The great management philosopher Peter Drucker coined the saying “Culture eats strategy for lunch,” and that adage is truer today than ever before. However, because culture is shaped by the attitudes, behaviors, and habits of the people who work in an organization, culture does not change unless and until its people change. In addition, people will not make and sustain positive changes in attitude and behavior unless they perceive a personal benefit.
For years, we have seen headlines about the healthcare “crisis” related to challenges of cost, access, safety, and quality. Many of these problems are largely (or perhaps completely) beyond the direct control of an individual hospital or even a large healthcare system. However, there is another healthcare crisis. This one is on the inside, and it is in our power as healthcare leaders to manage. This “crisis within” is reflected in the frequency with which concepts such as bullying, lateral violence, incivility, passive aggression, disengagement, and other forms of toxic emotional negativity (TEN) show up in the healthcare literature. It is a leadership imperative to create a workplace environment in which such behaviors are not tolerated.
In this issue of Frontiers of Health Services Management, feature article authors Lynne Cunningham and Marie Judd capture the importance of relationship management and communication to improve and sustain a more positive workplace environment to drive better outcomes. In this commentary, I explain why fostering a stronger culture of ownership in healthcare organizations is the solution and then share practical ideas for doing so. I describe communications initiatives at Midland Memorial Hospital (MMH), a 450-bed acute care hospital in West Texas, that have led to positive culture change and enhanced employee engagement. To conclude, I share a call to action.
Prevalence of Workplace Negativity
Gallup and other organizations that study employee engagement consistently find that, on average, only about 34 percent of employees are engaged in their work, while 53 percent are not engaged and 13 percent are aggressively disengaged (Harter 2018). Obviously, there are huge variations among organizations, even in the same industry. The experience of an employee or a customer of one shoe store, for example, could be very different from that of an employee or a customer of another shoe store even though both companies recruit the same types of people to sell the same products to the same customer base. The difference relates to the stores’ cultures and the respective degree of employee engagement or disengagement.
Unfortunately, despite the importance of the healing mission of healthcare organizations as opposed to selling shoes, the problem of disengagement and TEN might be even greater in healthcare than in other industries. This problem is reflected in negative attitudes and counterproductive behaviors.
Gallup chairman and CEO Jim Clifton estimates the cost to the US economy of employee disengagement to be $500 billion per year (Clifton 2011). Healthcare spending accounts for nearly 20 percent of the gross domestic product (Centers for Medicare & Medicaid Services 2018), so a straight extrapolation suggests that employee disengagement costs healthcare organizations close to $100 billion per year. This equates to $5,929 per employee per year, based on an estimated total healthcare employment of nearly 16.9 million people (Kaiser Family Foundation 2018).
Cunningham notes that the negative impact of employee disengagement goes well beyond the financial cost. It also registers in lower patient satisfaction, greater difficulty in recruiting and retaining the best talent, diminished image and reputation in the community, and an increased risk of serious medical errors. Georgetown University professor Christine Porath writes that “people working in an environment characterized by incivility miss information that is right in front of them. They are no longer able to process it as well or as efficiently as they would otherwise.” She cites a survey of more than 4,500 healthcare professionals in which “71 percent tied disruptive behavior, such as abusive, condescending or insulting personal conduct, to medical errors, and 27 percent tied such behavior to patient deaths” (Porath 2015).
Citing a poll of 800 managers and employees in 17 industries, Porath and a colleague reported that after exposure to incivility, a substantial proportion of employees intentionally decreased the amount of time and effort they spent at work. Many reduced their commitment to their organization and to providing great service to customers, and 12 percent left their job because of uncivil treatment (Porath and Pearson 2013).
The most pernicious expression of TEN is bullying and lateral violence, the prevalence of which is reflected in book titles such as Toxic Nursing: Managing Bullying, Bad Attitudes and Total Turmoil (Dellasega and Volpe 2013). A literature review I recently undertook revealed 115 articles published in the past five years with the word “bullying” in the title—and that was in nursing research alone. University of Cincinnati researchers have found that about 60 percent of new registered nurses quit their first job within six months of being bullied, and one in three new graduates considers quitting the nursing profession because of abuse (Townsend 2012). The American Nurses Association (ANA) sees incivility, bullying, and workplace violence as serious issues in nursing (ANA 2015). Incivility “can take the form of rude and discourteous actions, of gossiping and spreading rumors, and of refusing to assist a coworker” (ANA 2015, 2). Bullying includes “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient” (ANA 2015, 3).
Impact of Incivility
The negative impact of incivility in healthcare can be significant and far-reaching; it can affect not only the intended targets but also bystanders, peers, stakeholders, and entire organizations. If left unaddressed, incivility may lead to threatening situations or violence.
At the organizational level, TEN exacts an enormous toll on employee morale, patient satisfaction, productivity, and virtually every other operating parameter. It is a leading contributor to stress and burnout; compassion fatigue; and costly, unwanted turnover.
