Introduction

Joe’s first visit to Midland, Texas, was in May 2012 for a nursing leadership retreat at Midland Memorial Hospital (MMH), where at the time Bob was Chief Nursing Officer. MMH was constructing a new $176-million hospital tower. The day after the retreat, Bob and Joe donned hard hats for a tour of the construction project. Bob’s pride and excitement were obvious during the tour. The new building was needed to replace facilities that had been constructed not long after the end of the Second World War. That need was made more urgent by unacceptably low patient-satisfaction scores. The new tower, it was expected, would remedy that problem.

The new facility opened at the end of 2012. It was indeed beautiful, having been designed with patients, families, and staff members in mind. Private patient rooms feature an expansive view of West Texas, while ceiling-mounted automatic patient lifts over every single bed ensure that no nurse would ever suffer a back injury while trying to lift a patient. (MMH was one of the first in the nation to make this commitment.) A full-service cafeteria offers a wide range of gourmet and healthful food options, and on sunny days people can sit outside in a courtyard that features a walking labyrinth. From the nurses’ station to the chapel, every detail was designed to make the new facility beautiful and functional.

Despite the aesthetic beauty and operational ease, though, patient satisfaction failed to go up. Unfortunately, it actually continued to fall after the new facility opened. By the end of 2013, patient satisfaction scores were at record low levels. The accrediting agency cited the organization’s leadership for not having appropriately addressed these scores. Worse yet, there was mounting evidence that employee disengagement was on the rise. These problems weren’t reflected only in patient-satisfaction survey scores; they were increasingly obvious from the tone of patient letters, coverage by the local media, and staff conversations in hallways and break rooms.

At that point, Bob remembered Joe’s presentation about the “Invisible Architecture” of an organization, a construction metaphor in which the foundation is core values, the superstructure is organizational culture, and the interior finish is workplace attitude. Joe had called this “the blueprint behind the blueprint” and said that Invisible Architecture is the soul of an organization the way that bricks and mortar are the body. To the MMH leadership team, it was increasingly clear that in opening the new building, they had raised patient expectations, but in not simultaneously working on the Invisible Architecture, they had actually increased the gap between higher expectations and actual experience.

Values Coach has partnered with the team at MMH to implement many of the strategies described in this book. The initiative was launched during Nurses Week and Hospital Week of 2014, with every employee being given a copy of Joe’s book The Florence Prescription: From Accountability to Ownership, with a special foreword by four senior members of the MMH executive team. Results of the first validated VCI-17 Culture Assessment Survey, which were not a source of pride, were shared with everyone along with a challenge to do better. MMH was the first hospital in the nation to commit to The Pickle Pledge and to undertake The Pickle Challenge for Charity.* During a one-week period, the hospital turned more than 4,000 individual episodes of complaining into 25-cent contributions to the hospital’s emergency employee catastrophic assistance fund. In the years since, MMH has conducted The Pickle Challenge for Charity four more times, raising money for a number of causes including hurricane relief.

People at every level of the organization were engaged in a dialogue about the values at MMH; a new statement of values was defined and innovatively presented in a book that Joe wrote using those three core values as the title: Pioneer Spirit, Caring Heart, Healing Mission. This fictional story builds on the history and traditions of the organization and the community and paints a picture of a future vision in which Midland has become the healthiest community in Texas. The book was given to every employee, and managers were asked to lead team conversations about values and culture. Appreciating the importance of connecting personal and organizational values, more than 60 MMH employees have become Certified Values Coach Trainers (CVCT) and now teach the 60-module course on The Twelve Core Action Values in a two-day format that all current and new employees must complete.

MMH now has a Culture of Ownership training room and a Culture of Ownership page on the hospital’s website. Immediately outside the training room, a large framed poster says, “Proceed Until Apprehended: Leadership Does Not Require a Management Title” (a line from The Florence Prescription), which is a philosophy the leadership team has worked hard to promote. Every morning at 8:16 sharp, leaders and anyone else who wishes to participate (including patients and visitors) join in the Daily Leadership Huddle in the main lobby to reaffirm MMH’s commitment to being emotionally positive, self-empowered, and fully engaged, and to hear an update about hospital operations. During the day, the same information is shared in unit huddles across the organization.

The results have been remarkable. In many areas of the hospital, patient experience results have gone from record-low to record-high, and there has been a 180-degree shift in the tenor of letters received from patients and in media coverage. Employee engagement is the best it has ever been, which is reflected in best-ever clinical quality outcomes and determinants of value-based purchasing. Joe estimated the annual cultural productivity benefit to be more than $7 million, which MMH leadership considers to be a low estimate. While everyone loves the beautiful new building, an investment in the Invisible Architecture within that building of well under one-half-of-one percent of the cost of the visible architecture has probably had a bigger impact on employee engagement, patient satisfaction, and community reputation.

The best part is the impact that the Culture of Ownership work has had on the lives of the people who have embraced it. We share several of their stories in this book, as well as stories from those at other organizations embracing a Culture of Ownership. In the years since the Culture of Ownership project started at Midland Health, key principles including The Twelve Core Action Values, The Pickle Pledge, and The Self-Empowerment Pledge have been adopted by the Midland Independent School District and a number of other community organizations, with similarly positive results. Perhaps most gratifying, many people have taken these principles home and shared them with family members.

Chapters 1 and 2 describe the Invisible Architecture model and the importance of building a culture of ownership, illustrated with examples of values statements, culture codes, and attitude expectations (both best and worst) from healthcare and other industries. Chapters 3–5 further describes elements of the Invisible Architecture model in which the foundation is core values, the superstructure is organizational culture, and the interior finish is workplace attitude. Chapters 6–10 cover the importance of values-based leadership for fostering and sustaining a culture of ownership. Throughout this book, we share examples from real-world organizations, including many from industries outside healthcare (where some of the most progressive culture practices are often pioneered). Our focus in this book is on healthcare culture in particular, but healthcare organizations can learn and grow by paying attention to what works—and what doesn’t work—in other fields.

Finally, a key message in this book is that culture does not change unless and until people change, and people will not change unless they are given tools and structure and become inspired to make the commitment to use them. Building a Culture of Ownership is a gift to the people who work there. It is also an investment in the organization and the community. We hope it will be for you as well.

–Joe Tye and Bob Dent, January 2020