Organizational Culture: How to Create and Maintain a

Motivated Work Environment to Thrive in Today’s

Value-Based Healthcare Industry

Focus Paper

Rosalba M. Lozano, BBA, MBA, FACMPE Lean Six Sigma Green Belt

July 30th, 2019

This paper is being submitted in partial fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives.

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Introduction

“Company culture is the continuous pursuit of building the best, most talented, and happiest

team we possibly can.” – Andrew Wilkerson. How is organizational culture created and

maintained? Most importantly, why is organizational culture key to thriving in today’s value-based

healthcare industry? As medical practices and organizations move from fee-for-service

reimbursement to fee-for-value reimbursement, it is imperative for the cultural stability of the

organization to foster an environment that is positive in order to help the practice prosper. Patients

have higher standard of care expectations than before; therefore, healthcare practices must

revolutionize their internal operations through a devoted staff culture in which, employees strive to

meet and exceed patients’ expectations. From identifying why organizational culture is vital to

understanding the macro decisions that play a crucial role into creating and maintaining a thriving

and positive culture, this focus paper seeks to provide a clear understanding of internal

organizational culture. Through surveys from members of National Medical Group Management

Association (MGMA), research articles, pertinent books on this topic and respected interviewed

culture leaders, this paper will assist practice administrators and key stakeholders in most aspects

of how to create and maintain an organizational culture that will ultimately help any medical facility

thrive in the new healthcare landscape.

The purpose of this paper is for medical practice leaders to gain a better understanding of

why internal organizational culture is essential in today’s value-based healthcare and learn the tools

on how to create it and maintain it through time.

Background

With the tremendous amount of metrics, training, reporting, human resource issues, clinic

schedules and many other tasks that play a role in everyday work life, culture at times takes the

back seat in any leader’s priority list. What many healthcare leaders forget is that culture plays a

part of each of the duties mentioned above, creating a weaving effect of specific mindsets and

behaviors to accomplish daily tasks by all staff being on the same page. Having a healthy company

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culture fosters harmony and encourages even the lowest ranking staff member to be equally as

inspired as leaders up the chain. The Merriam-Webster Dictionary defines culture as a “set of

shared attitudes, values, goals, and practices that characterizes an institution or organization.”

Culture is so much more than this; culture affects every employee within every organization.

Culture is the way employees feel every morning when they wake up and get ready for a workday.

Culture is that pat in the back from the boss when the team accomplishes a goal. Culture is that

high five from a co-worker when a surgery or clinic day is completed successfully. Culture is that

hug from a patient as they leave the office or hospital saying, “Thank you for taking such good care

of me.” Culture is the way employees feel about their job while on the clock as well as how they

feel after they leave the office or hospital. Culture is the way employees feel about their work team.

Culture is the way employees serve patients every day. Culture is a way of life, and it is the family

environment that employers and leaders are empowered to create every day in their organizations.

Maya Angelou explained culture by saying, “I have learned that people will forget what you said,

people will forget what you did, but people will never forget how you made them feel.” Three

companies that continue to thrive, in large part, due to their culture and leadership include The Ritz

Carlton, The Walt Disney Company, and Mayo Clinic. Each of these organizations live and breathe

their mission every single day; they are great examples to analyze when it comes to culture.

The beginning of this paper focuses on a simple yet such important concept The Ritz

Carlton Leadership Center Training taught the author several years ago, that has inspired a journey

of culture-driven projects and career. First, the following three phases are fundamental when it

comes to embracing organizational culture. According to The Ritz-Carlton Leadership Center

Patient Excellence Workbook (24), there are three stages to becoming a passionate advocate. These

steps may be used interchangeably for anything the organization requires at the present moment.

This could mean a passionate advocate for culture, change, leadership, or patient care. These stages

need both a degree of effort from the employee and a degree of support from the employer for a

change to take place successfully:

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1. Conceptual: “Hearing It” Phase One

In phase one, it is essential for leaders to talk about culture and emphasize the importance

of it within the organization and 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-out of mind. Not having a

palpable culture will make it challenging to create a driven mission within any department.

Different ways leaders can communicate to staff consistently and ensure everyone is on the same

page will be discussed later in the paper.

2. Superficial: “Believing It” Phase Two

In phase two, once employees start hearing about the culture through different

communication channels, they will start believing it. This phase is when the wheels start turning,

staff begins to feel the culture around them and learns their role in it. This is the stage where

employees become empowered mentally and emotionally to start driving that same culture across

the organization, both internally with co-workers and supervisors, as well as externally with

patients, vendors, referral offices, or ancillary services.

3. Emotional & Personal: “Living It” Phase Three

In phase three, 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 mission of the company into

their personal lives, positively influencing their family and friends. Alternatively, as Leonard Berry

and Kent Seltman state 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” (31).“Living it” is the final

phase, this is where the author wishes every employee, leader, and organization will aspire to be

after reading this paper. It will not happen overnight, and it is not easy. It may require on-going

hard work and repetition; however, it is possible to accomplish if there is at least one individual

within every organization who believes in the company’s culture, vision, excellence in patient care,

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and believes in making employees feel valued and appreciated.

Organizational culture is exceptionally vital as it creates a motivated and engaged

workforce in an industry that essentially needs a team to function. The industry of healthcare is

compared to a metal chain with several iron links. On a macro scale, each link is compared to a

provider’s office, a hospital, or an ancillary service facility that is holistically needed to take care

of the patient. On a micro scale, each link is compared to a department within a hospital or different

provider offices that are owned by a more extensive network or individual departments within a

private practice. Whichever way this chain and these links are analyzed they are all connected and

forged from the same iron, symbolizing the team effort that is required to deliver the care that

patients deserve. Having a healthy organizational culture is like having a mighty glue stick that

helps create a bond and respect unlike any other. This, in turn, creates trust; a team without trust

has no bond and will forever 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. By decreasing turnover, the staff is helping build meaningful relationships

among each other and with patients helping the organization deliver excellence in patient care.

