Peter Drucker noted that "culture eats strategy for breakfast." This remark was popularized by Mark Fields, an executive of Ford Motor Co., who led the company's phenomenal turnaround. Fields reinvented a culture originally noted by bitterness, distrust and fear, and replaced it with one characterized by creativity, innovation and mutual accountability. The changes in culture at this automobile manufacturer are eerily similar to those that need to take place in many health care organizations.


The importance of culture to a health care organization's financial performance and patient outcomes is demonstrated by a study completed nearly five years ago by UHC, the University HealthSystem Consortium of medical hospital teaching institutions. It found that those institutions that had consciously implemented five primary drivers — a stronger shared sense of purpose; a more passionate and engaging leadership style; greater accountability and focus on results; an accountability system for safety, quality and service; and higher levels of collaboration — created health care delivery systems that were far more successful than organizations in which these drivers were less present ("Organizational Factors Associated with High Performance in Quality and Safety in Academic Medical Centers," Mark A. Keroack, M.D., M.P.H., Barbara J. Youngberg, J.D., et. al., Academic Medicine, Vol. 82, No. 12, pp. 1178-1186, December 2007).

No matter how far-reaching the vision or how brilliant the strategy, successful execution rests on a supportive culture. Culture is shaped by the consistent intentions and actions of leaders. It is the CEO's major responsibility to ensure that the culture supports the execution necessary to achieve the organization's vision.

Health Care Culture in Action

Through my work with The Leader's Toolbox and health care organizations over the last 10 years, I have found paradoxical elements of health care organization culture. As individuals, health care professionals are extraordinarily passionate about their work. Physicians, administrators and staff enter the profession because they want to serve the needs of patients. To fulfill that desire, physicians and health care professionals want to:

  • be part of a genuine team;
  • improve the way the work is accomplished;
  • improve outcomes and patient satisfaction;
  • be recognized for the good work they do;
  • work for a stellar organization.

Yet after some time, many of these individuals become cynical, focusing instead on day-to-day survival. Though they almost universally prefer a more collaborative work environment, few believe that the culture of their organization is conducive to effective teamwork. Most of these professionals desire change, but there is great resistance among them to do anything that challenges the status quo.

The competing views in health care organizations are striking. What physicians and other health care professionals say they like about their current environment are:

  • working with smart, capable people who are passionate about the work;
  • producing good outcomes;
  • having the capacity to become far better than we are;
  • having the potential to become far better than our competition.

What do physicians and health care professionals say they don't like about their work cultures?

Fear: Many want to make a contribution; but if they say what they think, there could be retribution.

Overconfidence: All players think they have the correct answer as they struggle to accommodate different points of view on issues that have few easy answers.

Too little time: People are focused on survival; there is little emotional reserve to focus on longer-term improvements even though most people realize they need to be made.

Hierarchy or structure: Decisions are made from the top down, even though many workers are highly educated and experienced and could contribute in more meaningful ways.

Narrow focus: There is a tendency to think in terms of one approach or one answer versus seeing the greater complexity. The organization moves from one flavor of the month to another without full implementation or integration.

Arrogance: Each person continues to think he or she is a top performer, even when the data show something else.

Lack of accountability: The organization touts that it wants to be the best, but there are few consequences for people who don't perform or who inhibit positive teamwork.

Poor information flow: Change requires significant coordination, yet the diverse stakeholders seldom understand the decisions from the top of the organization chart.

Me vs. us attitude: Even though diversity of talent is necessary to address the complex health care delivery and organizational challenges, each person and each department feels misunderstood and vulnerable, seeking to do whatever is best to survive or maximize the current position.

What's a CEO Supposed to Do?

If indeed "culture eats strategy for breakfast," then the work of a health care CEO is to take an honest look at the organization's culture and determine whether it aligns with the strategic intent of the organization. If it doesn't, fixing it becomes far more important than determining payment models, implementing electronic health records, participating in mergers and so forth. The good news is that culture change does not require divine intervention. If Mark Fields successfully realigned the culture at Ford to meet the new market realities, health care CEOs can certainly accomplish a similar feat.

Here are some relatively easy-to-implement steps to improve organizational culture. Many of these suggestions do not cost a nickel to implement and provide a stronger platform for growth and change:

Make meetings relevant. Meetings are the easiest way to implement a culture change. It is here that people learn what is important, what can be discussed and what is forbidden. They will see who makes the decisions and how they are made. Pay careful attention to how meetings are facilitated, and make sure the process aligns with the kind of culture you wish to create.

Focus on the important work. Most people in health care feel overworked. Too often they are focused on problems that may have some short-term consequences but are less critical to the organization's success in the longer term. The CEO must set the broad agenda, encouraging people to tackle the organization's most important issues, and allow people to take lesser issues off their plates.

Let people make a difference. As I noted before, most people chose the health care profession because they want to make a difference. You will build an engaged workforce if your people feel that they are contributing to the organization in a meaningful way. Encourage people to take some risks — to take on projects a little larger than they think they can handle. When people are trying to accomplish work that is new for them, provide them with mentoring and coaching support so they can be successful. At the same time, hold them accountable for results.

Take a third-eye view of your own behavior. Culture is not shaped by plaques on the wall or value statements in a strategic plan. They are created by the actions of the senior leaders. If the senior leaders model open dialogue and dissenting opinions, then this will encourage middle managers to follow suit. If we want others to work across organizational silos, then the CEO must encourage the direct reports to work collaboratively.

Focus on the small stuff. Culture is the combination of the small stuff — a hallway conversation, the determination of who sits next to whom, the way we show appreciation to someone who went the extra mile, how we demonstrate how we care about another person and so forth.

CEO Focus

What strategy should CEOs undertake? Maintain the status quo until the future becomes clear? Develop market superiority by buying and consolidating health care practices? Regardless of the decisions in the court system or the policies passed in Congress, or even the size of the organization, long-term superiority and success require careful attention to a cohesive corporate culture that aligns with strategy. Ford was unable to incorporate more effective operational practices or achieve profitability until it realigned the manner in which it used and encouraged the talents of its employees.

What is the payoff for paying particular attention to culture (the soft stuff)? Ford was the only one of the big three carmakers not to take government bailout money, and it has reported 11 profitable quarters in a row…longer than any other American car manufacturer. It has been rewarded handsomely for focusing on the right stuff.

Ralph Jacobson is the founder of The Leader's Toolbox Inc. in Minneapolis and a faculty member at the Physician Leadership College at the University of St. Thomas in St. Paul, Minn. He is the author of Leading for a Change: How to Master the Five Challenges Faced by Every Leader (2000) and Getting Unstuck: The Power of Paradox (forthcoming 2012). He is a member of Speakers Express.