A Few Thoughts on “Culture” in Healthcare

The big news in Boston healthcare last month was the announcement that Tufts and Boston University Medical Centers were calling off their proposed merger.  The Boston Globe wrote:

“Although they did not specify why the deal fell apart, the hospitals were apparently unable to overcome differences in culture, mission, and strategies for the future, analysts said. Culture always trumps strategy,”said Ellen Lutch Bender, president of the consulting firm Bender Strategies LLC.

I don’t know any of the details about the proposed merger, and certainly can’t tell you if the deal made sense.  But it also wouldn’t be the first partnership that failed due to perceived incompatibilities in organizational culture.  In fact, one of the great healthcare case studies in business school is about the ultimately failed merger of Stanford and UCLA health systems– a marriage that came apart after two years.  The cause, according to the Stanford Alumni Magazine?

The venture’s biggest downfall may have been that it never managed to bind the two institutions together with a common culture.

I’ve been thinking a lot about the concept of culture in healthcare.  You hear the term used frequently– generally to describe either some sort of social incompatibility between one group and another.  Besides mergers, the other time you hear the term used is to explain poor operational performance at healthcare organizations.   People in healthcare often finger “culture” as the explanation for a litany of disappointing outcomes, failed initiatives and poor performance.

As examples– you frequently hear of the Veteran’s Administration (VA) and the UK National health Service (NHS) as organizations with cultures that need to be fixed.   As much as colleagues (who know these organizations far better than me) will more readily implicate a lack of resources, staffing shortfalls and dysfunctional systems as the main causes for their pain–  you’ll often see articles referencing the VA’s lackadaisical “culture”  as the primary cause for the misrepresentations, falsified documents and operational problems at the agency.

The NYT wrote:

Rob Nabors, a former deputy chief of staff for Mr. Obama who was sent to work with the department, wrote last summer that a corrosive culture has led to personnel problems across the department that are seriously impacting morale and, by extension, the timelines of health care.”

The Washington Post commented that changing the VA’s culture [is] harder than selling soap” (a reference to Bob MacDonald, the new head of the VA and the retired CEO of Proctor and Gamble.

You’ll see a similar line of attribution in the UK.  There, multiple whitepapers examining the National Health Service in the UK (over the past twenty years!) have apparently concluded that “achieving meaningful and sustainable quality improvements in the NHS requires a fundamental shift in culture.”

For all the talk of culture in healthcare, It strikes me that we healthcare managers are probably a little glib in throwing the term around.  After all, organizational psychologists and anthropologists have made entire careers out of studying cultures and I have no doubt that the layman’s loose use of the term must make them nuts.

I recently stumbled across an excellent article, a review of culture as it pertains to healthcare quality, written by Dr. Huw Davies, Professor of Health Care Policy and Management at the University of St. Andrews and colleagues.  Davies makes the point that there is a huge amount of controversy in the field regarding the definition and nature of healthcare culture.

The first point Davies makes is that there is significant academic controversy concerning culture as something that groups either have or are.  Is culture a set of modifiable beliefs and actions that can be affected to improve the quality of healthcare in some way?  Davies writes:

This distinction is crucial for, if culture is something that an organisation has, then it may be possible to create, change, and manage culture in the pursuit of wider organisational objectives. However, if organisations simply are cultural entities, then their study may help us to understand the processes of social construction at work but offers less in terms of shaping change or assisting with management control.

In other words, in healthcare we’ve convinced ourselves that our efforts at cultural transformation (by hiring leaders such as Rob Nabors) will result in cultural and then the operational change we desire.  Davies argues that this isn’t a given.  This isn’t to say that culture doesn’t change over time– but that it’s likely more sticky and complex than we’d hope.  Worse, therelationship between culture and operational success is “equivocal, at best.” 

Davies makes two critical points about cultures in healthcare:

First is that in most organizations there are often multiple sub-cultures at work.  The two dominant cultures in most organizations are those of health managers and physicians.  Here is how the two systems fundamentally differ:

As a corollary, these are a limited number of ways that organizations can manage competing subcultures.  They can fit synergistically— a melding or cultures with the combination greater than the sum of its parts.  One culture can dominatethe other.  There can be separation of cultures.  Or there can be breakdown, where a culture refuses to acquiesce to another and conflict results.

I’d argue that every time I’ve been in an organization that was trying to improve culture (really, in most places a euphemism for trying to change the belief systems of physicians to make them more similar to those of healthcare executives) we’ve ended up hoping for synergy but usually stuck as either: 1) separate systems or 2) with the doctors dominated by administration or 3) in the midst of a cold war.

The other point Davies makes is that all of the work that we are undertaking to improve transparency, cost, top-of-license work and systems performance implicitly requires physicians to modify many core beliefs.  It’s an astute and important point.

Here are my takeaways:

Assuming you believe that culture can be changed through leadership (and I simply don’t know if this is true…), then:

1) The most important conflict in healthcare right now is the clash between physician and administrator cultures.  Bridging this gap– creating synergy between the two value systems– will be the primary challenge at most organizations.