Secondly, having a team that is strong, cohesive, and with a strong internal culture, helps

companies get through any organizational change or any significant change impacting the industry.

Anytime a company or department is undergoing any process improvement plan such as a Lean

Six Sigma process using the Kaizen model, Gantt charts, or workflow charts having a distinctive

internal culture and reliable team are needed to create progress and impact. For any leader to be

successful in implementing these tools, a great culture needs to be in place, one that can work

together and support each other through a time of adaptation. Having a team that lives and breathes

their organizational culture will thrive in any change, including change of management, which can

be a challenging adaptation in healthcare organizations around the nation.

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Lastly, the author creates the following points by applying them specifically to healthcare

based on general concepts from The Ritz-Carlton Excellence in Patient Experience Workbook –

The Integrated Model of Culture (5). The phrases below represent significant results of a vibrant

internal organizational culture that help visualize how employee engagement leads to customer

engagement to ultimately yield higher financial performance, or in other words, culture leads to

service excellence which, leads to profit.

a) Culture leads to service excellence

b) Service excellence leads to developing a brand

c) A brand leads to establishing customer trust

d) Customer trust creates engaged patients

e) Engaged patients become repeat customers

f) Repeat customers foster loyalty and a positive word of mouth

g) Loyalty and a positive word of mouth produce profits

Body

For growth, a healthy culture is essential in a healthcare organization. However, execution

is vital to transforming a typical workplace into one driven by a positive culture. As Henry Ford

explained, “A vision without execution is a hallucination.” Most importantly, creating a culture

starts with having the right people and the right leadership in place. This refers to having the right

leadership at every step of the ladder from the top down. The author calls this “The Triangle of

Leadership and Culture,” which, emphasizes that even though culture trickles from the top down,

every level below the top needs to be embedded and is equally as important. A diagram of “The

Triangle of Leadership and Culture” is included in the Appendices for visual aid.

The first tier starts with providers or the CEO as the main driving force. These individuals

need to lead through inspiration and not fear. One of the most significant actions a true leader can

showcase is apologizing when it is necessary. This simple yet complicated action speaks volumes,

and it makes any team respect their leader. By leading through inspiration and genuinely

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apologizing when necessary, leadership at the top can touch and inspire many lives underneath

them.

The second tier of leadership consists of administration or any sub-managers/departments.

These individuals are the daily driving force that continuously reminds staff of the organizational

culture. This second tier trains and sometimes hires the right people for the right job.

Lastly, the third tier consists of staff who are the actual employees running day to day

operations and are at the forefront of the business. These individuals are the face of every

organization and are typically in physical contact with patients. If the right people are at the top of

tier one inspiring and leading by example, organizational culture trickles down to tier two and tier

three ultimately yielding service excellence to patients. Tim Sanders states in Love is The Killer

App that “by putting staff first, organizations will ultimately deliver excellent patient care, and will

unwillingly create a culture of ‘I get to do this’ vs. ‘I have to do this’” (163). An “I get to do this”

culture is created by making staff feel appreciated and creating a feeling of gratitude versus duty in

employee’s daily tasks. Having a shared vision and plan to accomplish goals together versus

creating individualism in the organization will be second nature, as the team is in it as a whole.

Hiring the right individuals starts with having a proper job description that creates

psychological ownership of the company’s brand. One trick that administrators can use is to place

a specific task on the job’s description to see who sincerely read it. This could include anything

from asking the candidate to create a short video or ask them to email their favorite color to the

hiring manager. This task serves as a filter to know which candidates focus on attention to detail

and those who do not. Staffing agencies will typically create a scoreboard for each interviewed

candidate with negotiables and non-negotiables. This helps keep track of candidates as the

interview process continues and in turn, helps report back to the organization or practice.

If the organization is doing in-house recruiting, the necessary process would be to screen,

interview, and do post-interview scoreboards. For the screening stage, an initial pre-screening

phone call takes place with simple questions and broad topics covered. A sample screening question

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pdf is found in the Appendices. If the candidate qualifies to move forward to a face-to-face

interview, both competency in the actual job and critical thinking should be analyzed. Many

organizations nowadays also commit to doing a working interview to see the candidate in a real-

life scenario and to see how they would interact with patients, co-workers, and leadership. If the

candidate has successfully completed a working interview, a panel interview should follow. This

interview includes specific questions that other departmental staff and providers ask the candidate.

Following a panel interview, a Strengths, Weaknesses, Opportunities, and Threats (SWOT)

analysis of the candidate is created by the team. A sample Candidate Analysis SWOT Graph is

included in the Appendices, it outlines the candidate’s skills, character, experience, and results.

Grading the candidate on competency and character is equally as crucial for this staff member to

be an advocate of organizational culture. Think about what legacy the candidate wants to leave

behind? Is this the right individual for the company as a whole? If the candidate meets the

expectations on the designated scorecard, the next move is to call them back and ask for references.

The same screening questions used in the initial screening phone call can be used to call references

to get professional input.

The last step in hiring the right people for the right job is to energize the candidate via their

onboard training timeline after they accept an offer. The onboard training is the best opportunity

any organization will have to get new staff members excited about where they are working and

why they do what they do. In the words of Richard Brandon, “Train people well enough so they

can leave, treat them well enough, so they do not have to.” During the onboard training, it is

essential to share the company’s mission (what, how, and why), vision, values, and motto. Values

are fundamental; they guide companies and 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. Some examples of strong values are concentrating on the fact that

titles are meaningless because everyone shares the hard work, leading by example or honesty and

ethics in the workplace. Every organization will decide what is of utmost importance to them and

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how they wish to drive their staff and operations. During this onboarding timeline, communicating

the job description with a clear expectation of roles, responsibilities, and performance is vital to

ensure both parties are on the same page.

