By Bill Macaux, Vice President, Executive Development

What causes people to identify with and form an emotional attachment to an organization? Many would say culture. And what is it that motivates people to persevere in a common cause or mission? Values, of course, especially when they are understood, shared by, and reflected in their leaders. This article examines the role of leadership in culture change, the kinds of change needed to promote reform in our health care system.


"Organizational learning, development and planned change cannot be understood without considering culture as a primary source of resistance to change." Edgar Schein

Why should top management care about culture? Because culture makes a difference in performance. Studies indicate that 50% of mergers fail to achieve the benefits that were used to justify them, and 60% of Six Sigma projects fail to realize their goals. Much of this is thought to be attributable to the psychosocial variables that are shaped by culture.

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Nowhere has organizational culture become more cited as a critical factor than in health care. Consider the phenomenon of "disruptive behavior," which has been carefully analyzed in a recent white paper by Pascal Metrics (2011). We know that reform initiatives affecting quality, safety, patient experience, and cost call for changes in how work is done. But how easy would it be to realize a coordinated course of change with the behaviors below prevailing?


Behavioral Description

Divisive Behavior

  • Intentionally excludes others from the group
  • Talks about people behind their backs
  • Treats new people harshly


Intimidating Behavior

  • Sets others up to fail
  • Bullies other people
  • Tries to publically humiliate others


Disrespectful Behavior

  • Yells at other people
  • Turns their backs before a conversation is over
  • Hangs up the phone before a conversation is over


Inhibiting Behavior

  • Violates HIPAA
  • Uses a personal phone in ways that interfere with work
  • Fails to respond to phone calls, pages, and/or requests


Offensive Behavior

  • Touches people in overtly sexual ways
  • Makes comments with sexual, racial, religious or ethnic slurs
  • Shows physical aggression (e.g., grabbing, throwing, hitting, pushing)

SOURCE: Pascal Metrics Inc.  

Pascal summarizes research on the adverse effects of disruptive behavior: It is associated with medical errors, lower patient satisfaction, poor teamwork, and increased staff turnover. Unsurprisingly, it is also thought to reduce the effectiveness of electronic health records. Health care system leaders know this and still disruptive behavior continues to be prevalent in health care settings. Why?

There appears to be no lack of "hard" business reasons to justify culture change, and they are not the only kinds of reasons that matter. Patients and their families present in a state of vulnerability with expectations of getting the best care possible. When organizational culture impairs our ability to meet those expectations, most would agree there is a moral imperative at stake. We are letting them down!

Nor are we lacking calls to action or proven methods and practices for improving quality, safety, and the rest. Still, the adoption and spread of these improvements is slow, which leads to great variability in care between health systems and within the operating units of a single health system.

Most would agree that what underlies these problems goes beyond financial, technical, or managerial constraints alone. Ultimately, it is a question of leadership, the right kind of leadership, and perhaps having enough leaders. I believe that is what John Kotter might conclude.

This occurred to me as I reread his classic HBR article, “What Leaders Really Do” (1990). Although he wrote this piece years before the recent dramatic changes in health care, his views seem even more relevant today to health care leaders than they did then: "What leaders really do is prepare organizations for change and help them cope as they struggle through it."


"No one yet has figured out how to manage people effectively into battle; they must be led." John Kotter

Management and leadership are complementary "systems of action," according to Kotter. The former serves to bring order and consistency to performance. It formulates plans and goals, organizes roles and resources for execution, and controls performance to ensure realization of plans within budget. Most would agree that management of this kind is critical wherever quality and safety are issues.

Leadership sets direction, a vision for a future state—not some mystical long-term destination, but a specific end state in which the needs for reform have been fulfilled.  It identifies needs for change and formulates strategies for making changes. While management focuses on organizing, leadership seeks to align, inspire, and empower people. Management and leadership are complementary; good management is a practical reality check on leadership.

Like leading organizational psychologists (Czander, 1993; Schein, 1992; Boyatzis & McKee, 2005), Kotter believed that leading culture change requires tapping into peoples' feelings, helping them find their own value-based reasons for caring about change. Only with this kind of leadership, and in sufficient numbers, will an organization be able to sustain their change efforts in the face of the inevitable obstacles that arise along the way.

Of the functions that leaders perform—setting direction, aligning people, motivating action—perhaps setting direction is the most practiced. In a recent review of health care improvement initiatives, Perla, Bradbury, and Gunther-Murphy (2011) observed: "The movement to improve the quality of healthcare does not lack established interventions, powerful ideas, and examples of success and breakthrough results. Uptake of these advances, however, is limited, uneven, and slow."

What, then, is the kind of leadership we need in order to address these issues? How does the legacy culture restrain change? What kind of critical mass of energy and effort is required to spur action and ensure an increased pace of adoption that spreads throughout the organization?

Building the leadership capacity and culture of an organization begins at the top. There are important things that senior management can do, and then there are also ways in which they need to get out of the way after doing them in order to empower next-generation leaders throughout the organization. Here are some simple suggestions for how senior leadership can make a difference:

1. Identify and engage a larger number of high-potential leaders earlier. It is your job to spot them, and they should be representative of all levels and all departments.

2. Involve these leaders in the direction-setting task.  Have them analyze data, target opportunities for improvement, and create a vision of a specific future state as well as the initiatives that will create the “delta” between the current state and that future state.  

