By Joseph Cabral, MS, and Thomas H. Lee, MD
In healthcare today, organizational culture is essential to success. Performance matters as never before, and delivering care that is high-quality and also empathic, safe, and efficient requires a workforce that prides itself on excellence. The marketplace is increasingly driven by competition on value, which means organizations must not only be exceptional today, but also continuously improve.
This need for continuous improvement requires embracing what psychologists refer to as a “growth mindset,” which stems from the belief that improvement is attainable through hard work and perseverance and can best be achieved through the development of an engaged, collaborative, and highly committed workforce. Guided by this understanding, chief human resources officers (CHRO) of high-performing organizations have transitioned from being the “keepers of culture” to the “drivers of culture change.”
The concept of the growth mindset flows from work by Stanford psychologist Carol Dweck (2016), which has focused mainly on individuals but is relevant to organizations as well. In addition to assuming that improvement is always possible, a growth mindset assumes that individuals can learn from failure, thrive on challenges, and stretch their current abilities. In contrast, a fixed mindset assumes that capabilities are basically static; that if someone is already trying hard, qualitative changes in performance are unlikely and expecting them is unrealistic.
At the organizational level, creating a growth mindset requires leadership from the CEO and support from the executive team, but it’s the CHRO in particular who is responsible for cultivating the necessary social norms and values to achieve it. The CHRO must strive to maintain standards of excellence while also fostering a restless discontent with the status quo.
Because of the need for such change, the role of CHRO is becoming more expansive both in its charter and influence. Rather than focusing largely on the management of workforce policies and initiatives, CHROs in today’s forward-thinking organizations are drivers of culture change.
The CHRO’s new role
Organizational culture refers to the social norms and values that shape the behavior and interactions of an organization’s workforce. These norms and values should be “owned” by everyone on the senior management team, but CHROs have a particularly critical role in defining them, propagating them, and making them real. They must be articulated explicitly during the recruiting stage, and it is the responsibility of the CHRO to ensure that the promises made to and by the employee—the internal value proposition—are kept.
Four key functions characterize this role as keeper of culture.
- Articulate the employee value proposition.
During the recruitment process, the CHRO must ensure that the norms and values of the organization are communicated as a value proposition for prospective employees. In other words, candidates should be able to understand why they will be better off if they gain a position in the organization, above and beyond compensation. For example, prospective employees may be attracted to working for a stable and highly respected organization; as such, the recruitment process might emphasize that the basis of that respect and stability lies in the high standards of excellence that characterize the institution’s care.
- Emphasize organizational values.
During the onboarding process, the organization must emphasize the values that are most important to it. For example, at North Carolina–based Atrium, the onboarding process begins with a half day of community service to help new employees understand that the organization sees its role as something beyond providing reimbursed healthcare services. Other organizations ensure that every new employee understands key values through a range of communications, such as videos, discussions, or other means.
- Ensure that the values being communicated are real.
The CHRO must work assiduously to ensure that the values articulated by the organization are not just a campaign, but rather are truly modeled at all levels of the organization. Rhetoric and apparent hypocrisy lead to cynicism among clinicians and other personnel, and cynicism undermines the flexibility and resilience that are critical to high-quality care. Because culture is often determined “close to the ground,” CHROs must be tuned in to employee feedback and other forms of information from small units of the organization, not just the overall system. Averages from data across the total organization can mask serious problems at more targeted levels.
- Engage senior leaders as culture advocates.
The CHRO must be aligned with the CEO and utilize other senior management strategically to communicate the social norms and values important to the organization’s culture, and ensure that all leaders reinforce the norms and values through their own conduct.
These four key functions require adaptation for CHROs to be critical players in driving culture change. Articulating the employee value proposition, for example, now demands more than communicating a set of values to prospective and current employees. It requires the alignment of organizational goals with the responsibilities of different management levels.
The foundation of the hierarchy encompasses the tactical goals of supervisors and frontline team leaders. These goals are specific, and they often resemble a to-do list (e.g., manage length of stay, coordinate care with external clinicians, perform hourly rounding for inpatients, etc.). These goals support broader, operational goals of unit leaders and department directors, such as committing to zero harm, delivering care that is reliably empathic, reducing waste, and achieving consistent technical excellence. In turn, these operational goals track to the strategic goals of senior leadership, which should be both mission-driven and quantitative in nature.
Establishing a clear line of sight from the tactical- and operational-level goals to the overarching strategic goal helps motivate personnel at all levels to push hard to improve. When the connection is not obvious or well-articulated, improvement efforts can stall.
In many organizations, performance management tools such as balanced scorecards have been adopted to help leaders collectively take responsibility for the overall goal hierarchy, rather than focusing solely on their own operational area. Many organizations are beginning to embrace this idea of collective responsibility for the various dimensions of performance—safety, quality, patient experience, and workforce engagement—that are integral to delivering patient-centered health care.
It is the responsibility of the CHRO to nurture a culture in which leaders at all levels of the organization understand the interrelationships between all of these dimensions and with the top-level strategic goal; leaders must also have a clear vision of how their teams’ work influences progress toward that goal.
To this end, operational and strategic goals should be clearly communicated during onboarding, and the priority must be about meeting patients’ needs. We have observed that, when organizations assert they have multiple, equally important missions (e.g., research, teaching, patient care), it is difficult to create a clear goal hierarchy with operational goals that track up to the strategic priority. In turn, it becomes difficult to make choices in general, and difficult to persuade prospective and new employees that leadership has clarity on what matters most.
The CHRO, as a driver of culture change, must guide the CEO and the board toward creating clarity on the operational and strategic goals, articulating them, and managing them accordingly. The CHRO should align with the CEO to help senior leaders capture the stories that make the organization’s core values explicit, and ensure that these leaders conduct themselves in a manner consistent with expressed social norms.
Closer to the front lines of care, the CHRO must cultivate an understanding of the goal hierarchy among middle managers so the managers understand that the various dimensions of performance are intertwined. The organization must make that growth mindset a social norm for any manager who hopes to thrive in the organization over the long term. Managers should know that if they are not improving, they are failing. They also should know they are supposed to improve all the dimensions of performance, which they can achieve through building engagement of their frontline caregivers.
Finally, at all levels, to build a growth mindset, CHROs should encourage the celebration of not just excellence, but also improvement and resilience. The executive team should be capturing and repeating stories about patient units that improved their safety and other dimensions of quality, and showed their ability to learn from setbacks and deal with the unexpected.
The evolving role of the CHRO as the driver of culture change is more challenging but also more rewarding than the keeper of culture, and in today’s healthcare marketplace it is a more important one. It is central to strategy and a strong driver of business success. Clarity on the qualitative changes in this role will help some organizations adapt the role faster, which can provide a competitive advantage in this time of rapid evolution.
Joseph Cabral, MS, is chief human resources officer and president of workforce solutions at Press Ganey.
Thomas H. Lee, MD, is chief medical officer at Press Ganey.
- Dweck, C. S. (2006). Mindset: The new psychology of success. New York: Random House, 2006.