What Makes a Hospital Great? Culture


This has been sitting in my “to blog about” queue since March, but I wanted to catch up and post this article: “What Makes a Hospital Great” by Dr. Pauline Chen. Maybe it's not very “lean” of me to have so much “work in process…. but back to the issue at hand. What DOES make a hospital grrrrreeat?

Is it technology that makes a hospital great? The top surgeons? The MRI machines? The building's layout? The number of rooms?

Surprise, or maybe not a surprise to Lean Thinkers — it's the culture.

From the piece:

According to a study released this week in The Annals of Internal Medicine, the answer to the decade-long conundrum may have little to do with investing in high-tech equipment and evidence-based protocols. Instead, improving patient outcomes may require first investing in and focusing on the culture of the organization itself.

The article claims that business has known for a long time that it's all about the culture — they know that, but does the culture of most businesses reflect that knowledge? It seems not.

It's claimed that this is a biggest problem or weakness in healthcare (I'd tend to agree with that):

“It's how people communicate, the level of support and the organizational culture that trump any single intervention or any single strategy that hospitals frequently adopt,” said Elizabeth H. Bradley, senior author and faculty director of the Yale Global Health Leadership Institute at Yale University.

The best Lean healthcare organizations, like ThedaCare, focus a lot on the culture — but not in a vague, fuzzy way, but in a very concrete practical way. Their Lean culture is about how people communicate, in “Collaborative Care” teams and across the “value stream.” It's about managers providing support to make improvements happen so people can provide the best care; in other words, their daily management system.

Those daily behaviors and practices become your culture.

Again, from the article:

“A lot of people think that you have to go to a really big city teaching hospital with really expensive equipment,” Dr. Bradley said. “But we didn't find that to be true.”

You can get demonstrably better care in a small town like Appleton, Wisconsin, as published by John Toussaint MD and others in Health Affairs. Lower mortality, shorter “door to balloon” times, lower cost – it's because of the culture. And ThedaCare is NOT a big-city teaching hospital. They have a great culture and they provide excellent carwe.

A big part of the difference is a “blame-free culture” as we work on in the Lean movement:

At a low-performing hospital, such an error might result in doctors, nurses and pharmacists on the front lines blaming one another and hospital leaders taking care to remain uninvolved. But clinicians and leaders at a high-performing hospital would be eager to address the error, acknowledging it without disparaging one another and working together to re-examine and, if necessary, reconfigure the hospital's discharge process.

Instead of using mistakes and errors as reasons to fire somebody, we should use that error as a learning opportunity, so that we can prevent future mistakes that might harm or kill other patients.

The theme of “rocket science” comes up again, as I blogged about last week:

“We have to focus on the relationships inside the hospital and be committed to making the organization work,” Dr. Bradley said. “It isn't expensive and it isn't rocket science, but it requires a real commitment from everyone.”

Does your organization have that commitment?

I have a sad story in my head, from this past week, that I probably can't share (at least not yet) — a hospital that clearly does NOT have that commitment…. a hospital that is resorting to the old cheap trick of layoffs to try to save money, instead of seeing the Lean process through…

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Great article. Could not agree more. With shared values and a great culture and supports and organization can overcome poor strategy implementation (although, with a great culture, it is more likely the strategy would resonate with the culture and poor implementation is not likely).

    For half a decade staff in the health region I work have been telling senior leaders that despite policies on a just and trusting culture, staff work with fear and mistrust of management. Far too frequently (at least in the past… things have been getting better with a change in leadership) management behaviors contrary to a just and trusting culture have been tolerated. Even with the recent positive changes I would guess we are still 3 years away from meaningful cultural change.

    As consultant, I find myself asking the question of managers…”Does this action of yours truly reflect the values you want reinforced in the organization?” I know we still have a way to go when the answers fairly consistently are, “No, but…” or at best “Yes, but…”. Managers are all to often working with ambivalance of which values to represent… something you don’t see much of in great cultures.

    • PhysioWonk – I LOVE that consulting question of “does this action of yours truly reflect the values you want reinforced in the organization?” I am adding that gem to my tactics.

      Mark: Great post and I can’t agree more. I think many hospitals have identified the culture they want to have but do not check to see if actions taken help or hinder the culture they want. It is easy to say a “no fear” culture but then not realize (or call out) when subtle intimidations happen. How many places call for servant leaders but then hire people who think the phrase means they lead servants?

  2. Bravo and thank you, it’s about time that someone highlights how important the culture is in a healthcare administration levels. In order to get top notch care you have to be able to let the quality improvements flow from top down and bottom up. Great management that is closely working with stakeholders & all levels of staff can beat out heads and heals a hospital with the newest technology. Thanks, I’ll be sharing this one with some colleagues. :)


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