Viggiano, Thomas R. MD, MEd; Pawlina, Wojciech MD; Lindor, Keith D. MD; Olsen, Kerry D. MD; Cortese, Denis A. MD
The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary. - —William J. Mayo, MD, Rush Medical College Commencement, 1910
Mayo Clinic is a not-for-profit academic health center with integrated, comprehensive medical campuses in Rochester, Minnesota; Jacksonville, Florida; and Scottsdale, Arizona. The institution is distinctive in that it is a major academic medical center with a medical school that is not university based. Mayo Clinic evolved from a family practice of medicine established in the late 1800s by Dr. William W. Mayo and his two sons, Drs. Charles H. Mayo and William J. Mayo. This family practice grew into our nation's first integrated, multispecialty group practice and was renowned for quality medical care.
Mayo's Core Value and Institutional Culture
In 1910, Dr. William J. Mayo publicly articulated the guiding principle of the practice: “the needs of the patient come first.”1 This principle, the primacy of each patient's welfare, endures as the primary core value of the institution's culture and as the core element of a professionalism covenant between Mayo's personnel and patients.
Mayo Clinic leaders employ a systematic, “top-down” approach to emphasize that the institution accomplishes its mission by what Dr. William J. Mayo referred to as the union of forces. The institution's current mission statement, “Mayo Clinic will provide the best care to every patient, every day through integrated practice, education, and research,” summarizes our operational strategy to serve our core value. Union of forces acknowledges that advances in medical knowledge through scientific discovery must be translated with timeliness to improve clinical care and to enhance the continuous professional development and training of health care professionals. Union of forces also means teamwork, and Mayo Clinic personnel work collaboratively in teams within and across all departments to meet the physical, emotional, psychological, and spiritual needs of patients.2 All Mayo personnel are expected to contribute to a learning organization environment that is committed to providing the best outcomes, service, and value in the delivery of health care.3,4 This article briefly describes how Mayo's value-based culture of service inspires and enables Mayo personnel to demonstrate a profound commitment to professionalism in medical practice, education, and research.
Mayo Clinic Model of Care
Mayo Clinic leadership has responded to external changes in the health care environment by preserving its core-value-based model of patient service. In recent years, all academic health centers have been challenged by economic pressures, increased concerns about the safety and quality of clinical care, and the competency and professionalism of health care providers.3–7 Ten years ago, Mayo Clinic's Clinical Practice Committee became concerned that external policy changes aimed at short-term financial gains would be accompanied by long-term detrimental effects to the provider–patient relationship. To respond to the increasing time constraints placed on the provider–patient relationship, Mayo appointed a multidisciplinary, interprofessional workgroup to analyze and define the elements of an ideal patient care experience. The workgroup reviewed patient feedback and historical information, administered an electronic survey of staff, and conducted interviews with patients, physicians, allied health staff, administrators, residents, and students. The workgroup identified 20 core elements of an ideal patient visit and then conducted a survey of staff to rank-order the elements. All 20 elements were organized, and the workgroup produced a written document, the Mayo Clinic Model of Care, which publicly articulates Mayo Clinic's professionalism covenant with patients and explicitly describes the care experience patients should expect.8 The Mayo Clinic Model of Care reiterates the primacy of the patient's needs and welfare and defines elements of the provider–patient relationship and the institution's culture (List 1). The Model of Care publication is both a product of the institution's heritage and an attempt to preserve its culture by making explicit the key elements of a unique model of care. Mayo Clinic leadership and staff are committed to preserving the elements of this unique model of care when responding to external forces that affect health care policy.
Addressing External Challenges: Preserving Mayo's Culture
As Mayo's culture is integral to our effectiveness in serving our practice, education, and research missions, a consistent leadership strategy has been to preserve and enhance our core-value-based culture and model of care. We will discuss some of the actions that Mayo Clinic has initiated to preserve our culture and honor our professionalism covenant, while at the same time adapting our operational strategies to confront the challenging realities that all academic health centers face. This strategy is grounded in our belief that the greatness of a health center is measured in effective service to patients and society, and in current leadership research that maintains that an organization's greatness is achieved by preserving core values, adapting operational strategies, and remaining optimistic for a successful outcome.9 There are four key recent operational initiatives developed to preserve and support the Mayo model of care: the service essentials program, quality innovations programs, aligning individual and institutional values, and professional development.
