The underlying message of John Mitchell’s article (one of the most requested) is both correct and refreshing. Its content signals to me a CEO in a leadership mindset shift needed first to realize the importance of organizational culture and its many subcultures that contribute to the success of an entity. Organizational culture reflects the beliefs and behaviors in which, overtime, a body develops, learns and acts out each day. Its objective is the status quo [survival], and today in many healthcare organizations, survival is the only mindset.

Very few CEOs perceive the importance their role plays in leading and championing desired culture change to ensure its survival and competitiveness. Mr. Mitchell does as does the new CEO Jean Aycock at the Oconee Regional Medical Center, Milledgeville, Georgia.

Unfortunately, for healthcare, many CEOs do not see the importance of organizational culture as their primary responsibility. Some who do see it delegate it to other senior managers, e.g., human resources. The vast majority of CEOs do not understand how the power of their organizational culture correlates to their legacy or tenure success. Most CEOs focus on pleasing their board chair and feel partially accountable for the behaviors and beliefs demonstrated every day in their organization, about which they cannot change as they focus on the bottom line. I say “partial” accountability for their organization’s culture because full accountability is with the board of directors. I can safely say many board members do not understand this responsibility as one of their primary duties as many have revealed, “I was never told.”

Sam J. Mazzuca
Principal & Senior Consultant
Mazzuca & Associates
Omaha, Nebraska

Healthcare’s cultures seem to be in a vicious cycle of self-perpetuation in an organizational climate of mistrust, miscommunications, finger pointing, discrediting and hoarding of control.

Dysfunctional behaviors are condoned and rewarded every day by performance reviews, salary increases, budget appropriations and contract approvals. Healthcare cultures appear to be in a survival state of physical slowness and mental dullness.

Where is Healthcare Leadership?

Why is it so hard to see and feel the confidence and courage in the board of trustees, hospital management and medical staff leadership who are responsible for the cultures in their organization?

The board of trustees must step up and become accountable for setting a process for renewing their organizational cultures by realigning key stakeholders’ roles, expectations and behaviors for themselves, hospital management and medical staff leadership.

Most boards do not know they are accountable for their organization’s culture and continue operating in a traditional hospital governance model—which is the status quo.

Going Forward

The board of trustees should consider the following:

1. Discussing and coming to a consensus on a strategic initiative to develop new and better ways to communicate between and among board members, medical staff and hospital senior management.
2. Engaging an experienced relationship assessment consultant to ascertain what it will take to improve one-to-one key stakeholders’ relationships and communications.
3. Providing an assessment feedback to the board of trustees, hospital senior management and medical staff leadership characterizing (a) behaviors and beliefs, (b) interacting tendencies, (c) areas of strength and (d) areas of conflict and tension.
4. Establishing a collaborative plan of action with accountabilities and timetables for the board of trustees, the hospital’s senior management and medical staff leadership to renew, as well as reenergize their key stakeholders’ partnerships.

The board of trustees must require commitment and accountability of itself, hospital senior management and medical staff leadership. In doing so, working together as business partners with direct, honest and open communications, establishes the beginning of new rules of engagement.

How do board members get to know their medical staff without being perceived as micro managing or going around management’s back? A question asked by board members who admittedly say they do not know their medical staffs or how to approach them.

A board member shared with me that when she speaks with physicians, it often gets back to hospital administration and is perceived as going around management. She was lost as what to do.

Business is all about relationships but what if you are not in a relationship with your key stakeholders?

When presenting on the topic, “How to Improve Hospital – Physician Relationships” at regional board of trustees conferences across the country, I always ask for a show of hands on the question, “How many of your physicians are associated with your healthcare facility because of their relationship with the board of trustees?” Of the four conferences so far this year, with 100 plus attendees at each, I counted only two raised hands.

When the following question was asked at the same regional conferences “…in relationship to the chief executive officers and their executive teams,” only one show of hands was noticed.

And when this question was asked “…in relationship to the nursing staffs” there was no show of hands.

In addition, when I asked, “How many trustees had a board-driven policy declaring how they wanted their organizations to deal with their physicians?”—I had no show of hands.

Relationship Consequences

If key physician relationships are strained, fractured, deteriorating or plainly written off, you can clearly understand the reasons why. It may also be why the culture and values in healthcare relationships are deeply rooted with miscommunications and mistrust.

If the truth were known, many boards of trustees are not comfortable dealing with physicians, let alone know how; hence, they avoid the encounter. While some boards may be at ease speaking with the few physicians they know, other physicians often perceive this contact as favoritism.

Likewise, many physicians do not know who is on the board of trustees of their healthcare organization. In addition and above all, many physicians do not know what the responsibilities are for the board.

If boards of trustees have not discussed and come to consensus regarding a policy on how they want the organization to deal with their physicians, they can easily be perceived as micro managers or bypassing management when they seek out physicians.

Rethinking Relationships

The relationship of the board of trustees with their physicians must be rethought and new strategies developed on how they want their organization to deal with their primary rainmakers.

Discussing and arriving at consensus on the following question is essential.

Should the board of trustees establish a relationship with their medical staff?

If the answer is no (because that is why they have management), that is not acceptable.

If the answer is yes, then the board must develop a policy to improve the relationships with their physicians to whom they have delegated patient quality.

