“Culture: from the Latin cultus, which means care …”
— Daniel Coyle, The Culture Code: The Secrets of Highly Successful Groups, Bantam Books: A Random House Imprint, 2018
W.J. Mayo stated, “The health of the nation is its greatest asset.”1 However, the U.S. healthcare industry faces significant challenges — an aging population, reimbursement obstacles, legislative and regulatory uncertainty, staffing shortages, staff burnout, cybersecurity threats — all of which test the viability of this most precious resource. Crises such as the COVID-19 pandemic exacerbate these challenges.
Those who provide healthcare to the population have several levers to pull to improve organizational performance, normally covered in healthcare-oriented graduate program curricula. Another resource is professional associations such as MGMA and ACHE, which define competencies needed for effective leadership.
One influence often quoted but difficult to understand and manage is the shaping of an organization’s culture. Understanding culture enables one to work synergistically, rather than in conflict, and has implications for leadership. At Mayo Clinic, the legacy of Dr. William Worrall Mayo that began when he established a practice in 1864 in Rochester, Minn., is perpetuated by this concept of culture.
What is culture?
A search of academic databases and literature reveals that culture is a broad, complex, multifaceted and hard-to-define concept, which includes interpretations of culture as:
- That which can be articulated in terms of positive values2
- Embracing attitudes, values and norms which underpin activities3
- Tacitly understood rules guiding employees on what to do4
- Hard thing to measure and is subjective5
- In essence, the human glue that makes the company/organization unique6
- What is shared by employees with each other7
- How attitudes are toward change and about people8
- Defined by actions on the ground or the way we do things around here, is the residue of the past representing the emotional and psychological climate and is the way of living9
- As a reflection of the habits it develops10
- The accumulated, shared learning of a group11
- A pattern of assumptions12
- Taking on a life of its own13
- Reflects the importance of rituals, myths, stories and legends, the interpretation of events14
- The experience of the organization from an internal viewpoint in contrast to the brand, the external viewpoint15
- As like climate or the weather16
- How everyone makes sense of events17,18
Includes the assumptions, values, norms, patterns of behavior, symbols, rituals, artifacts, rites and rewards.19
Figure 1 captures culture’s shared themes and language, as referenced in many of the research materials used for this article. Culture’s themes and language profoundly influence the decisions made by an institution and its staff and inform how they work and achieve their overall mission. They also influence the engagement and joy of those within and new to organizational life.
To Peter Northouse,20 “leadership is a process whereby an individual influences a group of individuals to achieve a common goal.” Leaders play an indispensable role in shaping the culture through values, in adoption and in action. Culture is essential in defining and transforming interactions, processes and outcomes. Thus, understanding and appreciating the behavioral implications of leadership actions on culture are instrumental in shaping the future. Culture is not static and continues to evolve over years and decades while the foundational values remain intact.
Mayo Clinic culture
Organizational values define what is important, shape the principles of behavior, guide leaders in making decisions and represent the organizational ideals. Taken together, values help crystallize the “true North.”21
Mayo Clinic leads with the needs of the patient — “What is best for the patient?” — while eight other values complement that primary value. This defining concept creates a culture of “boundarylessness,” which “opens up the organization, removing walls to enable talent and knowledge to converge where needed,” write Leonard L. Berry, PhD, and Kent D. Seltman, PhD, in “The Enduring Culture of Mayo Clinic.”22
Mayo Clinic appreciates the importance of values and behaviors — our values in action — and the relationship toward a cultural understanding for effective leadership. It has a deep orientation for those new to the organization by an intentional attention on the following:
- Mayo Clinic’s values lead with a primary value, “The needs of the patient come first,” which is supported by eight additional values, condensed to “RICH TIES”: respect, integrity, compassion, healing, teamwork, innovation, excellence and stewardship.
- The values are supported by Mayo Clinic’s history,23 which is celebrated annually with Heritage Days, and inform the institution we are today and aspire to be in the future.
- The Values Council leads the efforts to reinforce how these values — the institution’s DNA — are directly relevant to our activities in practice, education, and research; how these values look when they are put into action, every day; and how the values can truly serve as an accelerant to achieve our strategic plan in the future. The council’s core activities include:
- Providing an education toolkit to supervisors, department chairs and others that offers many opportunities to start discussions regarding the values and values in action.
- Supporting values research projects with one or more hypotheses and aims based on the values.
- Conducting values reviews and facilitating values discussions with departments and other work units.