Service essentials program
In 2001, leading academic service researchers conducted a study of patient care at Mayo Clinic.2 During a five-month period, more than 1,000 patients, physicians, nurses, allied health professionals, and administrators were interviewed at campuses in Rochester, Minnesota, and Scottsdale, Arizona. The investigators also collected data as participant observers by observing more than 250 physician–patient interactions, observing surgical operations, checking into the hospital as patients, making hospital rounds, and even flying on the emergency rescue helicopter. The results of the study were discussed with all employees to identify opportunities to improve service. This study identified attributes that patients desire in the ideal physician,10 and the results of this study informed the development of the service essentials program, PLEASE CARE.
To address patient concerns about the quality and value of care, and to support the Mayo Clinic Model of Care, institutional leaders established the PLEASE CARE service essentials program in 2006. This program is based on the belief that a patient's service experience significantly influences their determination of quality and value in their health care. The acronym PLEASE CARE describes the attitudes and behaviors that Mayo staff should exhibit to help patients have the ideal patient care experience (List 2). The standards and behaviors of service excellence are communicated to all work areas by supervisors, and ongoing improvement programs and training resources are provided. These include Web-based modules, multimedia presentations, and classes to educate employees about listening, empathy, emotional intelligence, and caring. Employees are encouraged to share stories and effective practices, and to create posters for display in work areas. There are tool kits for supervisors to reinforce these behaviors and to recognize and reward employees. This program is designed to sustain employee awareness that each interaction with a patient is an opportunity to meet their needs. The aim of this initiative is to inculcate mindfulness that when you are interacting with a patient, you are the Mayo Clinic. Mayo's service essentials program is a patient-centered, employee-driven strategy to preserve Mayo Clinic's culture and to help all personnel anticipate and meet the patient's needs. One of those needs is the expectation of quality care.
Quality innovations programs
Mayo Clinic has strategically responded to the public's concern about quality, safety, and value in health care, all important elements of contemporary professionalism. The Clinical Practice Quality Oversight Committee was created in 2002 to provide direction and oversight to all patient care improvement activities. The committee created the Quality Innovation Program, which funds time for staff to develop, implement, and evaluate practice improvement projects aligned with institutional quality efforts. For example, one project created a Web-based tool to collect care process metrics across 17 Mayo-affiliated hospitals for patients with acute myocardial infarction. This tool analyzes and correlates process metrics with clinical outcomes and provides site-specific data to improve care processes and disseminate practice innovations. The following year, a Quality Management Services Department was created by consolidating several existing groups that were engaged in safety, quality, and accreditation readiness initiatives. Quality Management Services is a multidisciplinary department of professionals that provides training and consultation services and maintains a Web site with tools and resources for improvement projects. Within the past two years, this department implemented the Quality Academy, which trains individuals, teams, and future leaders to employ the principles and methods of quality improvement in their daily work. Mayo Clinic's residency programs have also implemented core training in systems-based practice and practice-based learning and improvement, and all of Mayo's quality resources are available to residents, medical students, and other health professions students in all educational programs.
This year, Mayo Clinic leaders launched a Creating the Future strategic plan to enhance the institution's capability to meet the needs of each patient. This initiative will connect people, ideas, and processes so that knowledge, resources, and best practices will be shared across departments. The goal of this strategy is to find and disseminate innovative ways to meet the needs of each patient and, by doing so, improve the outcomes, service, and value of health care. This strategic plan is based on the construct of civic professionalism.11 In communications that provide information on this initiative, it is stated that “every Mayo Clinic employee has a role to play in improving the service, quality and value of our care.” Thus, the values of each individual and the institution must be aligned.