One momentous day that the majority of organizations overlook is “Day One,” this is the

first impression the company will have on a new staff member. Companies can prepare a success

binder containing essential information and contacts about the new staff members role. Several

things can be done to make a new employee feel special on their first day; this, in turn, will help

open new employees’ minds and hearts to the company’s culture. Some examples are having a

simple “welcome to the team card” signed by all the staff and providers welcoming them, or leaders

can get creative by getting flowers or a “welcome to the team” kit. Another neat idea for leaders to

execute during the onboarding timeline is to have each new staff member whether they are a

provider or not, fill out a “staff preference card.” A staff preference card includes basic questions

about the new employee such as “What is your favorite color?”, “What is your favorite movie?”

“Do you practice any sports?” “Do you have any hobbies or collections?”. A staff preference card

helps any leader connect with their team on a more personal level, helping build a stronger bond.

A sample preference card is found in the Appendices. Having a continuous timeline to check-in on

the new hire, including a 3-week interview/meeting with the candidate to follow-up on how they

are doing goes a long way, and it helps get any questions out of the way before they are too late to

address. Bi-monthly follow-ups should continue until the 90-day probation period/evaluation takes

place. At the 90-day evaluation point, the company should officially welcome the employee. Many

times, this consists of handing out shirts or jackets with the company’s logo, office keys, or any

other official items.

The next step is to maintain a positive and productive culture through time. Hiring the right

people is a critical first step. However, retaining the right people is equally vital to sustaining culture

and is often forgotten by organizations and leaders. The 2018 Gallup Employee Engagement Study,

showcases that a third of staff members fall into the “superstars” category; these employees are

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self-starters and generate the majority of profits. Followed by about half of the workforce

categorized as “just there.” This large group has a great potential to be turned into superstars, which,

is why a large part of a leader’s time needs to be spent with this group. Lastly, about one out of

every eight staff members is described as actively “disengaged.” These statistics are fascinating;

readers are encouraged to start placing their workforce staff members into one of the three above

categories as the paper continues discovering several tactics to maintaining culture.

When it comes to maintaining an organizational culture, communication, and repetition are

key. Daily huddles, weekly lineups, monthly meetings, annual strategic planning meetings, or

annual company retreats should take place depending on what consistently works for every

company to create a culture of communication and trust. These communication channels help

prevent confusion, lack of trust and help the team be on the same page. Some of the characteristics

that the majority of the workforce admires based on the survey results found in the research of this

paper are the power of transparency, involving staff in decisions, and laterally helping departments

solve problems. When this level of collaboration takes place, it creates a magical environment for

trust and respect.

Regardless of position or tenure within the company, continually educating staff will lead

to the team feeling more confident about their job and this, in turn, will help make patients more

comfortable about the services rendered. Educating staff includes training for their department and

particular position as well as cross training if possible. Cross training helps form a team

environment and helps staff members know that they are there for each other when needed. It is

essential that leaders are consistent with management expectations regardless of the staff’s position

or years working for the company. Discipline is key to being a fair leader, as well as driving culture

in a consistent manner, especially when addressing unwanted behavior. There are situations that

every reader has been a part of that have not been easy to address; however, readers must remember

that as Mary Kelly states in her book Master Your World “Behavior that gets tolerated gets

repeated” (61). A great idea that helps in being a fair leader is to keep every staff member

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accountable for their duties through tracking metrics for every position. For example, an excel

spreadsheet can help keep track of the daily progress made by every staff member or having an

end-of-the-week debriefing meeting to go over the work accomplished are two simple ways to keep

staff accountable. These tools help leaders be fair across the board and help keep staff liable for

their responsibilities.

To continue with different tactics that help maintain an organizational culture and drive

excellence, stay interviews should take place at least once a year independently from annual staff

evaluations. Stay interviews are brief and very informal sit-down meetings leaders have with their

staff to ask how they are doing and how they feel about their job. Stay interviews are vital as they

help the organization analyze why staff and providers are content, and they serve as a guide to fix

anything that needs addressing within the company. Discovering any issues before an exit

interview, when perhaps it is too late to rectify a behavior or a process, is necessary to make timely

changes. If the organization has a strong workforce, it should strive every day to listen and to

improve its culture, workflows, and processes for the members working the trenches.

Another way to gauge how the staff is genuinely feeling toward their position, team, and

organization as a whole, is doing quarterly employee surveys. These surveys should be anonymous,

as they genuinely give staff and providers a channel to voice concerns, give kudos, or share ideas

for improvement. After anonymous surveys take place, leadership should communicate the

feedback to the employees. Leaders should state which changes are taking place and which ones

are not, along with reasons why. Perhaps that year funding is not available, or the organization is

tackling one project at a time based on priority. This tells the staff that they are heard and that their

input is valued. Samples of both stay interviews, as well as anonymous company surveys, are found

in the Appendices section of this manuscript.

Moreover, having employee incentive programs help distinguish an organization from the

rest in today’s healthcare world. Incentives are a great way to motivate staff and ultimately build

an exceptional culture. These could vary from tuition assistance, extended time off for vacation, a

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flexible or work from home schedule, giving staff new uniforms every so often, having financial

assistance for education or conferences, empowering staff by giving autonomy to self-manage and

ultimately create unforgettable experiences for patients, or having an “Employee Promise” where

the organization oaths to have an open door policy for improvement at any given time.