- Presenting the values recognition award to staff who demonstrate the values at the highest level, over the long term.
- Recognizing the importance of the partnership with the Franciscan sisters in Mayo Clinic history by perpetuating the Franciscan legacy at Mayo Clinic Hospital — Rochester, Saint Marys Campus, and across all of Mayo Clinic.
- Five frameworks in continuous use reinforce and manifest the values in action:
- The Model of Care includes attributes of collegial, cooperative teamwork and integration; an unhurried, comprehensive examination; partnership with referring physicians; access to the most advanced diagnostic and therapeutic technology; an academic, scholarly environment supporting research and education in a physician-led environment.
- The Model of Professionalism supports the definition of professionalism at Mayo Clinic — “putting our values into action” — and is a commitment to the patient partnership and delivery of compassionate care, supported by evidence-based medicine, teamwork supported by mutual respect and trust, the prudent use of resources, focus on the highest levels of integrity and excellence, lifelong learning, accountability, and work-life balance.
- The Model of Safety promotes attention to detail, clear communication, a questioning and receptive attitude, effective handoff and support, and the collective engendering of trust in a fair and just culture.
- The Strategic Plan to cure, connect and transform healthcare is a framework for a deep understanding of how investing in people and process improvement lead to outcomes of the highest-value care and mission advancing financial performance. It recognizes that technology will create new opportunities but will not replace the human touch.
- The Leadership Capabilities are inspiring values, engaging colleagues, thinking boldly forward, driving results, demonstrating courage for new approaches, leading with perseverance and a sense of urgency, and earning unwavering credibility.
- A commitment to diversity, equity and inclusion (DEI) plays a role in shaping Mayo Clinic culture. Led by the Office of Equity, Inclusion and Diversity, as well as by the complementary groups within the organization, these efforts include education and awareness, research, and policy and program development. DEI are woven into Mayo’s fabric, with supporting committees in departments and divisions to expand their reach. Individuals throughout the organization also support and participate in these undertakings. Through these combined efforts, Mayo strives toward its goal of continued improvements and demonstrated leadership in health equity; staff, patient and visitor engagement; and the enhancement of a welcoming environment for people of all backgrounds, cultures and experiences.
Reinforcing culture as leaders
As leaders consider strategies to implement, they must be mindful that their actions should reinforce the desired culture and aligned values to reach the organizational vision. These actions can be framed around:
- Evaluating and optimizing leadership strategies to lead through learning, lead others through developing relationships, lead organizations by achieving excellence with a focus on work-life integration and synergy (Figure 2), an integrated leadership approach. Each identified strategy, using the succession and talent management toolboxes and functions,25 may be considered for future development opportunities [onboarding, DEI practices, self-assessments, 360-degree feedback, leadership development plans, performance management, coaching, mentoring, stretch assignments, etc.].
- Modeling actions that reinforce the organization’s explicitly desired attributes during all potential interactions, from the hiring process through daily team huddles; communications; formal and informal meetings; training and development; process and quality improvement initiatives; the budgeting process; employee evaluations; strategic planning retreats; staff engagement/satisfaction assessments; well-being and resiliency programs; DEI initiatives; intentional mission and values assessments; operating policies and procedures; work milestones and celebrations; and intentional leadership development regarding culture reinforcement.
Culture represents the underpinnings that shape:
- Who we are: understood consciously and unconsciously as normal, intangible and unspoken; accumulated through generations that results in the expression of our history and shapes our reality.
- How we relate: as an expression of our values and language, the symbols, the look and feel, the social glue and the organizational immune system.
The future of all organizations depends on a manifestation of culture as operationalized by intentional, reinforced behaviors. It is vital to nurture and have a strong, positive culture as a foundation, especially during crises such as a pandemic. As such, the unique organizational frameworks are the ultimate strategic assets.26
Culture must be understood by leaders as a differentiator that enhances successful transformation and will define the future. These strategies rest on a foundation that can be collectively defined as the culture. Tending to these frameworks described above always has been part of the Mayo Clinic heritage, a learning culture with leader as learner and teacher.
Acknowledgments: The authors appreciate the detailed review of the manuscript by and input of Robert D. Brown Jr., MD, and Linda K. Matti, MSN, director and administrator of the Mayo Program in Professionalism and Values. We also acknowledge our colleagues at Mayo Clinic for providing inspiration for this article and the assistance of Ethan Grove in editing the manuscript.
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