1b) As a corollary: when people talk about “cultural” mismatch between two merging organizations, they are likely referring to a discrepancy between the degree to which physicians vs. medical administrators comprise each organization’s defining culture.

2) Cultural change will be accompanied by significant resistance, and needs to be done selectively by deciding which aspects of culture to keep and which to change.  Much of physician culture (the primacy of patients, personal accountability, etc… is actually to be envied by other professions).

3) Cultural change can’t be done in isolation, and needs to be accompanied by real work in the areas of reporting, strategy, finance and operations.

Davies concludes his superb article with a warning:

Recognizing that cultures do change need not imply that cultures can be changed in a predictable manner by policy or managerial interventions. Indeed, observations in other industries suggests that one of two circumstances must pertain if fundamental change is to be achieved: either the organization must be facing imminent crises leading to possible extinction or there must be considerable organizational slack available.

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9 replies »

  1. Values identification and congruence would be a good start. Cultures don’t change gradually and in my opinion NOT through leadership. They usually jolt to another paradigm from the bottum up when it is painfully obvious that the old entrenched paradigm has failed. We are very close in US Medicine if not already there

    Rick Lippin

  2. Docs are supposed to be agents of the patient. Period. That is the sand box we play in. We are not class action doctors working for the population or the happyness of policy folks or the Congressional Budget Office. We realize there are cost constraints and all kinds of larger needs: social population equity, gender and socio-economic and racial equity concerns. These should be in your sandbox; and ours is inside yours, like a nesting subset in a Venn diagram. We are supposed to butt against these societal boundaries for our patients, fighting to always gain beneficence for our patient. We are not supposed to erode these boundaries by being on your side. It is just like a courtroom in a western society.

    You will understand this when you get desperately sick.

  3. Read your article and agree that trivial payments for jumping through administrative hoops is an insult. It is an even bigger insult when physicians are told that there will be a “holdback” of 5-15% of their pay and that will be used as an incentive if you meet some purely arbitrary administrative measure. So that is definitely a problem.

    The other issue is that many of these metrics are made up as we go along. I have sat in meetings where the metrics seemed like somebody’s bright idea that day – even though nobody thought about how the data would be collected or analyzed or even if it was any good. In one of those meetings I saw such a confusing array of “metrics” and their associated incentives that I asked the big picture question: “Do we know if these metrics make any difference at all in patient mortality?” Dead silence. Everybody was too worried about case managing the metrics and making sure they were checked off in the EHR at the right time.

    These are huge problems. I realize that you want to see everybody get along, but there is no way I can consider anybody a colleague who simply wants physician compliance with unproven measures when I need to apply what I know to patient care and stay up to date. Drucker’s concept of knowledge versus production workers still applies here. As professionals we physicians are at the top of the knowledge worker ladder and yet I know of very few places these days where we don’t get treated like production workers.

    Small incentives for compliance with measures that have nothing to do with medicine is just further evidence of that.


  4. Stopping to make me think on Friday can be dangerous. Interested in your thoughts on role of gender in this cultural divide. I view hospitals (and hospital centered systems) as continuing to ignore the underlying assumption of why patients truly come to hospitals which is for 24/7 nursing care occasionally interrupted by physician care. Since nursing is still predominantly a female occupation, is this is a strong subculture or ignored third dominant culture? FYI I’m an economist and not a nurse.

  5. Great discussion on your blog post- “How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped”

    You’re certainly describing a culture in conflict, where it sounds as though the physician culture is actively suppressed by “corporate” interests. I’ve seen those types of organizations too. I can understand the anger.

    I’d offer that we’ll need to end up with systems that are both patient-centric and also operationally viable.

    I’ve previously written about physician/administrator alignment. Interested in your thoughts:


  6. Bubba- I think you’re right: culture is a loose term. And, like you, I’ve also heard it explained as “the way we do things here”. Davies tries to get to a definition in his article, and describes at least many of the generally agreed variables that describe culture: http://qualitysafety.bmj.com/content/9/2/111.extract

    He admits: “Given the contested nature of organisational culture, it should not be surprising that no consensus exists as to the range and definition of the organisational variables that fall within its purview.”

    What I’m trying to get at is 1) we are likely a little too quick to throw around the word; and 2) many of us make assumptions about the nature of culture in healthcare which may or may not be true. It may not be as changeable as we’d hope. There may be multiple subcultures in play.

    Most important, perhaps, is that much of the work that the system has undertaken to “improve” healthcare is in fact an implicit but generally unspoken attempt to change the “culture” of physicians.

  7. I challenge you to define culture in this context.

    As I understand it, culture is a vague, amorphous term that describes the way things are around here. Generally speaking the term is used by business types (as opposed to sociologists) as part of a stream of self-congratulatory b.s.

    As in: our culture is innovative, aggressive and empathetic.

    What does that mean?

    Give me a hard hitting definition and my mind may be changed.