A big part of giving staff incentives also relates to the team, and each member feeling

recognized, this is accomplished in a variety of ways that are at little to no cost for the company. A

big incentive budget might not be feasible; however, there are low-cost options available that can

help motivate the team, such as:

simple social events to help engage staff on a personal level

celebrating work anniversaries

recognizing annual goal accomplishments

rewarding staff based on core values

passing along thank you cards, emails or comments from patients

having a kudos board where staff and providers can write kudos to each other through the

month

giving back to the community by doing service events or doing volunteer hours for a local

charity organization.

The three most essential components for an incentive or reward program according to Mary

Kelly in the book Master your World are 1) the reward or incentive needs to have meaning to the

staff or team, 2) the reward needs to be hinged to a measurable action and 3) the reward cannot

come at the expense of others or build resentment [12]. The point is to make incentives personal

and to have staff feel appreciated for the work they are doing.

Of course, having incentives that motivate the workforce and set the organization apart is

wonderful; however, employers must offer competitive salaries. There are different tools to keep

up with the market. Networking is always a great informal way to stay afloat; however, two more

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formal channels are the National MGMA Annual Compensation Survey as well as Horne Business

Advisors Compensation Services. It is imperative for organizations to know where they stand in

wage offerings; these can range from premium, fully competitive, competitive, or marginal. Based

on where the organization stands on base salary compensation, yearly incentives, and reward

program decisions for every staff and department can be determined.

Organizations continue to struggle with a certain percentage of the workforce for whom no

matter how well these staff members are compensated or incentivized, at the end of the day they

are not the right fit the company, and they are not delivering the results required for that position.

The inevitable must take place after progressive discipline has been in effect with no significant

change by that staff member or provider to improve. Terminating employees is something that has

to take place in order to maintain organizational culture, team morale, and work stability. Many

leaders linger terminating employees that hinder the overall well-being of the company; this is one

of the most damaging indirect actions that affect organizational culture. The longer these

individuals are employed, the more harmful this is to the morale of the team and daily operations.

The traditional steps of progressive disciple start with an informal conversation to see what the

issue is, followed by a verbal warning that is typically documented, then a formal written warning

takes place and finally suspension to allow the employee to think about how to the wish to move

forward upon returning to work. If nothing changes after these steps have taken place, termination

should occur. The 4 UN’s are a good rule of thumb to use before any termination, given by Scott

Foster, Director of Talent Acquisition at Whelan Security, at the Change Management Conference

Session for Florida MGMA Annual Meeting in 2018:

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

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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 have been met, meaning the employee is aware, they are

capable and trained, yet the employee is still not performing, then this means they are

unwilling to change.

4. Unemployed: Therefore, this will ultimately lead to termination.

Letting go of employees at the right time sends a message to the rest of the staff, letting

them know which behavior is not tolerated. When termination is taking place, it is vital to have a

documented exit interview, regardless of the circumstances. An exit interview is an excellent

opportunity for every organization and leader to know how they can improve and what the staff

member loved about their job. Hopefully, stay interviews, and constant communication happen

before this point, and the exit interview is more of a formality that needs to happen for human

resource purposes. An important thing to keep in mind is to measure turnover in trends and not as

a percentage for accuracy since many times there will be high turnover when significant

organizational change happens or at a specific time within an organization. For example, a change

in leadership takes over the company, and a complete overhaul in staff takes place for the better.

Discussion

With the help of National MGMA member communities, healthcare practice leaders from

across the country responded to surveys in respect to what employees’ value most from their

employer and what motivates them the most to do a great job. There were two types of questions

utilized for this research. For questions 1-4, respondents were given a scale from 1 to 100.

Questions 4-8 were open-ended to give respondents more freedom on the feedback they shared.

Survey answers show several key factors that motivate employees to perform at their peak;

however, the answers convey one united message. The culture, the people, and how organizations

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treat each other as human beings play the most prominent role in motivating the workforce to do a

great job in day-to-day tasks. Below are the survey questions, followed by a summary of all

participant responses (detailed responses found in the Appendices):

1. Question: How confident are you in knowing your company culture (mission, vision, and

values)? (0 meaning you do not think this is important and 100 meaning you believe in it

so much that you could probably tell me your mission statement and values from the top

of your head).

Response Analysis: There were a total of 183 respondents that on average, felt 80%

confident in knowing their company culture and being comfortable stating their

mission, vision, and values. The survey results show there is room for improvement

throughout many organizations, to continue conveying the organization's internal

culture by constant repetition and action. The goal is for leaders to get employees and

staff closer to the 100% mark and making staff confident about their company culture

to the point where every member of the team will be able to not just recite but truly

embody their mission, vision, and values. These responses urge readers to think about

the different tips and insights shared in this focus paper and to choose one or two action

items leaders can take back to their organization and make an impact to improve the

above 80% statistic.

2. Question: How important is it to you that any new hire and existing staff fit with your

company culture and are open to working well in a team setting? (0 meaning you really do

not care, 100 meaning you find this a make or break for someone working in your

company).

Response Analysis: There were a total of 183 respondents for this question which, felt

strongly (93%) about any existing staff and new hires fitting in and embodying their

company culture, to the extent this would make or break employees working for their

organization. This response is significant and holds valuable information, given that

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leaders throughout the country highly value organizational culture and desire a

cohesive and united front when it comes to sharing teamwork, mission, vision, and

values.

3. Question: How much do you value verbal appreciation from co-workers or supervisors

when you do a job well done? (e.g., receiving a "thank you for going above and beyond,"

"you did great today," "we could not have done it without you") (0 meaning you do not

like receiving verbal appreciation, 100 meaning you perform best when this appreciation

is received).

