How is the Water?: Assessing the Culture of Academic Medicine

There are these two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys, how’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, “What […] is water?”

David Foster Wallace, Kenyon College commencement speech1

Organizational leaders have two primary tools to shape the trajectory and success of an organization: strategy and culture. Despite often being more challenging to characterize, the impact of culture is profound, as famously expressed by management guru Peter Drucker and later popularized by Ford CEO Mark Fields: “culture eats strategy for breakfast.”2

Organizational culture is said to be “the sum of values and rituals which serve as ‘glue’ to integrate the members of the organization”3 and is foundational to the performance and wellbeing of an organization. If we are fish, our culture is water—the invisible forces surrounding us that reinforce our values and beliefs, and ultimately influence our behaviors. While we may be vaguely aware these forces exist, we are seldom able to fully describe or influence them.4 However, efforts to describe, measure, and assess culture offer us tools to shape norms and values, allowing for strengths to be identified and supported while addressing weaknesses with targeted interventions. Furthermore, the ongoing evolution of healthcare from hospital-based to system-based through mergers and acquisitions will undoubtedly impact the cultures of involved hospitals.5 Thus, a nuanced understanding of culture may help maintain what makes a given healthcare organization unique, cultivate shared norms and ways of thinking that attract talent, improve patient safety and physician wellbeing, drive innovation, and enhance the experience of being within and belonging to an organization.

Some tools have already been developed to assess dimensions of healthcare organizational culture, with particular attention toward patient safety and quality of care.6,7 Academic medical centers (AMCs), however, have not been examined specifically and deserve their own assessment. By virtue of their “tripartite mission,” AMCs differ from most healthcare organizations in that they not only focus on taking care of today’s patients via clinical care, but also invest in care of future patients through training and research. Residency and fellowship programs prepare the next generation of providers while research produces practical knowledge and tools to advance future healthcare delivery. While outcomes related to current clinical care are easier to capture, those related to research and training can be more difficult to understand and manage. Management of an AMC, then, involves balancing the tangible needs of today’s patients with those of tomorrow’s patients, and investing resources accordingly. A framework to describe this unique combination of cultures in AMCs would fill an important gap in the literature and in manager’s tookits.

We propose a conceptual framework for assessing the culture of an AMC (Fig. 1). AMCs contribute to stellar patient care through direct clinical care, training, and research, an integrated system facilitated by management.

F1FIGURE 1:

Components of culture in an academic medical center striving to provide excellent patient care: clinical, training, research, and management.

CLINICAL CARE

Stakeholders in clinical culture are those involved in providing clinical care. In an AMC surgical department, this would include attending and resident surgeons, nurses, physician assistants, and many support staff who care for patients. Values prioritized in clinical culture may include safety, teamwork, inclusiveness, respect, clear communication, and commitment to excellence. Tools to assess clinical culture may target particular values. Of these values, safety culture has been especially well-studied. For example, the Safety Attitude Questionnaire quantitatively measures aspects of culture such as safety climate, teamwork, and working conditions, while the Manchester Patient Safety Framework is a qualitative tool carried out through facilitator-led workshops that helps describe what an organization would look like at different levels.8 Annual staff surveys, interviews, apps, questionnaires, and even audit and incident reports are now commonplace to measure other aspects of clinical culture and perceptions of care delivery.7 Although some tools, such as the Nursing Culture Assessment Tool (NCAT), focus on specific groups, instruments to measure clinical culture should make an effort to include a wide variety of role groups collectively.

RESEARCH

Research fuels new developments in medical technology and treatment that can benefit current as well as future patients.9 In an AMC, stakeholders in research culture include directors of research centers, physicians who lead and are part of research labs, research assistants, and other staff who contribute to research. Values prioritized in research culture include innovation, integrity, humility, lifelong learning, collegiality, and collaboration. Interventions in the resident research curriculum have been recognized to contribute to research culture in an AMC.10 However, tools to study research culture exist mostly outside the healthcare sphere, developed by universities and other organizations invested in higher learning. For example, the University of Glasgow has run recent Research Culture Surveys that include both quantitative and qualitative questions designed to measure perceptions of research culture and inform research policies.11

TRAINING

Training serves future patients by educating the upcoming generation of physicians who will care for them. In an AMC, stakeholders in training culture include residency and fellowship program directors, attending surgeons, surgical residents, advanced practice providers, nurses, and medical students. Organizational culture can influence how trainees are selected and how they are taught. Values prioritized in trainees may include proficiency, autonomy, teamwork, and understanding of the community, while those prioritized in mentors may include faculty development, accountability, competency, communication, respect, and humility. Tools to study training culture are still developing. They have included, for example, open-ended questions designed to assess positive and negative aspects of the operating room as a workplace and learning environment,12 as well as rankings of competency expectations in residents. Also, the Organizational Cultural Inventory, which has been used across business and military contexts to measure 12 thinking styles of individuals in a group, has been used to gauge what values and characteristics are considered important in incoming trainees.13

MANAGEMENT

Management in an AMC has the unique challenge of balancing the needs of current and future patients. Management culture can influence the other aspects of organizational culture through decisions based on the values prioritized for their clinical, research, and training operations. Management that takes steps to diminish hierarchy and promote open discussion, for instance, will foster a more supportive and psychologically safe culture for their trainees; and to the extent that cutting-edge clinical research is sometimes unable to attract outside funding in its initial stages, management can support research endeavors with clinical revenue. Stakeholders in management culture include, but are not limited to, the chief executive officer, chief financial officer, physician medical directors, chairs of departments, division chiefs, and staff involved in an administrative or managerial capacity. Values prioritized in management culture may include fairness, clarity, mentorship, and support. Tools to study management culture in healthcare are not widely used but have included, among others, the Competing Values Framework and the Hospital Culture Questionnaire.6 The Competing Values Framework has been applied to top hospital managers to identify 4 distinct value types (clan, adhocracy, hierarchy, and market); while the Hospital Culture Questionnaire can be used to measure employee opinions of dimensions such as supervision, employer attitudes, role significance, hospital image, staff benefits, cohesiveness, and workload. In the business literature, many additional tools are used to influence and manage corporate culture that could also be applied to healthcare management.6

THE MGH EXPERIENCE

No single culture is best. However, the experiences of our institution can serve to illustrate the rationale behind the framework we provided here to assess culture. At our own institution currently, the challenges of assessing departmental culture are especially pressing as 2 large AMCs integrate under an umbrella organization. As our institutions move forward, we are actively applying the above framework to assess our current culture and to monitor for any changes that come with the integration.

Over the past decade, our leadership strove to develop departmental cultures that anticipate the needs of our patients and workforce, and achieve the cutting edge of clinical care, research, and training. As chief of surgery, Dr Lillemoe has developed a collective clinical team dynamic, broke down interdepartmental silos and emphasized concepts of family, empowered, and developed junior faculty and residents, and increased diversity and inclusiveness of perspectives and backgrounds. As chief of cardiac surgery, Dr Sundt has similarly built a culture where the importance of the team supersedes that of the individuals, and facilitated synergistic relationships among staff to improve the clinical efficacy, and research and training excellence. With these changes in place, we are eager to monitor how the wider systems integration may influence our departmental cultures. And we hope that other academic departments of surgery will continue the work of applying studies of culture more broadly to improving organizational function and patient care.

CONCLUSION

The goal of all healthcare organizations is to deliver high-quality care to patients, but academic medicine does so in a unique way because of its responsibility and challenge as leaders of innovations. A comprehensive understanding of the culture of an AMC, therefore, can provide valuable tools for our leaders to continue to be engines of growth in medicine.

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