Every hospital and health system has a history. Each underwent significant developments that occurred at critical junctures extending back to the organization’s beginning. Taken together, these developments lead to an array of institutional distinctions including core capabilities and points of differentiation. It is also out of that history that the values that constitute organizational culture emerge. Yet many, perhaps most, health care organizations remain ahistorical — they ignore a strategic asset of considerable importance.
In May 2011, an EF5-strength tornado ripped through Joplin, Mo. At St. John’s Regional Medical Center, the twister brought 45 seconds of destruction and loss. St. John’s staff and the community affirmed everything that makes humanity a wonder: Nurses spread their bodies over vulnerable patients to protect them from wind-driven debris. A surgeon completed a hip repair with a flashlight as the building came apart around him. In the entrance to the emergency department, a floor tech grabbed a man being catapulted through the air and shielded him from the onslaught.
All of this took place in a thunderous shower of glass shards, building parts and equipment. The hospital went dark and began to smell of broken gas lines. Nurses, techs and visitors navigated the blackened interior by the light of their cellphones. According to Eric Adler and Laura Bauer, reporters from The Kansas City Star, they comprised a phalanx that moved patients and the injured “on backboards, in wheelchairs and wooden chairs, in sheets on sagging mattresses ... over debris, and down two, seven, nine flights of stairs.”
Outside, hundreds of volunteers were inbound in an armada of cars and pickups. They dodged downed trees and power lines to converge on St. John’s and help with the evacuation. Meanwhile, a vivid demonstration of the vital role of a hospital in a crisis emerged as the community’s injured struggled toward the hope they placed in St. John’s. Also on the move were 135 physicians who soon poured into the destroyed hospital – 110 from neighboring Freeman Health System.
In 2005, Hurricane Katrina devastated most of New Orleans’ hospital capacity. Jeff Myers, M.D., chief of pediatric cardiothoracic surgery at Tulane Medical Center, witnessed the kind of teamwork that deserves to be chronicled and retold forever. When staff at Tulane realized that a 15‑year‑old boy on a heart assistance device had just 25 minutes of battery power left, they siphoned the gas out of cars in the medical center’s parking deck to run a generator that kept the device running.
The device weighed about 300 pounds and had to be maneuvered downstairs through the hospital and onto the roof of the parking garage. A nurse hand-pumped the boy’s heart until he could be hooked back up to the device in a rescue helicopter. It was HCA that linked together a network of ham radio operators who guided the fleet of rescue helicopters over a city without power. In the end, those copters helped safely evacuate 1,200 patients from Tulane.
The Joplin tornado and Hurricane Katrina are examples of extreme history. There are an abundance of stories of individual and collective heroism at St. John’s and Tulane. In these stories are embedded values worth illuminating and celebrating as well as strategic lessons worth preserving. History in extremis tends to reveal the character of an organization. Like pounding storm surf, it washes away the sand and reveals the rocks. Not all of history’s important events involve extreme circumstances, of course. Many arise in relatively tame but invariably extraordinary conditions.
Enduring organizations tend to demonstrate their best virtues when challenged. Abundance can dull an organization. Scarcity, on the other hand, can force the emergence of values worth perpetuating, including tenacity, teamwork and persistence.
Ask someone at Johns Hopkins Medicine about its shared values and it’s likely he or she will mention “entrepreneurial discovery.” Early in Hopkins’ history, philanthropic endowments were relatively low. As a result, physicians and researchers had to do more with less. This scarcity forced them to be more creative and more focused on their work than on facilities and amenities. They were much like entrepreneurs who begin in a garage.
After they were recruited from Vanderbilt in 1941, surgeon Alfred Blalock and his gifted assistant, Vivien Thomas, found that their lab at Hopkins left much to be desired. But Thomas and Blalock got the small lab cleaned up and, working with pediatric cardiologist Helen Taussig, delivered a fix for the world’s blue babies. They made history with what they had.
History is replete with fortuitous accidents converted to disciplined success. In 1958, Mason Sones, a Cleveland Clinic cardiologist, inadvertently injected contrast dye into the right coronary artery of a patient. The patient’s heart flatlined. Sones got it restarted. But he also got the first real-time image of arteries in action and the idea that would lead him to develop the coronary angiogram.
The tip of the catheter that injected the dye was only millimeters off target. But as Brie Zeltner wrote in The Plain Dealer, “Those fateful millimeters would also propel a local hospital and its surgeons into the national spotlight, paving the way for an explosion of patient referrals from across the country and the world, relentless growth and an international reputation for the diagnosis and treatment of heart disease.”
Sones and other physicians at Cleveland Clinic were regarded by the cardiology establishment as mavericks. They faced withering skepticism and criticism. Until it became clear that the clinic’s methods were too clearly effective to deny, it had to endure being labeled as a home to quacks. In retrospect, that accusation provided Cleveland Clinic a strong historical incentive to embrace the innovation that often comes with being a maverick.