Response Analysis: There were a total of 182 respondents to this question, and verbal

appreciation is valued at 79% in the workplace for a job well done. This high

percentage in the results shows how much a simple “thank you!” or “great job today!”

can go in any team or organizations culture. Company’s do not need to break the bank

to make their team feel appreciated or an integral part of the internal culture. These

survey results support how much verbal appreciation is still valued and very much

cherished even in today’s society of high technological and electronic communication

and how much verbal communication should be performed daily by every leader in the

workplace.

4. Question: How much do you value a healthy and transparent internal communication

system in your company? (e.g., supervisors letting staff know when any changes are

coming down the pipeline, having routine meetings or discussing projects/solutions

together) (0 meaning you do not believe communication is important, 100 meaning you

value communication so much you could not work in a place that did not communicate

well with their teams).

Response Analysis: There were a total of 182 respondents, who highly value (90%) a

healthy and transparent internal communication system within their company. So much

so, that survey results show respondents would not work in a place that did not

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communicate well within their teams. Given that this percentage is the highest of all

survey responses, communication needs to be a vital and palpable part of every

organizational culture and a part of the company’s values. It takes an extra amount of

effort; however, taking the time to communicate within each department consistently

and the company as a whole is imperative. Making the team feel a part of any

development taking place, letting them know in a timely manner what is coming down

the pipeline, taking employees suggestions and ideas into consideration, having daily

or weekly huddles to debrief, having monthly meetings, planning out office social

gatherings to name a few examples all make a monumental difference in any

organizational culture. These simple yet vital activities help stimulate communication

within the company and make a team united, one that is ready to face any challenge

and celebrate every success together.

5. Question: What makes you feel the most appreciated and motivated in your job that your

senior leadership and the company does for you? If you do not have any work motivation

instilled by your company or supervisors, what would you like to see done to change this?

Response Analysis: There were 171 respondents to the above question, it is exhilarating

that 140 of these responses, making it about 82% had nothing to do with money, raises,

or bonuses. The survey results reaffirm the focus of this paper, showing that leaders and

staff need a strong and positive internal organizational culture to thrive and stay

motivated in today’s healthcare workforce. The following are some of the answers given

by respondents: “gratifying to see culture passed from one generation to another,

verbal recognition, making staff feel like a human being versus just an employee, taking

opinions and ideas into consideration, communicating any positive or constructive

feedback in a timely manner, a simple thank you, acknowledgement of a job well done,

bringing cake for birthdays and making the team feel special, working in a respectful

team environment, having an interest in the teams personal life, being recognized for a

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job well done in public, appreciating the work it takes to complete assignments

successfully, appreciation of loyalty, not being ignored.” A fair compensation needs to

be in place from the responses to this question; however, having a company culture that

has a clear mission, vision and values driving leadership, staff and day to day activities

will many times outweigh a high paying salary.

6. Question: What makes you stay working for this company?

Response Analysis: There were a total of 171 responses to the above question, and

culture comes up numerous times in this survey response. 146 of these responses had

nothing to do with salary or compensation being the main factor of why respondents

want to stay working for their current company, making this about 85% of answers.

The detailed responses on this question are a clear indicator that the teams employed

in each organization at the moment are still working there due in large part to the

culture and the people they interact with every day. These are some of the responses

from the survey: “our incredible team, good chemistry with supervisor, making a

difference, the people I work with, the physicians, flexibility, mission, ability to be

creative, partners are respectful to each other and foster a positive work environment,

being part of a cohesive team that values me, shared goals and values, appreciate the

support I get from supervisors, feeling valued, culture, company’s core values, having

evaluations based 50% on citizenship and how we treat others, feeling of belonging,

believing in the mission, fitting well with company culture.” Answers to this question

support the importance of creating and maintaining organizational culture by leaders

and staff in healthcare companies across the country.

7. Question: What does your company need to do or continue doing if they wish to keep loyal

employees working for them for many years to come?

Response Analysis: There were a total of 172 responses to the above question, a lot of

the answers call for better transparency and communication, maintaining competitive

18

salaries and again the overall message of continuing to build a culture where people

come first. The following are some of the answers: “allowing employees to contribute

to ideas and learn new things, having a culture that promotes communication, keep

valuing people, develop teamwork, do a better job at verbal recognition, continue to

show appreciation, keep treating employees with respect, transparency, better top-

down presence, stay true to core values, continue to invest in culture and team,

continue offering competitive salary and benefits.” A lot of these responses also focus

on having competent salaries and bonus structures that will help keep employees

motivated in the workforce, hence why it is vital to know where each organization

stands in compensation ranges and to ensure competitive wages are a part of the overall

employee incentive program.

8. Question: What prohibits you from performing at your best in this company?

Response Analysis: There were a total of 170 respondents to this question, and the

majority of responses give the reader a good idea that healthcare leaders across the

country are asking for communication and a positive organizational culture. The

following are some of the responses: “not being included in meetings, negativity, not

understanding how change is impacting the department, burnout, politics, poor

leadership, attitudes of partners, not having a clear mission, lack of transparency and

communication, not being heard, high turnover, not having the information needed,

lack of cooperation, not holding people accountable, work overload, lack of time, short

staffed.”

The results from the above 1 through 8 questions are attached in a pdf document,

showcasing detailed responses. The survey performed was anonymous and was offered through

different National MGMA member communities, specifics such as demographics, organizations,

or tenure from respondents are unknown. As the results portray, acts of appreciation and a simple

19

“Thank you” go a long way. The importance of culture is at the center and core of all the answers

to the survey questions, outlining the importance of creating and maintaining an exceptional

organizational culture. The author hopes that some of the ideas and steps outlined above in this

focus paper can be of help in achieving a great organizational culture for the reader.

