Improving Quality Starts With Changing the Culture




Physician autonomy

“It’s hard to change a culture that involves doctors without doctors being centrally involved, but the professional culture of physicians can be a significant block to change,” observes Jack Silversin, DMD, DrPH, president of Amicus Inc., a Cambridge, Mass. consulting company that works with physician organizations.

“Take the culture of physician autonomy,” explains Silversin’s partner, Mary Jane Kornacki. “We’ve always wanted the best and brightest to go into medicine, and now we expect these very intelligent people to accept guidelines that they perceive as taking away their clinical decision-making authority. It rubs them the wrong way.”


“Deep down, most doctors are ambivalent about leadership,” Silversin notes. “For the most part, maintaining collegial relationships is more important to them than organizational goals. Being a follower is inconsistent with most physicians’ self-identity, so it is a stretch for them to feel accountable to a leader. What they want from their physician leaders is advocacy for their interests and protection from having to change.”



In the Amicus model, leadership, shared vision, compact, and culture are the foundations for lasting organizational change. To implement specific initiatives, leaders have five “change levers” at their disposal: align a change team, involve physicians to enhance change design and implementation, develop urgency for change, address resistance, and build consistency.

“Things weren’t changing as quickly as we wanted them to,” recalls William Rupp, MD, vice chair for planning of the Mayo Health System and former president and chief executive officer of the Luther-Midelfort-Mayo Health System, an integrated delivery system based in Eau Claire, Wis. “Then we heard Jack talk, and we began a compact discussion that lasted for a year and a half.”

You’re going to object that no discussion that takes 18 months could be called “compact,” but the “compact” Rupp refers to is the informal understanding between physicians and their medical group, hospital, or strategic partner that defines what each party expects to give and get. The new compact at Luther-Midelfort commits physicians and everyone else in the organization to continuous personal change and improvement.


“We never try to change the culture by going directly at the culture,” says Bard, who includes a slide titled “Culture Eats Strategy for Lunch” in his presentation. “We embed it in performance improvement initiatives so people can see that living a new culture enabled them to achieve an outcome they hadn’t been able to achieve while operating in the previous culture.”

Strategies and simple rules


Next, Bard helps leadership unearth the current culture by identifying the seven or eight “simple rules” — the unstated do’s (cans) and don’ts (can’ts) that largely are invisible but experienced by everyone in the organization, accounting for how most business gets done.


The next steps identify where culture is likely to “eat” strategy. These encourage performance-improvement teams to discard existing rules that get in their way and to invent new ones that lead to the desired outcomes. Team leaders are surveyed over the course of a year to identify the emerging new rules that were most helpful.

“The organization’s leaders serve as the champions of these new rules, not the imposers of them, by encouraging local teams to adopt new and useful rules,” says Bard. “We then help leadership support the new rules with recognition and a performance-management system that rewards new behaviors. Over a period of several years, the new rules serve as the foundation for the evolution of a new culture.”

Luther-Midelfort, for example, began to improve patient safety a year before the Institute of Medicine’s 1999 report focused national attention on medical errors. New Coumadin protocols reduced the percentage of patients with unacceptable INR (international normalized ratio) levels from 25 percent to 2 percent. A new insulin protocol generated similar results.

“That’s flat-out better medicine,” says Rupp.


In too many health care organizations, it’s still considered OK to treat staff members disrespectfully. Achieving real performance improvement can very difficult with a staff that operates in what Bard calls “resentful bondage”: where employees lack real commitment to performance and outcomes, focusing instead on assigned duties and tasks.

High turnover is a symptom of a disrespectful workplace. If that’s confirmed in confidential interviews, employees are asked to identify two behaviors that would change their experience of their workplace. These then become explicit new simple rules that contribute to measurable performance improvement.

In a respectful workplace, everybody says “I take care of patients,” as opposed to ‘I answer the phones,’ or ‘I book appointments.'”

MANAGED CARE September 2002. ©MediMedia USA

Our most popular topics on