But when an explosion destroyed the Cleveland Clinic in 1929 and killed 123 patients and staff, including two of the clinic’s founders, scarcity took on a new meaning. This was reinforced when within weeks banks in Cleveland and around the nation began to fail. It would have been understandable if the clinic’s leaders had surrendered to overwhelming misfortune. Instead, they cashed in their personal insurance policies and mortgaged their homes. Then they began reconstruction of the clinic and added three floors.
By 1980, East Cleveland was characterized as America’s most impoverished urban community, the Cuyahoga River had caught fire, and the city of Cleveland had become the butt of jokes, including the frequent request that the last person to leave Cleveland “turn out the lights.” Cleveland Clinic didn’t leave. Instead, it served as a key catalyst for Cleveland’s renewal by investing in new buildings, pioneering the placement of ambulatory centers in the suburbs, acquiring community hospitals and luring luxury hotels to its campus. It demonstrated a dogged persistence.
Remembering the low points
To be meaningful, history needs to be honest. It’s not all heroes and high points. If history is to serve as a call to our better angels, there needs to be a pragmatic acknowledgement of the alternatives.
Katrina juxtaposed the good and the bad. While Herculean efforts evacuated the vulnerable, shooters throughout New Orleans targeted rescuers, including the helicopters trying to evacuate pediatric patients from Tulane. Tulane security officers struggled to keep looters out of the hospital, and a Marine sharpshooter who roped down to Tulane’s rooftop did his best to dissuade those shooting at helicopters by putting his laser-targeting dot on their foreheads. Eventually, the hospital could no longer be secured. Four hundred patients and staff were forced to move to the parking garage, where they slept and waited.
According to the Pulitzer Prize–winning historian Gordon Wood, “Historical knowledge takes people off a roller coaster of illusions and disillusions; it levels off emotions and gives people a perspective on what is possible and, more often, what is not possible.” Honest history not only showcases behavior worth embracing, it also identifies vulnerabilities in need of attention.
After the tornado, St. John’s (now Mercy Hospital) went to work on its lessons. One conclusion was that engineering and construction of the hospital facilities needed to be significantly upgraded to meet the possibility, however remote, of another EF5 tornado. The old hospital was torn down and a new one built. It was a costly but, in retrospect, necessary move. Less costly was the creation of “emergency grab bags” that included, among other things, a flashlight.
Rise and fall
Looking for historical analogies and metaphors outside health care can provide powerful insights.
Before Sam Walton and Jeff Bezos there were Richard Warren Sears and his partner, Alvah Curtis Roebuck. They got their start in 1886 by selling affordable, gold-filled pocket watches to farmers and other passengers at a train station in Minnesota. A new partner, Julius Rosenwald, brought discipline and strategy to what would become Sears, Roebuck and Co.
By 1960, Sears was, in the words of Donald Katz in The Big Store, "a superpower, as invincible a business as the nation it served.” It was also described by the press as “the colossus of American retailing” and the “monster of the Midway.” One in five Americans shopped at Sears with regularity.
Sears’ sales volume was bigger than the entire tobacco and furniture industries combined. It dwarfed the entertainment and lodging industries. Elevator operators at Sears retired with several hundred thousand dollars in the company’s stock gained through its profit-sharing program. It is impossible to overstate the influence of Sears on the American landscape during its heyday. According Katz, Sears “became a part of the background noise of everyday life.”
In retrospect, it is possible to discern the early foundations of the Sears phenomenon. It brought a nearly unimaginable breadth of goods to people who had never before had easy access to them, particularly rural Americans. It accomplished this through the use of a new government program, Rural Free Delivery, that brought mail, including the Sears catalog, along the country’s expanding network of roads. Sears also brought a high level of comfort in buying products sight unseen by prescribing the quality standards for those products and describing them in detail in its catalog.
Small-town retailers hated Sears and did everything they could to slow its expansion. When its rural customers moved to the city and their children moved to the suburbs, Sears followed them. Suburban shopping malls were built around anchor stores, one of which was invariably a Sears.
To those familiar with the emergence, growth and seeming invincibility of Wal-Mart and Amazon, Sears’ story should ring some bells. Recent news stories have heralded what would appear to be the death knell for the "colossus of American retailing” with widespread predictions that the company will declare bankruptcy by the end of 2017. The broad lessons? Everything that goes up will eventually come down. And there are patterns of success that persist.
Organizations that last certainly must share some characteristics that have made them durable. A historical view of America’s most durable organizations, those that have been around for a century or more, reveals some similarities.
For example, General Electric, Johnson & Johnson and Procter & Gamble all operate a relatively diverse portfolio of enterprises unified by a consistent set of non-negotiable operating principles. Leaders of the various enterprises are afforded the freedom to meet the unique competitive challenges of their sector while adhering to tight alignment with overarching operating principles — there is a “GE way,” a “J&J way” and a “P&G way.” These durable organizations are simultaneously loose and tight, flexible and resolved.
