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    Rosalba Miranda Lozano
    Rosalba Miranda Lozano, BBA, MBA, LLSGB, FACMPE

    With the tremendous amount of metrics, training, reporting, human resource issues, clinic schedules and other daily tasks, culture at times takes a back seat in a leader’s list of priorities. What many healthcare leaders forget is that culture plays a part in everything a leader does, weaving specific mindsets and behaviors to help staff perform as a team.

    Having a healthy company culture fosters harmony and encourages inspiration throughout the organization. Merriam-Webster defines culture as a “set of shared attitudes, values, goals, and practices that characterizes an institution or organization.”1 Culture is so much more than this; it affects every employee within every organization. It influences the way employees feel every morning when they wake up and get ready for a workday. Culture is the way employees feel about their job while on the clock, as well as how they feel after they leave the office, whether that is in-person or working remotely. Culture is a way of life.

    Three phases for passionately advocating

    According to The Ritz-Carlton Leadership Center Patient Excellence Workbook,2 there are three stages to becoming a passionate advocate. These stages need a degree of effort from the employee and a degree of support from the employer to ensure change:

    1. Conceptual (“Hearing it”)

    It is essential for leaders to talk about culture and emphasize its importance within the organization and with daily tasks. If no one is talking about culture through words or actions for employees to see and hear, culture will seem out of sight and out of mind.

    2. Superficial (“Believing it”)

    Once employees see and hear about culture through different communication channels, they will start believing it. This phase is when staff begin to feel the culture around them and learn their role in it. Employees become empowered mentally and emotionally to start driving that same culture across the organization, internally with coworkers and supervisors, as well as externally with patients, vendors, referral offices or ancillary services.

    3. Emotional and personal (“Living it”)

    Once a team member reaches the emotional and personal phase, they can genuinely start acting and creating a culture around them. This phase often is not limited to professional working hours; these culture advocates may carry the company’s mission into their personal lives, positively influencing their family and friends. Alternatively, as Leonard Berry and Kent Seltman describe in Management Lessons from Mayo Clinic: “When a value becomes part of the employee’s DNA, it guides not only the way the day-to-day work is performed, but it also gives employees the power and moral authority to act in unique situations.”3 “Living it” is the final phase: It will not happen overnight, and it is not easy. It may require ongoing hard work and repetition.

    Having a healthy organizational culture is like having a strong glue stick that helps create a bond and respect. This, in turn, creates trust; a team without trust will struggle to accomplish goals. When a team reaches a certain level of trust toward each other, staff members are engaged and feel a sense of belonging; this, in turn, decreases turnover. Lower turnover helps build meaningful relationships among staff and their patients, helping the organization deliver excellence in patient care.

    A strong, cohesive team also helps companies get through any significant change. Any time a company or department is undergoing a process improvement plan, such as a Lean Six Sigma process, having a distinctive internal culture and reliable team are needed to move forward. For a leader to successfully implement new tools, a great culture will help the team work together and support each other through a time of adaptation.

    The role of hiring in culture

    Hiring the right individuals starts with having a detailed job posting that conveys the company’s brand. Consider including a specific task in the job posting — anything from asking the candidate to create a short video or email their favorite color to the hiring manager. This task serves as a filter to find out which candidates focus on attention to detail.

    For in-house recruiting, consider assessing a candidate with a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis, outlining the candidate’s skills, character, experience and accomplishments. Grading the candidate on competency and character is crucial for the interviewer to be an advocate of the organization’s culture. Will the candidate be a good fit with the company’s culture?


    Another step is to energize candidates via their onboard training timeline after they accept the offer. The onboard training is the best opportunity to get new staff members excited about where they are working and why they do what they do. During the onboard training, it is essential to share the company’s mission, vision and values. Values are fundamental, as they guide individuals on how to act in day-to-day operations. Values include the company’s internal and external etiquette with providers/co-workers as well as patients and referral sources.

    Many organizations overlook “Day One,” the first chance to make a good first impression on a new staff member. Companies can prepare a success binder containing essential information and contacts for the new staff member. By doing so, new employees’ minds and hearts will be open to the company’s culture. For example, a simple “welcome to the team card” signed by the staff and providers, or leaders can get flowers or a “welcome to the team” kit. Consider a “staff preference card” that includes basic questions to be answered by the new team member about hobbies, favorite movies, etc., to help leaders connect with their team on a more personal level and build a stronger bond.

    Post-hire follow-up

    Having a timeline to check in on the new hire, including scheduling a three-week post-hire meeting with the candidate to follow up on how he or she is doing helps address any issues. Bi-monthly follow-ups should continue until the 90-day probation period/evaluation takes place. At the 90-day evaluation, the company should officially welcome the employee. This can include handing out shirts or jackets with the company’s logo, office keys or other official items.