A retreat with full discussion should center on:

1. Identifying current perceptions that each
1. board member has of his or her current relationship with the medical staff.
2. medical staff member has of his or her current relationship with the board of trustees.
2. What work relationship expectations does the
1. board have from their medical staff?
2. medical staff have from their board?
3. Developing an explicit written “hospital – physician relationship policy,” describing the working relationship expectations each has of the other will certainly improve accountability, communications and trust.

Creating New Expectations

A particular board of trustees, after full discussion amongst themselves, engaged the hospital’s executive team; their medical staff leadership came up with the following action plans to establish their first ever “hospital – physician relationship policy.”

1. The board of trustees executive committee integrates itself with the medical executive committee to establish a joint conference committee which meets monthly.
2. The board chair, chief of staff and chief executive officer meets weekly for an hour to discuss strategies and operational issues.
3. The board of trustees encourages the development of a medical staff leadership council, which is responsible for not only recommending clinical operations improvements, but also defining and prioritizing broad-base physician needs, and for upward and downward communications to and from the medical executive committee, hospital management and board of trustees.
4. New physician orientation and on-boarding process includes attending and being introduced by the chief of staff at the board of trustees meeting.
5. The board and hospital management have two major social functions a year for the full medical staff members and their significant others.

Some business relationships require special attention and care. Boards must take the initiative to bring their key stakeholders together to assess their current relationships and develop the necessary action plans to improve these relationships.

Physicians’ Perceptions

When I asked a family practice physician why he had this perception, he, in turn, asked me if I had seen their physicians’ lounge. I should take the time and then I would know what he meant.

When I toured the lounge, I saw a poorly lit room with worn furniture — a small cluttered desk with one phone and an outdated desktop computer and thermos of coffee with a short stack of Styrofoam cups on an end table.

Another physician related his frustration with the intensive care unit’s availability, noting the situation had been ongoing for a year. If physicians were the medical center’s #1 customer, he would not have lost the needed patient revenue for his practice and the inconvenience his patients and their families experienced in being transferred to an ICU at a competitive hospital 90 miles away.

When I further inquired about the intensive care unit not being consistently open, I was told a staffing issue had been plaguing the unit. The medical center could not attract or retain critical care nurses and the situation was further acerbated by absenteeism.

Physicians know they are their healthcare organization’s #1 rainmakers, yet many are not made to feel the importance of their contribution to the organization. Most physicians realize the board and hospital administration have little clue to their needs or expectations, or for the organizational bureaucracy they encounter every day when implementing their clinical patient orders.

Transparent Reality

The attitude at the top—board members and management teams—is very transparent and drives the organization’s attitude toward the physicians, which manifests itself in many ways by well-intentioned persons.

Most organizations rely on implicit expectations when dealing with physicians; these are unwritten and unspoken rules, requirements or understandings among people.

Board policies shape the way management and medical staff undertake their work. Boards are accountable for setting policy with directions and behaviorial expectations. They must be clear in what they want the organization to do or refrain from doing.

Is your Medical Staff Customer Service Policy clear throughout the organization?

When was the last time your board of directors discussed and approved an explicit policy with expectations on how they wanted the organization to conduct and transact business with their physicians? If the answer is never, why not?

When people have a clear understanding of what is expected of them in providing customer service to physicians and meeting those expectations, trust grows and relationships develop. The opposite occurs when customer service expectations are not clear and not being met; trust diminishes and key stakeholders’ relationships become strained.

Do you have organizational consensus?

The board may be in policy consensus but it does not guarantee that hospital management and their staff agree.

Going back to the story shared by the physician about the conditions of the physicians’ lounge—in the corrective action, the board and hospital management established an ad hoc committee of management and doctors to determine and recommend remodeling options.

Within 90 days, the lounge had a complete makeover which included new furniture, a kitchen area with food, coffee machine, etc. The dietary department became accountable for daily replenishment and environmental services was responsible for daily cleanliness.

The efforts by the board, hospital management and the ad hoc committee were well received by the physicians. Within a couple days of the lounge’s reopening, a nursing supervisor and a small band of nurses expressed a subtle resentment at the upgrade done for the doctors and not for the nurses.

Regarding the physician’s story concerning the inconsistency of the intensive care unit’s hours, the board and hospital management approved a physician-led ad hoc committee to determine action plans and recommendations to enhance the credibility of the ICU.

Within 90 days, a well-respected internal medicine physician assessed the intensive care unit users to determine both its strengths and areas needing change. He made the following recommendations: (1) become the unit’s medical director for one year, (2) schedule physician education for the unit’s nursing staff and (3) collaborate with nursing management to transfer the unit manager and find her replacement. Interestingly enough, nursing salaries were not a major issue. Hospital management collaborated making the long-needed changes in the unit’s leadership. A formidable minority of employees perceived the physicians were now running the hospital.

Do you have organizational commitment?

Commitment begins with the board of directors being accountable for setting policy and expectations. People look to their hospital management to take the time to share and clarify such expectations and consequences. Shared accountabilities create ownership and build relationships of trust and support.

Development of a “physician customer service policy” is the responsibility of the board. Its successful implementation is with the hospital management and their staff who must fully understand performance the expectations and consequences when interacting daily with physicians.