At the personal level, TEN is manifest in negative self-talk, poor self-image, anxiety, and a fear-based perspective on life. In particular, workplace disengagement is a leading cause of depression and failure to achieve personal and professional goals (Hallowell 2010).
One Hospital’s Response
The following are some of the communication structures and processes put in place at MMH to improve working relationships and the patient experience:
- Weekly CEO message. Each Monday, all employees receive a top-of-mind, one-page message from CEO Russell Meyers, FACHE. He connects the dots between strategic priorities and outcomes with transparency, recognizes staff, and acknowledges challenges to overcome.
- New employee experience. During the first four days of orientation for all new employees, we set the foundation for our culture and make expectations clear. All new employees receive the following foundational training:
- Patient safety training with the Agency for Healthcare Research & Quality’s TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) curriculum.
- Patient experience training with the Baird Group’s Power of One service excellence tools.
- Two days of training centered on the culture of ownership and 12 core action values discussed in the book The Heart of a Nurse Leader: Values-Based Leadership for Healthcare Organizations (Dent and Tye 2018) to connect personal values to the hospital’s core values.
- Huddles. As both Cunningham and Judd mention in their articles, huddles are an effective way to cascade pertinent information to the masses. At MMH, we have the following:
- The daily leadership huddle begins at 8:16 a.m. and lasts no more than 14 minutes (Thrall 2016). The leadership team pledges to turn every complaint into a blessing or a constructive suggestion and to recite the day’s promise from the self-empowerment pledge (Tye and Dent 2016). We follow with service excellence stories and reports of what recently went well. Then we discuss in detail the previous day’s throughput and challenges for the coming day. Patient safety reports, announcements, and recognitions complete the huddle. All information is placed on a one-page PDF and sent to the leadership team and board members.
- All departments and units hold huddles during each shift to share pertinent information from the daily leadership huddle and other information for their respective areas.
- Leadership rounds. Cunningham and Judd discuss the importance of making rounds in the organization. Leaders at MMH block off time for “Sacred 60” rounds each day from 10:00 to 11:00 a.m. to visit employees and patients in their areas of responsibility and areas of influence. They share outcomes using PLATO (proactive leadership attention to outcomes). Leaders ask about and follow up on any patient safety issues.
- Performance check-ins. Leaders meet with their direct reports at least once a month to discuss performance outcomes, recognize contributions, coach, and mentor.
- Recognition. Leaders formally recognize outstanding employees with awards such as the Bravo Award and the DAISY Award for nurses.
- Professional governance. Our professional governance structure is completely interdisciplinary and interprofessional, encompassing nursing, ancillary services, hospitality and support services, and medical staff. As part of a full hospital team, each person has an opportunity to help improve their workplace environment and patient outcomes.
- Social media. Many of our departments have private Facebook pages where members can share information. This information includes announcements, recognitions, and other pertinent posts that employees can see and respond to. Although leaders administer the pages, any member can post information and ask questions.
- Breakfast and brunch. Breakfast with Bob is a monthly informal gathering of a small group of frontline managers (no directors or other executives) from throughout the hospital. With no agenda, attendees freely discuss with me what is going well and what challenges must be overcome. Brunch with Bob is an informal roundtable for frontline employees from around the hospital to discuss successes and challenges. Each of these gatherings builds trusting relationships and open communication.
Culture of Ownership
Over the past several years, MMH has made substantial efforts to move from a culture of accountability to a culture of ownership. In a culture of accountability, people are motivated because their feet are held to the fire. In a culture of ownership, people are motivated to walk across hot coals out of sheer commitment, pride, and loyalty. There are three essential requirements for a culture of ownership (Tye and Dent 2017):
- Be emotionally positive. We must actively remove toxic behaviors from the organization. When a common language to end these behaviors takes hold, the few bad actors will stand out like a sore thumb. Leaders must address these negative influences relentlessly. In the end, the behaviors you tolerate will be the culture you allow. As cultural anthropologist Jean-Jacques Decoster explains, “A culture is a people’s adaptation to an environment” (personal interview, October 6, 2018); as leaders, we must establish positive workplace environments.
- Be self-empowered. Adopt a “proceed until apprehended” environment in which people can do the right thing at the right time to make a difference. Self-empowerment allows for more open and transparent communication between frontline employees and leadership. It allows for policies, procedures, and other strategies to be safely challenged.
- Be fully engaged. Leaders must be highly visible to develop strong relationships with employees based on open and honest communication. Leaders must take time to recognize the contributions of individuals and teams through formal and informal means. In a healthier and more positive workplace environment, the numbers of engaged employees might move beyond the 34 percent measured by Gallup. This is how we can do better with less.
In their feature articles, Cunningham and Judd do outstanding jobs outlining their own evidence-based leadership principles. They reinforce the need for healthcare leaders to develop strong relationships with employees, pay attention to and communicate outcomes, be more inclusive in decision-making, and recognize the impact and contributions that employees make. Their ideas—and those offered in this commentary—can help create and sustain a healthier, more positive workplace environment with improved outcomes.