Winning The (Office) Culture Wars

Colorado Permanente Medical Group was in deep trouble - financially and culturally.

In 1998, only 80 percent of its own physicians would recommend the group to a friend. Only 77 percent would choose it again themselves, down from 94 percent four years earlier.

Good, skilled people were leaving in droves; the annual turnover of primary-care physicians was a staggering 20 percent. When employees were asked if physicians treated them with respect, only 68 percent said yes. Net income? It went from $29.02 million in 1994 to a loss in 1998.

"We lost members, lost doctors, lost money. We had plummeting service, morale, and income," says Jack Cochran, MD. Physicians had given up and staff didn't care.

Cochran could have quit on the group, too. Instead, he dove in hard, becoming executive medical director and turning the culture on its head.

Today, 97 percent of physicians would recommend Colorado Permanente Medical Group, which is part of the Kaiser Permanente network, 83 percent of staff feel they are treated respectfully, and physician turnover rates dropped to 6 percent last year.

This year, the group has had visits from Kaiser executives from all over the country, the Institute for Healthcare Improvement, and the National Committee for Quality Assurance (NCQA), all wondering how the group turned things around.

The cultural dilemma

Colorado Permanente isn't alone, of course, in facing apathy, low morale, and disrespect. Toxic office culture is breaking the backs of lots of practices.

Does any of this sound familiar?

• Staff showing up just to do enough to get by and get home.

• Staff flagrantly ignoring rules about patient privacy or safety.

• Physicians disrespecting staff - not bothering to learn their names or just calling them "the girls," not taking their suggestions seriously, yelling at them.

• Staff arguing, gossiping, or even fist-fighting.

• Physicians battling over perceived injustices so intently that they can't even have office hours at the same time.

"What you see out there is incredible," says Kenneth Hertz, an independent consultant with MGMA Healthcare Consulting Group who helps practices change their culture. His favorite example: He visited a cardiology practice where a patient came in and sat in the waiting room. The receptionists saw him sitting there, but did not speak to him. Two hours later, the patient complained about his wait. The receptionists' defense: "Well, he didn't check in with us."

This is the stuff that tries our souls, that diverts us from patients and makes Monday mornings cold and ugly.

But it isn't just annoying. It's hurting your practice financially. There is no way to focus the troops on productivity, better billing processes, or collecting copays when everyone is busy gossiping about what Brenda or Bob did yesterday.

But it's also the stuff that seems damned hard to change. If you recognize a problem, it's easy to put it down to personality conflicts, laziness, or - my personal favorite - what happens when you have a lot of women on staff.

That's all baloney. Culture can change. Practices can be healthier. And Cochran proved it.

Making a leader

Looking back, Cochran claims he had just the right set of skills to turn around the general attitude at Colorado Permanente: "Number one, inexperience. Number two, naivet?. Number three, passion." A more experienced manager might have realized how Herculean a task changing workplace culture can be, but as it was, he didn't know any better. Besides, he argues, too much emphasis is placed on depth of background, and too little on enthusiastic guidance, when it comes to business managers.

People actually working in the office "are looking for leadership," he says. "Not experience."

And that, right there, is the secret to his success: passion and leadership. Cochran has it in spades.

"American healthcare is in real trouble, and physicians are content to complain about it and document it. We need to get involved. ... We need to comprehensively opt in for patients, and not just when they are sick ... so that the patient is always represented. We need to be involved in all the important conversations in healthcare. ... If we're not involved, we'll get whatever healthcare changes are handed to us."

To him, changing culture is about refocusing everyone on what matters: patients.

"No individual or group can make an optimal contribution to create a sustainable solution in healthcare by primarily focusing on their own agendas and needs," reads a statement Cochran includes in a presentation about Colorado Permanente's turnaround. He thinks physicians need to look past personal agendas for better hours or more pay and focus on the patient. That focus brings better hours, more pay, and more political and cultural clout in the end.

So when Cochran took over, his first step was to meet with every physician in small groups over a three-month period. The physicians were his starting point, not the administrators - and not the hordes of outside consultants Colorado Permanente was then employing.

At first, most of the physicians told him there was nothing they could do to improve things. They felt like Cochran or someone else should give them the answers, not the other way around. Cochran refused to accept that and drove the physicians to agree on three constants: preservation and enhancement of their careers, optimizing the care experience for patients, and streamlining the care process. Everything they did would focus on these things, and they designed teams meant to get there.

"My leadership role is to develop leadership," Cochran summarizes. "The principles are simple; the work isn't easy. ... You have to be restless and relentless."