Aligning individual and institutional values
Mayo Clinic systematically engages in personnel management practices to support the model of care. Recruitment and hiring practices assess the alignment of an individual's values with the institution's values.2 Mayo has programs for orientation, training, and development that acculturate and assimilate new employees. There are policies, advisory committees, ongoing programs, and regular assessments of all personnel, including patient surveys, 360-degree evaluations in work units, and performance reviews to provide feedback to staff on integrity, communication skills, patient service orientation, teamwork, and commitment to learning and improvement. There are ongoing celebrations of Mayo Clinic's heritage and culture with newsletters including appreciative comments from patients, historical presentations and displays, social events, an annual quality conference, and an annual heritage week.2 There are numerous awards for employees that recognize achievement in caring, teamwork, service, excellence, and leadership. The consistent focus of these administrative practices and traditions is professionalism: all employees are confidently expected to subordinate self-interests and to work together to place the needs of the patient first. Accordingly, the institution has implemented programs to meet its responsibilities for the professional and leadership development of staff.
In 2001, Mayo Clinic implemented a comprehensive, multilevel career and leadership development program for physicians and scientists.12 The aims of this program are to meet the evolving needs of the institution in the ever changing health care environment, and to meet the changing developmental needs of individuals throughout their careers. The curriculum is designed to enhance skills that serve patients and develop future leaders. Early career development efforts include orientation and acculturation to the institution, and enhancement of personal and team effectiveness. Early leadership development programs enhance skills in developing people, leading organizational change, and managing finances to achieve the mission. Experienced leaders learn methods to achieve the best outcomes for patients, and strategies to enhance quality, safety, service, and value, in the institution's health care delivery processes. Senior leadership development offerings enhance skills in aligning and motivating people, decision making, strategic planning, and execution of strategy. These programs are available to administrators and other health professionals, and there are numerous other career and leadership development offerings for all health professionals.
Mayo Clinic Model of Education
Mayo Clinic is an independent, degree-granting institution that administers educational programs through five Mayo Clinic College of Medicine schools: Mayo Medical School (undergraduate), Mayo School of Graduate Medical Education (residencies and fellowships), Mayo Graduate School (PhD and master of science), Mayo School of Health Sciences (32 programs including physical therapy, nurse anesthesia, and others), and Mayo School of Continuing Medical Education. Mayo Clinic's educational mission is “to provide the best biomedical education to enhance patient care and advance medical science.”
During the past two decades, there has been much concern about professionalism in medical practice and education. There has been a significant increase in the number of publications on the topic of professionalism in medicine, and numerous professional societies have conducted discussions about professionalism that have often focused on the struggle of health care professionals to stay centered on their values.7
Stimulated by the national dialogue on professionalism, Mayo Clinic convened a retreat in 2001, where all Mayo education programs examined the national concerns about professionalism, reviewed the Mayo Clinic Model of Care document, and created the Mayo Clinic Model of Education. This education document articulates our professionalism covenant with patients and with learners in all our educational programs.13 The initial draft was reviewed with leaders, staff, and learners to ensure that input from key stakeholders was included. This document describes the commitment that learners should expect from all educators, with acknowledgement that Mayo Clinic's commitment to learners is second only to its commitment to patients. The essence of the covenant with learners is that Mayo Clinic educators will exhibit the highest standard of personal and professional conduct and confidently expect the same from their learners. Specifically, the learner covenant stipulates that educators will
* convey the primacy of patient welfare in the practice of medicine and research,
* provide an environment enriched by scholarship,
* manifest concern for every learner's success,
* respect learners as colleagues,
* set high standards for personal and professional conduct, and
* expect the same high standards of personal and professional conduct from learners.