Furthermore, the author appreciates the opportunity to have been able to interview and

share the responses of two inspirational leaders that currently work or have worked in companies

that are beacons in society exemplifying world-class organizational culture. Even though neither

organization is healthcare related, both of these organizational culture examples can be translated

into any service industry, including healthcare. Lee Cockerell, Retired Executive Vice President

for Walt Disney World Resort, and Jason Bockhorn, Senior Travel Industry Sales Manager for The

Ritz-Carlton Amelia Island, graciously gave the answers to the below interview questions. The

interviewee’s responses reaffirm how clear it is that these companies have thrived through the years

in large part due to an impressive internal culture that has been embedded into every staff member

in day to day operations.

1. Question: What is your name, your position, and what company do you work for or have

worked for?

a. Lee: “I am retired now. My name is Lee Cockerell, I was the Executive Vice President

of Disney World for 10 years, and I opened Disneyland Paris. Before that, I was with

Hilton Hotels for 8 years and Marriott International for 17 years.”

b. Jason: “Jason Bockhorn, I am the Senior Travel Industry Sales Manager for The Ritz-

Carlton Hotel Company (Marriott International).”

2. Question: What is culture to you?

a. Lee: “The way people behave and treat others.”

b. Jason: “Culture to me is a group of like-minded individuals working together in

harmony and cooperation looking to strive for the same goals.”

20

3. Question: What is your company’s culture?

a. Lee: “Everyone matters, and they know they matter. We respect, appreciate, and value

everyone.”

b. Jason: “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: Ladies and

Gentlemen service 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.” (detailed

list of values outlined in Appendices).”

4. Question: Why is culture important in any organization?

a. Lee: “Great people will leave if the culture is not respectful and professional, and they

will not serve the customers. Until the organization is committed to the employees, they

will not be committed to the organization.”

b. Jason: “Culture in any organization is important to keep things unified and the team

on track. It fosters harmony in the workplace. It creates innovation. A culture creates

loyalty.”

5. Question: How do you create a culture within an organization?

a. Lee: “The people at the top (CEO) sets the direction and expectations for how people

are treated, trained, developed.”

b. Jason: “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.”

21

6. Question: How do you maintain culture in an organization?

a. Lee: “By hiring the right people, training them with clarity and treating them right.”

b. Jason: “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.”

7. Question: What are the specific methods/tools that your company uses or developed to

create and maintain culture alive every day?

a. Lee: “We make sure everyone matters, and they know it. We continually communicate

our expectations for professionalism; we continually train and coach our teams; we

appreciate, recognize, and encourage everyone all the time.”

b. Jason: “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 where teams participate in

games in their knowledge of the company’s culture and ethics.”

8. Question: What keeps you working for this company?

a. Lee: “I enjoyed being a leader and teacher because I could help people be better every

day.”

b. Jason: “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.”

9. Question: Any last thoughts, comments, experiences, stories you would like to share that

would help fellow healthcare leaders across the country understand culture better and

realize its power within an organization?

a. Lee: “Treat every single patient and staff member respectfully. Treat everyone like it

was your mother, father, son, or daughter. Treat everyone the way you would like your

22

loved ones treated and cared for. For a great culture, hire them right, train them right,

and treat them right.”

b. Jason: “Many long-term Ritz-Carlton employees are often heard saying that they

‘bleed blue.” This is meant as a way to say that they are loyal to this company and

everything for which it stands. When the company keeps everyone rowing in the same

direction, that leaves little doubt and very few questions as to where the company is

headed. The culture alone makes it clear why you are here and why you want to be a

part of something bigger. I hear it all the time when I am traveling for work. Yes, there

are sometimes hotels more beautiful than ours, or newer, or in better locations. But

what keeps our guests and employees returning to The Ritz-Carlton time and time

again are the employees and the culture within they live and work every day.”

These interview questions and responses give leaders across the country affirmation that if

people are put first and the staff is treated with respect, companies will succeed. The author hopes

that these responses inspire companies to do better for their team, to continue to maintain their

culture, to remind their staff why they do what they do and to continue letting employees know

they matter. Even if there is no culture set in the reader's organization, the author hopes that this

paper will inspire readers to build one starting by creating a mission, vision, and values not just on

paper but in actions in day to day operations.

Conclusion

Without culture, employees are going to work only to get a paycheck. Organizations and

leaders need to give staff a more significant and profound purpose for going to work every morning

other than a financial incentive. A fair salary needs to be in place for this to work, of course;

however, it should not be the only driver. For example, according to a Netflix documentary titled

Mayo Clinic, all of Mayo Clinic physicians are salary based which, helps the organization drive its

mission in putting the patient first and helps physicians stay away from making unethical decisions

regarding patient care based on reimbursements or pay. Readers must not forget that people make

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or break a culture in an organization; healthcare leaders need to set an example of what the company

culture looks like and what behavior is not tolerated or rewarded. As Lee Cockerell stated in his

interview, “We need a unified team working together to achieve goals.” Organizations cannot

accomplish excellence in patient care alone, especially not in healthcare, as it is a system which is

organically linked to provide the patient with the best possible care.

The fact that about 85% of survey responses indicate that the main driving factor for

employees working for their current organization traces back to the culture, how the staff feels they

are treated, and the people that make up their team speaks volumes about what healthcare leaders

and staff wish to continue feeling and experiencing in their company. About 93% of survey

respondents felt so strongly that a new hire or legacy employee needs to be a good fit with their

company culture to the point where this would be a make or break that staff member continuing to

work there, tells us how valuable teamwork is in healthcare organizations across the country. The

Ritz-Carlton, Walt Disney, and Mayo Clinic are all organizations that are leaders in exceptional

organizational culture, that translates into staff delivering excellence in customer/patient care, all

three driven by a shared mission that is exemplified by its people every day.