3. Promote informal communications networks among leaders.  This will lead to the relationship building that can support alignment checking and coordination of action.

4. Get to know your people and encourage them to get to know one another.   People perform best when they understand their interdependencies as well as what drives others, including their interests, experience, values, and motivations.

5. Use what you learn about one another.  Once there is deeper understanding of individual commonalities and differences, this knowledge can be tapped to appeal to shared values, recognize progress, encourage others when times are tough, and build a sense of cohesion.

6. Rely on encouragement rather than control.  Leaders need to model and encourage a constructive mentality.  This means focusing on including rather than excluding, offering feedback rather than criticism, and surfacing issues early rather than letting them fester.

There are individual and group development methods that can be tailored to the organization, which help foster this relational pattern of interaction among the growing cadre of leaders. As this group of leaders undergoes the stages of group development, authentic cultural norms, which promote positive change, will also quite naturally emerge. Not only do these leaders acquire accountabilities for these norms, they also cultivate an even deeper, person-based sense of responsibility for them.

This course of action by senior leadership prepares the organization for change. Helping them cope as they struggle through the change process then becomes an ongoing priority. Part of that struggle consists in breaking old habits associated with the legacy culture, whose purpose may have been to restrict and control with hierarchy and closed departmental boundaries. If the new culture is to empower leadership and initiative at all levels, more open boundaries and delegation of authority will be needed.

Performance & Development

To summarize, there are reasons for management to care about culture and culture change. Indeed, it is inconceivable that any health system could navigate the challenges of reform absent significant culture change. The business of culture change concerns leadership more than management, hence successful health systems will need to build a bigger, more able group of leader-managers. Performance will depend upon development, adaptive development.

The Challenge-Development Curve

I have written elsewhere about the challenge-development curve. Increasing levels of challenge,  like those associated with stretch assignments or organizational culture change, stimulate learning and development up to a point (b) beyond which further increases in challenge overwhelm us (b-c).

This curvilinear relationship between level of challenge and gains in development (a-b-c) is moderated by access to resources: expert advice; stakeholder feedback; group problem solving; and mentoring. These effects are represented in the green line b-d, which leads to adaptive change.

The effect of moderators is mediated by other, person-based factors: a practiced capacity for reflection; openness to self-examination and personal change; and an ability to communicate openly and repair ruptures in relationships.

Keep this graphic image of adaptive change in mind. Recall Kotter's definition of leadership: "What leaders really do is prepare organizations for change and help them cope as they struggle through it." Now let's consider a few practical “how to” design features that senior management might wish to incorporate in their approach to leader development and culture change.

First, preparing for change and coping with the struggle is largely about effectively addressing what I have called moderating and mediating variables in the challenge-development curve. Moderating variables provide "scaffolding." They consist of resources that enable people to stretch out of their zone of current competence and try new ways of doing things. Mediating variables—such as openness to feedback—catalyze the effect of moderating variables, including the stakeholder feedback itself.

Second, we know that transfer of learning is a critical factor in development. That is why action learning is the design of choice. Each future leader applies his or her learning directly to a project that is strategically important. All projects are vetted by management to ensure alignment and relevance. What facilitates learning is a combination of peer interaction, group-based learning modules, and facilitated reflection to deepen insight into the psychosocial factors essential to leading culture change.

Third, a fundamental principle that is reinforced throughout the action learning leader development program is systemic attribution of cause. As Don Berwick of IHI is inclined to say, systems are perfectly designed to deliver the results they are currently delivering. There is seldom a simple division of good guys and bad guys, know-it-alls and know-nothings. We all play a role in the system that generates our current problems, so let's focus on what needs to change rather than on blaming one another.

Fourth, culture change via action learning is a practical, trial-and-error process. Therefore, we must inoculate against setbacks by properly framing expectations. Sometimes we will get it right very quickly. Other times we may repeatedly fail. As Winston Churchill said, "The secret to success is learning how to go from failure to failure without loss of enthusiasm."

Finally, communication must be a key theme for development. You only need to consider the examples of disruptive behavior mentioned earlier to appreciate how verbal and nonverbal communications can hinder progress. It is also helpful to distinguish between communication for understanding and communication for influence. Unless the former precedes the latter, people can feel disrespected, and change can feel manipulative.


Nothing in this article should surprise the average health care executive. However, intellectual awareness is not the point. We must ultimately recognize what keeps us from advancing and dealing with culture change. Most often it is not mere practical matters alone (money, skill, time, etc.). Our readiness to act on our awareness of problems and needs for change is more frequently driven by feelings of fear and uncertainty, a lack of how-to knowledge, or concerns about having a leadership team equal to the task.

The way we disarm any of these inhibitions is to face them directly. Pascal Metrics has not only written a white paper on disruptive behavior, they have developed and validated a tool for measuring this important and problematic aspect of culture. Consider using it as one pathway into culture change. Setting direction requires data, information, analysis, insights, and ideas. And by all means, involve others in the process. If you have not done a very good job of identifying high-potential leaders, work on that first.

If you need help from experts who have worked with other senior leadership teams on these matters, then seek it out. This is not something you can or should delegate to your head of human resources. Building leadership capacity and navigating culture change are in the wheelhouse of top management; they are matters of governance and fiduciary duty. Delegating the things you find most daunting or least ready for is usually not the answer.

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