Mayo Clinic expects learners and teachers to demonstrate all of the attributes and behaviors of professionalism. Students and faculty use anonymous online surveys to assess each other for integrity, effective communication, team effectiveness, commitment to service, commitment to learning and improvement, humanism, and leadership, and there are programs for peer- and self-assessment for learners. Educators mentor new teachers and learners to preserve and enhance a culture that values patient welfare foremost in an environment enriched by research and teaching. It is understood that the institution expects the highest standard of professional conduct from all personnel. However, it is also understood that the primary attribute of professionalism is placing the needs and welfare of the patient above all other considerations. At Mayo Clinic, professionalism means living this core value. The institution's value-based culture of service facilitates the coherent integration of professionalism into the daily activities of all employees and learners. Mayo's culture has always had a powerful influence on the formation of future health care professionals and scientists, and it is a most positive hidden curriculum14 to facilitate the accomplishment of the desired outcomes of our educational programs.
Mayo Clinic's culture of caring, service, teamwork, and excellence empowers all staff to voluntarily do what is necessary to help patients and colleagues. The profound allegiance of Mayo Clinic personnel to its patient-centered core value connects all to the purpose and meaning of their work, elicits collaboration and extra discretionary efforts, and fosters an environment that is committed to excellence and continuous improvement. Mayo Clinic personnel appreciate being allowed to practice medicine as they believe it should be practiced.2 In a staff satisfaction survey conducted by an external consulting firm in 2006, 96% of physicians and 94% of nurses responded that they were “proud to work at Mayo Clinic,” and 97% of physicians and 94% of nurses “would refer relatives and friends for medical care.” Mayo Clinic does not have written employment contracts, yet Mayo's attrition rate for physicians is 2.4%, which is below the national average of 6.7% for academic physicians. Mayo Clinic's attrition rate for nurses is 4.0% compared with a national average of approximately 20%.2 The loyalty of Mayo Clinic personnel is reflected in high staff satisfaction measures and low attrition rates.
There is evidence that Mayo Clinic's value-based culture is enduring. The culture which originated more than 100 years ago in Rochester, Minnesota, has been successfully replicated in Mayo Clinic's academic health centers in Florida and Arizona. The strategy for replicating the culture at both of these newer campuses was to build the core values into every aspect of the institutions' development.15 There are also more than 18,000 physicians and scientists who have trained at Mayo Clinic and who remain connected to the institution as members of the Mayo Alumni Association. These alumni have incorporated Mayo Clinic's core value into their professional activities, and many serve leadership responsibilities in universities and communities throughout the world.
According to Schein,16 the essence of culture consists of basic assumptions or unconscious, taken-for-granted beliefs that guide thought and behavior and that and serve as the ultimate source of group values. Argyris and Schön17 refer to these implicit basic assumptions as theories in use that define perceptions and reality and determine the actions that individuals take in various situations. Christensen and Overdorf's18 research maintains that an organization's capability to respond to change is determined by it ability to align three factors: resources, activities, and values. The diligent emphasis on a primary, patient-centered core value establishes a focal point that enables Mayo Clinic personnel to collaboratively align their behaviors, work activities, and resources to accomplish the institution's mission despite continuous change in the health care environment. The constant focus of Mayo Clinic's culture on patient welfare provides all personnel with both a moral compass to guide thought, actions, and reflective practice, and a yardstick to measure their success.
A covenant is a formal agreement between two or more parties to do or not do something specified.19 In Mayo Clinic's culture, professionalism is regarded as a covenant with patients that every employee is expected to honor day in and day out—every patient, every day. Perhaps this covenant was best explained to people who were not familiar with Mayo Clinic at the opening convocation of Mayo Medical School in 1972. The school's founding dean, Dr. Raymond Pruitt, summarized Mayo Clinic's professionalism covenant for the incoming students. He used these words to describe the agreement between provider and patient that the students were entering: “Together, they cherished an imperative for the humane in an age made rich by technology and science. And this was the covenant of their ordination; that with the eyes of compassion they assessed the brilliance of their technologies, and with the yardstick of the humane they measured the benefactions of their science.”20
The authors extend their appreciation to Linda L. Blank, Robert G. Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC), for her assistance in the development of this manuscript. This work was presented at the 2006 AAMC Annual Meeting as part of the Robert G. Petersdorf Scholar Project: Perusing Professionalism and Creating Value: What Roles Do Leadership, Institutional Culture, and Environment Play?