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“Culture influences how we deliver care, how we interrelate with our colleagues, and how we treat our patients.”

–Peter Pronovost and Eric Vohr, Safe Patients, Smart Hospitals

Chapter Goals

  • Explain why a great culture is vitally important for both the employee and the patient experience and is a nonnegotiable element of being recognized as being a great place to work.

  • Share 10 reasons why Peter Drucker was correct in saying that culture eats strategy for lunch, illustrating each one with real-world examples.

  • Describe the concept of the culture code that originated in Silicon Valley, the importance of defining your cultural philosophy, and ways that stories (including six-word stories) can shape culture.

  • Explain why “the right bus” is the wrong metaphor and why a much more appropriate metaphor is “the galley ship.”

  • Understand that culture does not change unless and until people change because culture is an organizational reflection of the collective attitudes and behaviors of the people who work there.

In his 2005 commencement speech to the graduating class at Kenyon College, author David Foster Wallace told this story: Two young fish are swimming along, minding their own business, when they come upon an adult fish passing the other way. The adult says, “Morning, boys. How’s the water?” The two youths swim on until, finally, one looks at the other and asks, “What the hell is water?” Explaining water to a fish is like explaining air to a child—it is everywhere, but it is invisible; you can feel it, but you can’t touch it; and, most importantly, you can’t live without it. “The point of the fish story,” said Wallace, “is merely that the most obvious, important realities are often the ones that are hardest to see and talk about” (Wallace, 2005). The same thing is true of culture—it’s like the water we swim in but are oblivious to until it is pointed out to us by an outsider.

Culture is the personality and character of the organization. It is shaped by the collective attitudes and actions of the people who work there. But in most healthcare organizations, there is not one single culture, and probably never will be. Rather, a healthcare organization is like a patchwork quilt of subcultures, including nursing, pharmacy, environmental services, the business office, and the medical staff. These subcultures often have sub-subcultures—within nursing alone, there are significant differences between medical-surgical, critical care, pediatrics, peri-operative, emergency, and long-term care. Different cultures can even exist within one unit, depending on staffing and timing (as anyone who has worked both day and night shifts can attest).

Wall Street and Silicon Valley have a lot in common; companies on the street and companies in the valley all recruit bright, ambitious people and seek to maximize profits. But the experience of working in high tech is usually quite different from the experience of working in high finance ...

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