must not have two standards, one for doctors and one for everyone else. We could not permit physicians to get away with bad behavior that we would never tolerate in another employee. Leveling the organization by calling everyone a caregiver resets our purpose and, at a very basic level, reminds people why they come to work every day. It’s also an important step in having people recognize they are part of a highly functioning patient-care team. If you work for Cleveland Clinic, you’re part of the organization’s mission, which is providing care to patients. Therefore, you are a caregiver.
The conversation about labeling everyone a caregiver was not a smooth one. We had some physicians who vigorously argued that if you weren’t a nurse or doctor, you weren’t a caregiver. Likewise, we had many employees who never directly impacted a patient contending they were in no way caregivers. We listened to these views but held firm. As Patrnchak often pointed out, this is not just about a name we call each other, but about changing how we think about our talent. Cleveland Clinic long referred to physicians as the “professional staff,” which implied to many that if you weren’t a physician or scientist, you weren’t valued as a professional. Caregiver sends the subtle but important message that everyone is valued.
Everyone Must Know the Goals
All these points about alignment around caregiving apply equally to organizational alignment around important goals. Early in my tenure as CXO, we held a retreat for one of our community hospitals. Every leader and manager was in attendance, and the purpose was to engage the group in improving the patient experience. The retreat opened with a Jeopardy-like icebreaker. The five or six people seated around each table were considered a team and took turns answering questions from the “Jeopardy board.” One table chose the category “safety,” and the card was flipped to reveal the statement “Identify patients correctly.” The moderator inquired whether anyone at the table could answer what the statement meant to the hospital. The team passed, so the statement was reread to the entire room. Again, silence! No one knew the meaning or how it related to healthcare. This was remarkable to watch. No single manager from the entire hospital—all senior leadership included—could correctly name one of the Joint Commission’s six national hospital patient safety goals for the year.12
This incident provoked another striking realization for me. We can train members of the general public to call 911 in an emergency, avoid elevators during a building fire, and put on their own oxygen masks in the event of airplane cabin depressurization before assisting a child. But not a single leader in that large, Joint Commission–certified community hospital could correctly identify a key requirement for hospital safety, which all of them were responsible for managing. Were they incompetent? Unaware? Did they go to their jobs every day ignoring basic safety requirements for which all hospitals are held accountable? Not exactly.
Juxtapose this story with my account regarding the number of people who helped care for my surgical patient. Each person affected not only the patient experience but how we delivered quality and provided safety.
If we agree that the top priority in a hospital is safety and everyone is responsible for it, then we need to ensure that the entire organization is wrapped around it. Every one of those people caring for my patient could have an impact on safety. For me as a surgeon, it’s making certain we adhere to specific processes, such as doing a time-out before starting the operation. For nurses, it’s double-checking what medications are being administered to a patient. For the food-service worker, it’s verifying that the patient receives the correct diet. For the environmental-service worker, it’s making sure the room is clean and uncluttered to prevent germs and falls. Everyone has an important individual role, but we also have a collective role to be there for the patient. We have to take ownership of what is at the center of what we do, which is Patients First.
If we see a disoriented hospital patient trying to get out of bed or having a seizure, we don’t need a medical degree to know something’s wrong and that we must immediately call for help. The same goes for walking into the room and seeing a puddle on the floor. Any one of our multitudes of caregivers should be aware that this poses a danger and do something to correct it—either wipe it up or warn people and call environmental services. We all have a role in safety.
Now apply this concept to the satisfaction side of the patient experience. Every person interacting with the patient and family should demonstrate the same courtesy, empathy, and compassion. We should all be kind, project caring, and try to be helpful. Everyone entering the hospital room should utilize a basic framework for interacting. The point is that everyone needs to align around the patient.
Standardizing Who We Are
In our journey to develop our culture, Cleveland Clinic had adopted the Patients First motto, made the patient experience a strategic priority, and rebranded employees as caregivers. Now it was time to pull together other essential elements, including shared mission, vision, and values.
Some of the hospitals we had acquired had different mission statements and values. Our move toward integration required us to finally think about a unified One Cleveland Clinic. Our founders’ original mission, “to provide better care of the sick, investigation into their problems, and further education of those who serve,” became the unifying mission for the entire Cleveland Clinic health system. This meant that longstanding mission statements of some acquired entities went by the wayside, as Cosgrove felt strongly that our success stemmed from the defining mission of our founders. With input from the entire organization, the executive team created a new vision statement further galvanizing organizational focus on the patient and reinforcing that our quest for excellence would be continual.
Our vision became “Striving to be the world’s leader in patient experience, clinical outcomes, research, and education.” To our existing four values known as the “four cornerstones”—quality, teamwork, innovation, and service—we added compassion, to speak of the human side of care delivery. Integrity was also added to reinforce what we wanted caregivers to bring to work every day.
At the same time we were committing to a common mission, crafting a new vision, and augmenting our values, the organization was at work on a variety of other major initiatives. For e
xample, there was a significant impetus to improve quality. We were beginning to integrate our health system operations. HR was transforming the workforce with employee wellness programs and engagement planning. In the fall of 2009, as our executive team rehearsed presentations for a year-end organization-wide leadership retreat, it became utterly apparent that we lacked a connection between all of these endeavors. Our presentations were clunky and uncoordinated, and a frustrated CEO left the room.
As we regrouped to tackle the problem of a cohesive focus and message, C. Martin Harris, our chief information officer, who was organizing the planning retreat, started to sift through our accomplishments and undertakings. He pointed to our Patients First orientation and our vision of a great patient experience. Patrnchak remarked about our “most important asset,” our people. We all chimed in about important safety, quality, and other initiatives. Harris kept pushing us to think about a unified theme. That’s when we had a corporate epiphany. Our efforts to improve safety, quality, and the patient experience would align our caregivers. We had renewed commitment to ensuring those caregivers were satisfied and engaged. The key to achieving our enterprise goals was an engaged workforce. We made the connections, and we finally recognized that we needed to treat our people (our caregivers) like we treated our patients (our customers).
At our strategic planning retreat a few weeks later, I presented a slide articulating that improving safety, quality, and the patient experience would require us to build and sustain a culture of highly engaged, satisfied caregivers, which would allow us to achieve our enterprise goals (Figure 5.1). The unified message resonated with Cosgrove and our leadership. One of the institute chairs e-mailed me after my presentation, saying we had nailed it. The message was simple and the linkages were clear, and it launched our development of Cleveland Clinic’s culture.
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