    The next step is to maintain a positive and productive culture. Retaining the right people is equally vital to sustaining culture. The 2018 Gallup Employee Engagement Study reported that a third of staff members are in the “superstars” category; these employees are self-starters and generate the majority of profits. About half of the workforce can be categorized as “just there.” This large group has the potential to be turned into superstars, which is why a large part of a leader’s time needs to be spent with them. Lastly, about one staff member out of eight is described as actively “disengaged.”4

    When it comes to maintaining a strong organizational culture, communication and repetition are key. Daily huddles, weekly lineups, monthly meetings, annual strategic planning meetings and annual company retreats should be instituted to create and nurture a culture of communication and trust. These communication channels help prevent confusion and lack of trust. Transparency, involving staff in decisions and laterally helping departments solve problems are important to staff. When this level of collaboration takes place, trust and respect are evident.

    Ongoing education

    Continually educating all staff will help the team to feel more confident about their job. In turn, this will help make patients more comfortable about the services rendered. Educating staff includes departmental training and training for their position, as well as cross-training if possible, which promotes a team environment and helps staff members know that they are there for each other. It is essential that leaders have the same expectations regardless of position or years working for the company. Discipline is one of the keys to being a fair leader, as well as driving culture in a consistent manner, especially when addressing poor performance. Leaders should hold staff accountable for their duties through tracking metrics. Two simple ways to hold staff accountable are using a spreadsheet to help track daily progress or having an end-of-the-week debrief to go over weekly accomplishments. These tools help ensure fairness and help keep staff responsible.

    Stay interviews

    Stay interviews are another tactic to maintain organizational culture and should take place at least once a year independent of annual staff evaluations. They are brief, informal sit-down meetings leaders have with their staff to ask how they feel about their job. Stay interviews are vital as they help the organization understand what makes staff and providers content, and they serve as a guide for addressing company issues. Discovering issues before exit interviews, when it may be too late to rectify a behavior or a process, is necessary when making timely changes. If an organization has a strong workforce, it should strive every day to listen and improve its culture, workflows and processes.

    Employee surveys

    Another way to gauge staff engagement is by conducting quarterly employee surveys. These surveys should be anonymous, as they give staff and providers a channel to voice concerns, offer praise or share ideas for improvement. After anonymous surveys take place, leadership should communicate the feedback to employees. Leaders should state which changes are taking place and why. This tells the staff that their input is valued.

    Incentives to grow

    Employee incentive programs can help distinguish an organization in today’s healthcare world. Incentives are a great way to motivate staff and ultimately build an exceptional culture. These could include tuition assistance, financial assistance to attend conferences, extended vacation time, flexible or work-from-home schedules and/or empowering staff by giving autonomy to self-manage. Consider promoting an “Employee Promise,” in which the organization has an open-door policy for suggesting improvements at any given time.

    A big part of providing incentives also relates to the team and each member feeling recognized, which can be accomplished in a variety of ways at little to no cost. A big incentive budget might not be feasible; however, there are low-cost options that can help motivate the team, such as:

    • Social events to help engage staff on a personal level
    • Celebrating work anniversaries
    • Recognizing annual accomplishments
    • Rewarding staff based on core values
    • Passing along thank you cards, emails or comments from patients
    • Having a kudos board on which staff and providers can praise each other through the month
    • Giving back to the community through service events or volunteering for a local charity.

    According to author and economist Mary Kelly, PhD, CSP, retired CPAE Commander, U.S. Navy, the three most essential components for an incentive or reward program are:

    1. Meaning to the staff or team
    2. Hinged to a measurable action
    3. Cannot come at the expense of others or build resentment.5

    The point is to make incentives personal and to have staff feel appreciated for the work they are doing.

    Termination’s role in culture

    Terminating employees is a necessity to maintain organizational culture, team morale and stability. Many leaders refrain from terminating employees who affect the overall well-being of the company. The longer these individuals are employed, the more harmful it is to team morale and daily operations. There are four “un” words to use before any termination, according to Scott Foster, director of talent acquisition at Whelan Security:

    1. Unaware: Has the employee been made aware of what they are doing? Has the employee been made aware that what they are doing is incorrect? Has the employee been made aware of what they are not doing but supposed to be doing? Has the employee been made aware of what changes need to take place and how to make them? Has the employee been made aware of how their actions or behavior are affecting the team, morale, culture and patients?
    2. Unable: Has the employee been adequately trained to accomplish their duties and responsibilities? Does the employee physically have the resources and skill sets they need to perform at their best? Is the employee capable of performing their duties?
    3. Unwilling: If the above two points have been met, meaning the employee is aware, capable and trained, and the employee is still not performing, this means they are unwilling to change.
    4. Unemployed: Therefore, this will ultimately lead to termination.6

    Terminating employees at the right time lets the rest of the staff know which behavior is not tolerated. During termination, it is vital to have a documented exit interview, regardless of the circumstances. An exit interview helps leaders find out how they can improve and what the employee enjoyed about the position. It’s important to measure turnover trends rather than turnover percentage, because there will often be high turnover when significant organizational change occurs that results in an overhaul of staff.