There are unfortunate and common consequences for medical practices and companies that

do not possess a strong, positive, and long-term organizational culture. These results take place as

a ripple effect from the lack of culture starting by staff becoming disengaged since they do not have

a “why” or a bigger purpose to come to work every day other than a paycheck. As Simon Sinek

proclaims on his famous Ted Talk How Leaders Inspire Action, “There must be a “why” for leaders

and employees to do what they do.” The message he delivers is that everyone knows “what” they

need to do in terms of a job function, everyone, for the most part, knows “how” to do what they

need to do, but very few people and organizations instill the “why” they are doing what they do.

Having a disengaged workforce creates a high turnover. High turnover on top of being expensive

as leaders have to take time and resources to fill positions and retrain to get back to working at full

capacity, it creates a less personal experience for patients. Overall, high turnover creates an

24

inconsistent experience for patients. Patients want to create a relationship and a bond with their

healthcare team; they want to feel at ease and know that they will be taken care of. Once patients

feel comfortable with specific staff members, it creates a unique relationship in an industry that is

natively invasive in privacy. With a high turnover, patients might look for other options to service

their healthcare needs. All technical and medical care being equal, patients will choose a more

personal medical visit to attend their healthcare needs.

Healthcare is unique. It is unlike any other service industry, and all healthcare leaders are

privileged to take care of the healthcare consumer - The Patient. Having the privilege to take care

of patients every day is one the most vital and pivotal lessons learned through working in

healthcare, that is many times forgotten amid many day to day tasks healthcare leaders and staff

have to perform. As Leonard Berry and Kent Seltman describe in Management Lessons from Mayo

Clinic “Healthcare is dissimilar from most other services in significant ways, first healthcare

customers are usually sick or under significant stress; second healthcare is a need more than a want;

third healthcare services are inherently personal, no other service requires people to get undressed

both emotionally and physically; fourth healthcare customers require more holistic and customized

services; lastly healthcare customers are at risk of being harmed beyond their existing medical

problems by medication errors or infections a lot can go wrong when delivering care”(11). Given

that staff, providers, and healthcare leaders are dealing with a unique service and a unique

consumer, the importance of a healthy organizational culture is more vital than in any other service

sector. Healthcare organizations must have the right internal culture which 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. In summary, just like blood supplies oxygen to cells and

tissues in our bodies providing essential nutrients for human beings to function; culture supplies

the same nourishing to an organization making employees and leaders feel a part of something

greater and empowering them to make a difference every day.

25

Bibliography/Graphics/Appendices

I. Reference List

Angelou, Maya. “Maya Angelou Quotes.” Good Reads, 22 May 2019, https://www.goodreads.com/quotes/5934-i-ve-learned-that-people-will-forget-what-you-said-people.

Berry, Leonard L., and Kent D. Seltman. Management Lessons from Mayo Clinic. McGraw-Hill, 2008.

Brandon, Richard. “A Quote by Richard Branson.” Goodreads, Goodreads, www.goodreads.com/quotes/1192705-train-people-well-enough-so-they-can-leave-treat-them.

“Culture.” Merriam-Webster, Merriam-Webster, 2019, www.merriam-webster.com/dictionary/culture.

Foster, Scott. “Change Management, The 4 UN’s of Management.” 2018 Florida MGMA Annual Conference. Ringmasters in Healthcare, 21 June 2018, Orlando, Hyatt Regency.

Harter, Jim. “Employee Engagement on the Rise in the U.S.” Gallup.com, 26 Aug. 2018, news.gallup.com/poll/241649/employee-engagement-rise.aspx.

Henry Ford Quote: “Vision without Execution Is Just Hallucination.” Quotefancy, quotefancy.com/quote/28665/Henry-Ford-Vision-without-execution-is-just-hallucination.

“How Great Leaders Inspire Action.” Performance by Simon Sinek, www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action/up-next?language=en. 2009

Kelly, Mary, Ph.D. Master your World. Denver: Kaimana Publishing, 2013. Print.

“The Mayo Clinic.” Burns, Ken, et al., directors. Netflix, Inc., 2018.

The Ritz-Carlton Leadership Center. Excellence in the Patient Experience Workbook. 2015.

Wilkerson, Andrew. “12 Inspiring HR Quotes on Company Culture.” Rise, 15 Apr. 2019, risepeople.com/blog/hr-quotes-company-culture.

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II. List of Graphics

The Ritz-Carlton Leadership Center. Excellence in the Patient Experience Workbook. Becoming a passionate advocate graph.

27

Lozano, Rosalba Miranda. “The Triangle of Leadership and Culture Diagram.” 19 May 2019.

“Perform a Job Candidate Analysis.” Perform a Job Candidate Analysis, 2019, www.swotanalysis.com/candidate-analysis-how-to-guide.

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“Stay Interview Sample Questionnaire.” Helpside, www.helpside.com/wp-content/uploads/2017/12/Stay-Interview.pdf.

29

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III. Appendices

Lozano, Rosalba. “FACMPE Manuscript Survey Data- Organizational Culture.” Survey Questionnaire. March 20th, 2019 to April 30th, 2019. (PDF attached in submission email).

Lozano, Rosalba Miranda. “Staff Preference Card Sample.” 19 May 2019.