Focus on the vision

Cochran knew intuitively what many experts told me makes the difference in practice after practice when it comes to changing office culture: focusing on what matters and having physicians take the lead. While everyone acknowledges that changing a contentious practice is so complex that there can't be simple answers, I also heard repeatedly that a renewed sense of purpose is at the heart of the matter.

Hertz says that in small practices he visits, messing around with mission and vision statements seems like overkill to the staff and physicians.

"In small offices run by a physician or their spouse, culture is not an important issue. They focus on clinical issues. They are concerned about administrative things, but think 'Oh, just do your job; everything will be fine.' It doesn't work like that. ... Culture is critical to what drives everything in the practice," he says. "I think we have a tendency to almost promote [bad] situations. So often in doctors' offices you talk about front-office staff versus back-office staff, this staff, that staff."

All of that division detracts people from staying focused on the practice's overall mission, which all of them have in common, Hertz argues: "I go back to the vision, value, and mission. If everyone understands that we are all part of the same team - this is not a bunch of little teams - and the practice's success is dependent on all of us," then you've already taken the first big step to a better office culture.

No one makes the time to talk about these things, acknowledges James Carter, lead facilitator for Repario, a company based in Lake Tahoe, Nev., that works on team and employee development. "We rarely have time to sit down and talk about these "soft" issues that really affect productivity and happiness in the organization."

Still, Carter says making the time is crucial, and, like Cochran and Hertz, suggests focusing all minds on the bigger picture.

For instance, he says to ask gossipy or fighting staff, "What's your real motivation for sitting in this chair right now doing what you're doing?" An activity might help staff focus. Carter advises asking "why" five times. "Why are you here? Why that? Why that? Get down to the real reason you're there. Why are you doing what you're doing?"

Hopefully, the group can come to consensus around shared values.

"The physician could say, 'In this culture, we're about this or that. ... These are the values I agree with, and I think we all do. If, bottom line, your values at the end of the 'why' exercise don't connect, if you don't value these things, you should go. It just won't work.'"

Here's another tool for helping people understand the values of an organization. Ask staff to define what sort of office behavior they'd put in these three categories of employee behavior: common ground, underground, and battleground.

Common ground is where staff spend most of their time; it might include things like speaking politely or meeting deadlines. Underground behavior might be gossiping or going behind someone's back. Battleground means open war - throwing charts, yelling.

"What's interesting [are] the lines between these areas," says Carter. The line between underground and common ground is fuzzy." Defining these as a group helps people understand what's OK and what's not OK.

Hertz imagines a more straightforward conversation - a meeting where the physicians share with staff what made them choose a medical career to begin with, and what they want the practice to be. That encourages staff to share what their values are.

"Put that on the table, develop common points of connectivity within the office. From that you can begin to develop the appropriate behaviors and the kinds of things that are important in the practice and lay it out in writing."

Displays of affection

No matter what the core values of the practice are or how they are arrived at, it's the physician - as Cochran discovered - who must take the lead in living those values and making the practice live up to them.

"It has to start up with the doc," says Hertz. "If the doc doesn't ... live it and exemplify it, it will never happen ... . The staff tends to be a reflection of the physician culture in the practice ... . There's doing it and there's really doing it: If the doc shows up at 9 a.m. everyday when patients are scheduled at 8, why should staff think timeliness is important? What example [are you setting] if you come in the door every day for 10 years and never say hello to anybody? How can you expect them to be compassionate with patients?

"Physicians do not begin to understand the impact that they can have on their staff," Hertz emphasizes. "When the physician shines his light on a staff member ... the results are extraordinary. I have seen a staff that has gone through a long, long, long, day ... and a doc will just walk around and say, 'I know it was a tough day. Thank you so much for all you did.' And it just lifts people up. You can literally see it. People actually straighten up."

Employee recognition by physicians can play a powerful role, but it does need to be recognition that is related to the organization's cultural goals. "It needs to be strategic," says Chester Elton, vice president of Performance Recognition at O.C. Tanner, a Salt Lake City-based employee recognition company. "Recognizing excellence is not just for showing up. It ties back to your core values. ... Recognition is the most powerful way you communicate what you value most."

Elton adds that recognition has to be done right. "Good recognition is frequent and specific. It's not just, 'great job' or 'hey, sport ...

It takes five positive comments to balance one negative comment, Elton adds, so go heavy on the praise.

Kim Cameron, PhD, professor of management and organizations at Michigan Business School, Ann Arbor, adds that physicians or other leaders can't expect culture to change just because they declare that the new culture is different.

"You can't change culture just working on the right brain," he says. "People need stories about what they can become. ... That captures their heart."

