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    By Jason Foltz, DO, family physician and chief medical officer, ECU Physicians/Brody School of Medicine, East Carolina University; Paige Tyson, manager of training and engagement, ECU Physicians/Brody School of Medicine; Martha Dartt, RN, MSN, FNP, chief nurse executive, ECU Physicians/Brody School of Medicine, East Carolina University; and Robert J. LaGesse MSM, CMPE, FACHE, interim executive director, ECU Physicians/Brody School of Medicine, East Carolina University

    Over the past five years, ECU Physicians has been on a quest to achieve the Quadruple Aim in healthcare. In our first three articles featured in MGMA Connection, we highlighted our approach to setting our strategic framework, striving for an exceptional patient experience and improved health outcomes for our patients. However, at the core of any improvement work in healthcare is a resilient team, empowered to make change focused on our core purpose — “to provide the highest quality and most compassionate healthcare to the people of Eastern North Carolina while educating the next generation of health professionals to do the same.”

    Part of this journey required a significant effort to change our organizational culture to accomplish our core purpose, focus on our core values and empower our teams to improve care and service to our patients.

    Assessing and, when necessary, adjusting your organization’s culture is essential for change initiatives. Changing culture is challenging. It takes a focused determination to value the role each team member plays within the organization and ensuring their work is linked back to your core purpose. Robert Glazer’s words are very fitting: “The employees business leaders need to worry about most are not the ones who leave the company, but rather the ones who quit mentally but stay in their role.”1

    Peter Drucker’s famous quote, “culture eats strategy for lunch,” is important to remember when looking at constructing an organizational strategy. Recognizing that organizational culture will subvert any strategy leaders may wish to implement, it is important to assess and adjust culture before implementing strategy. As noted in this series, “[a] dedicated leadership team, focused on a core purpose with a foundation based on the Quadruple Aim can begin to change the culture of your organization to one with a group mindset passionate about serving the needs of its patients by providing high-value care.”2


    To fully achieve our goals and shift the organization to meet a future focused on the Quadruple Aim and maintain financial viability, we needed to develop a shared purpose within all individuals at all levels of our leadership teams. To be successful, we needed to take the time to bring our leadership teams together to understand the shared need to take action and to provide them the tools necessary to achieve our shared strategies.

    We began our focused QUEST (quality, utilization, efficiency, satisfaction, teamwork) initiative by establishing quarterly “boot camps” for all clinical leadership teams across our practice. This included our department outpatient medical directors, nurse administrators, patient access managers and chief academic department administrators. Each boot camp focused on a “state of our union” presentation so that each leader had a shared mental mindset of where we’ve been, our current situation and the envisioned future. It was crucial that we explained the future vision in a way that developed an action mindset. Each boot camp started with a reminder of our core purpose and value statement. The half-day boot camps had well-defined agendas and a focus on interactive problem-solving. Topics focused on leadership development, issues our organization faced, and goal and objective development at the departmental level.

    While it’s important to mentor and develop your leadership teams, it’s also essential to train the frontline clinical staff on the “who, what, how, and why” of the need to adapt to the ever-evolving healthcare environment. We developed an ambulatory care academy focused on getting as many of our clinical staff through a day-and-a-half-long conference. Topics included healthcare transformation, quality improvement goals and tactics, patient communication techniques, de-escalation training, principles of TeamSTEPPs (Team Strategies & Tools to Enhance Performance and Patient Safety), and structured standardized patient scenarios.

    Once the educational foundation was established, we embraced the importance of team communication at the unit level. Many principles were outlined in our article, “Patient satisfaction starts with effective, efficient communication”3; however, we invested in the TeamSTEPPs training program, developed by the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ).

    TeamSTEPPS is an evidence-based framework to optimize team performance across the healthcare delivery system. It provides practical, easily implementable tools that enhance team structure, communication, leadership, situation monitoring, and mutual support that improve care delivery and patient safety. A key element of TeamSTEPPS is respect and understanding of each individual’s role in the delivery of safe and efficient care.  

    In addition to enhancing communication techniques within the team, it is essential that the organization has an effective communication platform. While maintaining our monthly leadership meetings within nursing, physician and administrative chains, we created a quarterly “QUEST” newsletter emailed to clinical team members to ensure they regularly receive key messages around our strategic aims. It is also a forum to share praise, videos and updates.

    Without noting progress, individuals can lose focus, so we provided report cards. By providing updates on key performance indicators (KPIs) down to the unit level, we kept people interested in learning where they stood compared to others in the organization. This included recognizing individual units for achieving specific operational and organizational quality goals.

    While educating our team on their role within the changing healthcare system is important, we realized that to truly change culture, we needed to address how we interacted with each other. In September 2019, we implemented FISH!, interactive face-to-face training that reminds our staff of the importance of “being there,” “making someone’s day,” “choosing our attitudes” and “having fun” while maintaining professionalism and poise in our day-to-day roles. Not only do we choose to practice these principles with our patients, but also with our teammates at work. 

    While this training was great for employees, we found it essential to ensure our new hires were appropriately indoctrinated to what it means to be an employee of ECU Physicians. Each of our new employees complete a personality assessment using True Colors International training. It’s a great way for our employees to understand who they are, identify their strengths and weaknesses, and embrace differences, which is what makes a healthy team. 

    The COVID-19 pandemic presented us with a unique set of challenges to continue to build on our shifting culture. In response to COVID-19, we realized that we needed to alter our approach to face-to-face training. To do that, we created a virtual training option that ties the concepts of True Colors, FISH!, and TeamSTEPPS together. A strong foundation has been built through understanding ourselves and collaboration. This virtual training will allow our employees to dive into specific team strategies to utilize in the clinic, such as strengthening team huddles and mutual support for one another. We cannot provide high-quality compassionate care to the people of Eastern North Carolina if we can’t communicate with and support one another.


    Our quest for the Quadruple Aim is a continuous process, but at its core is recognizing the value of every team member and empowering them to work toward achieving our organizational goals. In pursuing excellence, it takes a commitment to strategic planning and engagement activities. To quote Robert Glazer again, “We are what we repeatedly do. Excellence, then, is not an act but a habit … Many think about excellence as an outcome. The reality, however, is that excellence is a byproduct of the many decisions we make each day and how we choose to act in each one of those instances.”4


    1. Glazer R. Friday Forward: Inspiration & Motivation to End Your Week Stronger Than It Started. Naperville, Ill.: Simple Truths, 2020.
    2. Foltz J, Hopkins PD, LaGesse RJ. “Healthcare’s Holy Grail: The quest for the Quadruple Aim.” MGMA Connection. March 2, 2020. Available from:
    3. Foltz J, Hopkins PD, Thompson J, LaGesse RJ. “Patient satisfaction starts with effective, efficient communication.” MGMA Connection. Sept. 1, 2020. Available from:
    4. Glazer.

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