At the heart of history are two central questions: What happened? and Why? For example, since 1790, New York has remained America’s largest city. Charleston, S.C., on the other hand, was among the six largest all the way through the 1830s. By 1840, it had dropped to the 10th largest and thereafter disappeared from the list of America’s biggest cities. So, what happened and why? Trade winds had favored Charleston as a seaport. Then the steamship made trade winds irrelevant; from then on, ships were able to head directly to northern ports, including New York.
In the early 1800s, Charlestonians were among the richest individuals on the planet but eschewed industrialization and contemporary business practices. Then, of course, the Civil War devastated Charleston. New York, on the other hand, has long made business its primary preoccupation, and this included trading with both the Union and the Confederacy. The Civil War fueled its growth.
Celebrating past accomplishments
Confidence doesn’t arise in an organization overnight. It has to be built from past success. And for that to occur, past successes need to be recognized and understood. When organizations face seemingly overwhelming obstacles, history can provide the rationale for optimism by demonstrating that formidable challenges have been overcome in the past and can be overcome in the future. Like confidence, the basis for organizational pride must be authentic.
Constructive organizational swagger derives from past accomplishments worth being proud of. History reveals that, although individuals can have a disproportionate impact, collective effort needs to be recognized. Unless success is democratized, organizations can slip into waiting for a knight on a white horse to ride in when it is group effort that is needed to save the day.
Without history, collective memory and learning are sacrificed. The important is extinguished by the daily press of the urgent. Most historians and anthropologists assert that the very ascendancy of humanity was made possible by the ability to act collectively, but a collective that doesn’t retain what it learns loses its advantage. Authentic lessons of the past are the stuff out of which “learning organizations” are made.
Rather than invent a list of organizational values at a retreat, it’s much better to discover (or rediscover) them by looking back for examples of values worth emulating. Out of those examples, stories can be crafted so leaders can say with credibility, “This is what we have stood for in the past and what we should stand for in the future.”
To the extent history underpins, validates and reinforces the values that compose organizational culture, it can also demonstrate fulfillment of mission and vision. It can illustrate those instances when the organization, operating in a world of scarce resources, made decisions that kept it focused on its purpose and set aside commitments that would have been outside the boundaries of its mission.
Vision, too, can be reinforced by history because the future conveyed in the vision ought to represent a logical and credible extension of the past and the present: “Here’s where we were. Here’s where we are. And here’s where we’re headed.” Strategies to achieve the vision then build on past initiatives so there is continuity of effort. While abrupt shifts in strategy may be necessary in a true crisis, in many instances they cause organizational whiplash and confusion.
History provides lessons about what to be. It also provides lessons about what to do (as well as what not to do). Strategies and tactics that worked in the past have a good chance of working in the future because they have the benefit of having generated shared experience and competency. Persistently and clearly explaining what’s worked in the past makes that knowledge relevant and accessible to those engaged in the daily work of the organization. Absent development of such a collective memory, organizations too readily succumb to an ailment described as FWMTF (forgot what made them famous).
Experience and infrastructure are built over time. In other words, they are products of the past. Understanding and articulating organizational history is essential to being constructively opportunistic.
Telling the story
If history is to be useful, it must be told. Storytelling is a critical leadership skill. When communicating priorities and direction, it is always good to wrap the message in a story. Stories are proven tools for engaging, motivating and guiding an organization. History provides the richest reservoir of compelling stories — stories that spotlight behavior worth emulating. The heroes of the past invariably provide inspiration for the heroes of the future.
Leaders can use stories about an organization’s past to shape culture. They can link mission, values, vision and strategies to pivotal events in the organization’s evolution. And they can conduct “after action” sessions designed to capture in writing “what we learned” from significant developments. For example, a major investment in acquiring physicians’ practices will hold important lessons not only for the present but for the future. But unless that learning is captured and remembered, it will drift away.
Some hospitals and health systems have written and published their histories. This is true, interestingly, of some of the most powerful brands in health care including Mayo Clinic and Cleveland Clinic. Hopkins has also been intentional in preserving and communicating its history.
It behooves every hospital and health system to capture and consider its history. One way to do this is to hire a historian. A good historian can dig through documents, conduct interviews and write the organization’s story. Within many hospitals and health systems, there are often individuals with a strong sense of the past who may be willing to volunteer as historians.
In turbulent and uncertain times, it’s important to have something secure to anchor yourself to. As pioneering mountain climbers scaled steep walls of stone, they first tied themselves to pitons that were driven into the rock as solidly as possible. Those pitons were quite literally secured in the climbers’ past and positioned to save them should they fall in the future. An honest, well told history can do the same for an organization.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.