Physicians, then, cannot only be a role model of positive behavior but can also tell "stories" about instances that exemplify what the culture can be. Imagine a staff meeting where a physician stands up and tells everyone a very specific story like this:

"Yesterday, we had a patient in the office who we all know can be very challenging. But I saw that Rebecca noticed her struggling a little bit to understand how she should take her meds. Instead of getting frustrated, Rebecca sat down, took out her own spare calendar, and wrote down the exact medication and what times the patient needed to take them. That's what I see this practice being to each patient."

Rebecca sure feels good and everyone else begins to sense what is important.

Take the underground approach

Do such public displays make you uncomfortable? Well, surprising changes can also happen under quieter circumstances.

Cameron suggests a strategy of quiet revolution. Essentially, look for small things you can do that will drive the practice closer to the desired culture but that no one will bother to resist.

Poland, Cameron points out, is the only former Soviet bloc country to transition to a democratic state without a single gunshot. Why? Cameron credits a group called KOR, a coalition of people who decided, even under communism, to live freely. They cleaned up litter, planted gardens, gave blood. The government, they reasoned, wouldn't resist them going into classrooms to volunteer. But each action like that was a decision to act without restraint. KOR expanded hugely. When communism was toppled, the people of KOR just took over organizations; they already knew how to behave in a free way. "Small wins led to a peaceful revolution," Cameron summarizes.

He used the same tactic when he became dean of a business school that Cameron perceived had a second-class mentality. Students and faculty alike walked around campus every day feeling that if they were really good, they'd be at Harvard or Penn.

Cameron realized all the announcements and meetings in the world wouldn't change that. So he did it "with a hundred small things."

He hung flags showing the native countries of all students, brought back alumni who were now top CEOs to talk on campus, created a new logo, and displayed important books by faculty. "No one resisted any of these things, but each one contributed to changing the identity of the place," he says now.

Similar things would work in healthcare. Say good morning, pick up the kitchen, move some desks, bring in a water cooler. "Give people something to see. Help people see that things are different," Cameron says.

Measure success

To make change real, of course, you need to measure it and report on your successes and failures.

Cochran's campaign feels so substantial because he has before-and-after data from physicians and staff about their perceptions and respect for Colorado Permanente. He measured:

• Physician satisfaction - Would you recommend the group to a friend? Would you choose this group again?

• Staff satisfaction - Do physicians in your work unit treat you with respect? Do physicians support you in providing quality service?

• Patient satisfaction - Would you recommend the group? Are you happy with the way you are treated by staff and physicians?

• Income - A solid analysis of profit and loss.

Different groups might measure different things. What you measure should reflect the problem areas and goals for the organization. What's measured is less important than that you do the measuring. People need to be able to see the changes over time. One of the funny things about culture is that it is hard to objectively recognize it. It's just part of working someplace. Measuring helps you focus on the progress you've made instead of the day-to-day issues that will still crop up.

Be realistic

And, make no mistake, you'll still have problems no matter how successful your cultural renaissance is. Changing people, changing culture is incredibly hard.

"Say we have an intervention. What is the percentage of change we can expect from someone? Maybe a 10 percent change - tops - is achievable, looking at the situation realistically. That means that nine times out of 10 you're going to see the same crap you always have," stresses Carter.

"The real problem is a week or two after an intervention when you look around and feel like you are the only one who has changed and is trying," he adds. "It always gets worse before it gets better. We hear this statement all the time and because it is worse, everyone wants to give up. What they fail to realize is that 'worse' is actually good. This means that people's awareness has been raised and they are 'seeing' more of the behavior that does not fit with the values they all said they wanted. This is a good thing. As long as the focus stays on the positive and does not slip into the negative - 'I am the only one giving 100 percent' - the informal culture will gradually change."

What's necessary, Carter says, is to switch your own mental model so that you are looking for the one time out of 10 that things actually go right, then point that out with positive reinforcement. Assume that everyone is doing what they can and just keep plugging away to solve the problems that do happen.

Carter once saw some research that stuck in his head. It compared two organizations, one successful, one not. One organization was filled with problem-solvers. Whatever it took to get the job done, they scurried around and made it happen. The other group was filled with complainers; the complaint box was always full.

The successful one was the one with the full complaint box.

Why?

The complaining team had a method to solve the problems they identified. Complaints were actually answered, and systems were put in place to fix them. The first group had problem-solvers, all right, but which problems were they solving? Since no one ever "complained," everyone was acting individually. They never knew what their real problems were until it was too late.

The moral? Don't just expect everyone to be happy with the inefficiencies in your office and call that a better culture. Have the courage to look at the problems and fix them. After all, isn't that what doctors do?

Pamela Moore, PhD is senior editor, practice management, for Physicians Practice. She can be reached at pmoore@physicianspractice.com

This article originally appeared in the October 2005 issue of Physicians Practice.