    Organizations and leaders need to give staff a more significant and profound purpose for going to work each day beyond a financial incentive. A survey of about 170 MGMA members found that about 85% of respondents say that the driving factor for employees working for their current organization can be traced back to culture, how the staff feels they are treated and the people who make up their team. This speaks volumes about what’s important to healthcare leaders and staff in an employer. About 93% of survey respondents felt that a new hire or legacy employee needs to be a good fit with their company culture. This tells us how valuable teamwork is in healthcare organizations across the country.

    There are unfortunate and common consequences for medical practices and companies that do not possess a strong, positive and long-term organizational culture. Staff often become disengaged since they do not have a “why” or a bigger purpose to come to work other than a paycheck. Having a disengaged workforce creates high turnover, which can be costly as leaders have to take time and resources to fill positions and train new staff to get back to working at full capacity. It also creates a less personal experience for patients. With high turnover, patients might look for other options to meet their healthcare needs.

    Having the privilege to take care of patients every day is one of the most vital and pivotal lessons learned through working in healthcare. Staff, providers and healthcare leaders are dealing with a unique service and a unique consumer, and the importance of a healthy organizational culture is as vital as any other service sector. Healthcare organizations must have the right internal culture that keeps providers and staff motivated to perform their best every day; patients deserve world-class care when they trust a particular institution for their well-being.

    Having the right conversations

    For more expert insight into how top-performing companies address organizational culture, I interviewed Jason Bockhorn, senior travel industry sales manager for The Ritz-Carlton Hotel Company/Marriott International.

    What is culture to you?
    Culture, to me, is a group of like-minded individuals working together in harmony and cooperation looking to strive for the same goals.

    What is your company’s culture?
    Our company was founded on a community of culture. And in our everyday actions, we live and breathe The Ritz-Carlton Culture.

    • We have a Motto: “We are Ladies and Gentlemen serving Ladies and Gentlemen.”
    • We have a Credo: “The Ritz-Carlton is a place where the genuine care and comfort of our guests is our highest mission. We pledge to provide the finest personal service and facilities for our guests who will always enjoy a warm, relaxed, yet refined ambiance. The Ritz-Carlton experience enlivens the senses, instills well-being and fulfills even the unexpressed wishes and needs of our guests.”
    • We have Service Values (“I Am Proud To Be Ritz-Carlton”):

    1. I build strong relationships and create Ritz-Carlton guests for life.
    2. I am always responsive to the expressed and unexpressed wishes and needs of our guests.
    3. I am empowered to create unique, memorable and personal experiences for our guests.
    4. I understand my role in achieving the Key Success Factors, embracing Community Footprints and creating The Ritz-Carlton Mystique.
    5. I continuously seek opportunities to innovate and improve The Ritz-Carlton experience.
    6. I own and immediately resolve guest problems.
    7. I create a work environment of teamwork and lateral service so that the needs of our guests and each other are met.
    8. I have the opportunity to continuously learn and grow.
    9. I am involved in the planning of the work that affects me.
    10. I am proud of my professional appearance, language and behavior.
    11. I protect the privacy and security of our guests, my fellow employees and the company’s confidential information and assets.
    12. I am responsible for uncompromising levels of cleanliness and creating a safe and accident-free environment.

    • We have our Three Steps of Service:
      1. A warm and sincere greeting.
      2. Use the guest’s name. Anticipation and fulfillment of each guest’s needs.
      3. Fond farewell. Give a warm good-bye and use the guest’s name.

    Why is culture important in any organization?
    Culture in any organization is important to keeping things unified, the team on track. It fosters harmony in the workplace. It creates innovation. A culture creates loyalty.

    How do you create culture within an organization?
    You create culture in an organization by first being organized with the vision of the culture. Writing down the steps and how to live this on a daily basis with the team.

    How do you maintain culture in an organization?
    You maintain the culture by being consistent with the messaging and talking about it every day. Having the team talk about the culture so much that it is more or less ingrained into their memories.

    What are specific methods/tools that your company uses/developed to create and maintain culture alive every day?
    We have a CTQ (Commitment to Quality), which is read every day at department line-ups at every Ritz-Carlton Hotel around the world sharing the same messaging. Some hotels do a form of Olympics every year during which teams participate in games in their knowledge of the company’s culture and ethics.

    What keeps you working for this company?
    What keeps me working for the company is exactly everything I have talked about above. I know that every day I come to work; I am here as part of a unified team looking to create the exact same guest experience as I want to create.

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    1. “Culture.” Merriam-Webster, Merriam-Webster, 2019. Available from:
    2. The Ritz-Carlton Leadership Center. Excellence in the Patient Experience Workbook. 2015.
    3. Berry LL, Seltman KD. Management Lessons from Mayo Clinic. McGraw-Hill, 2008.
    4. Harter J. “Employee Engagement on the Rise in the U.S.” Gallup. Aug. 26, 2018. Available from:
    5. Kelly M. Master your World. Kaimana Publishing, 2013.
    6. Foster S. “Change Management, The 4 UN’s of Management.” 2018 Florida MGMA Annual Conference. Presented June 21, 2018. Orlando.


    Rosalba Miranda Lozano

    Written By

    Rosalba Miranda Lozano, BBA, MBA, LLSGB, FACMPE

    Rosalba Miranda Lozano can be reached at

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