STAFF PREFERENCE CARD

1. What is your favorite color?

2. What is your favorite food?

3. What is your favorite drink (alcoholic/non-alcoholic)?

4. Do you have any favorite activities, TV shows (personal, w/family/spouse)?

5. Are you a sports fan or have done any sports that you are still very engaged in?

6. What are your favorite hobbies?

7. Do you have any collections of any sort?

8. What motivates you the most to do a great job every day/accomplish special projects?

9. When you are given ___________________ you feel most appreciated in the workplace.

10. List top items that you would like to receive as a thank you/appreciation for a job well done.

11. What do you value most about your work? /What makes you get up and come to work every day? /what drives you? /what motivates you?

12. You feel the most down/ un-motivated when ____________________________ happens.

13. What are some things you would like to learn in the workplace?

14. Anything else you would like to share with me about you :

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Lozano, Rosalba Miranda. “Sample Screening Interview Questions.” 19 May 2019.

SAMPLE SCREENING INTERVIEW QUESTIONS

Candidate Name: _____________________________ Date:____________ Time :_________

BEHAVIORAL

Tell me about yourself? Are you currently employed?

What do you know about our organization?

Why healthcare? Why this organization? What made you apply for this position?

Brush through resume: explain each job, why moving from one to another, cultures in

past jobs

Most significant learning points/experiences you’ve learned in your past jobs?

What would co-workers/management have to say about you?

Useful references for me to contact?

What makes you who you are today?

What is your biggest motivation to come to work every day?

Greatest strengths/weaknesses?

SKILLSET

Computer savvy: examples what the candidate has done in past jobs

Experience handling a multi-line phone system or any other technical duties

Customer service experience

Reaffirming traveling position, full-time commitment 40-hour work week, 8 am to 5 pm,

is this a problem?

Give me examples of how you can multi-task and keep organized being detailed oriented

Are you familiar with HIPPA regulations, medical terminology?

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Lozano, Rosalba Miranda. “Sample Company Yearly Survey.” 19 May 2019.

YEARLY PERFORMANCE EVALUATION FOR “XXX COMPANY”

Date: _____________

This is an anonymous survey that is put together by “XXX Company” every year to help gauge what we are doing great and what we need to improve to serve our employees and patients better. It is our goal to always listen to the most important voice that guides this organization- our people. Your honest feedback and ideas are truly appreciated, once all survey answers are received, we will share the changes that are taking place and why as well as which ideas are not and why not. We greatly appreciate you taking the time to answer this.

1. What are we doing great? What would you like the company to continue doing? What are some specific examples of things/actions/processes that we should continue doing that have positively impacted the morale, teamwork, patient care?

2. How can we improve to be a better company to work for? What are some specific examples of things/actions/processes that we should try to implement to positively impact morale, teamwork, patient care, and employee engagement?

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Cockerell, Executive Vice President (Retired and Inspired) Walt Disney World Resort, Lee. “FACMPE Organizational Culture Interview.” 13 Mar. 2019.

INTERVIEW QUESTIONS: 1. What is your name, your position, and what company do you work for?

I am retired now. My name is Lee Cockerell, I was the Executive Vice President of Disney World for 10 years, and I opened Disneyland Paris. Before that, I was with Hilton Hotels for 8 years and Marriott International for 17 years.

2. What is culture to you?

The way people behave and treat others.

3. What is your company’s culture? Everyone matters and they know they matter. We respect, appreciate, and value everyone.

4. Why is culture important in any organization? Great people will leave if the culture is not respectful and professional, and they will not serve the customers. Until the organization is committed to the employees, they will not be committed to the organization.

5. How do you create culture within an organization?

The people at the top (CEO) sets the direction and expectations for how people are treated, trained, developed.

6. How do you maintain culture in an organization? By hiring the right people, training them with clarity, and treating them right.

7. What are specific methods/tools that your company uses/developed to create & maintain culture alive every day?

We make sure everyone matters, and they know it. We communicate continually our expectations for professionalism, we continually train and coach our teams, we appreciate, recognize, and encourage everyone all the time.

8. What keeps you working for this company? I enjoyed being a leader and teacher because I could help people be better every day.

9. Any last thoughts, comments, experiences, stories you would like to share that would help fellow healthcare leaders across the country understand culture better and realize its power within an organization?

Treat every single patient and staff member respectfully. Treat everyone like it was your mother, father, son, or daughter. Treat everyone the way you would like your loved ones treated and cared for. For a great culture, hire them right, train them right, and treat them right.

34

Bockhorn, Senior Travel Industry Sales Manager The Ritz-Carlton, Jason. “FACMPE Organizational Culture Interview.” 12 Mar. 2019.

INTERVIEW QUESTIONS:

1. What is your name, your position, and what company do you work for? Jason Bockhorn Senior Travel Industry Sales Manager The Ritz-Carlton Hotel Company (Marriott International)

2. 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.

3. 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: Ladies and Gentlemen service 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: 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.

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We have our Three Steps of Service: 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.

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

5. 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.

6. 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.

7. What are specific methods/tools that your company uses/developed to create & 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 where teams participate in games in their knowledge of the company’s culture and ethics.

8. 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.

9. Any last thoughts, comments, experiences, stories you would like to share that would help fellow healthcare leaders across the country understand culture better and realize its power within an organization?

Many long-term Ritz-Carlton employees are often heard saying that they ‘bleed blue.” This is meant as a way to say that they are loyal to this company and everything for which it stands. When the company keeps everyone rowing in the same direction, that leaves little doubt and few questions as to where the company is headed. The culture alone makes it clear why you are here and why you want to be a part of something bigger. I hear it all the time when I am traveling for work. Yes, there are sometimes hotels more beautiful than ours, or newer, or in better locations. But what keeps our guests and employees returning to The Ritz-Carlton time and time again are the employees and the culture within they live and work every day.