Culture is defined as a set of norms and values binding a group or organization. Sociologists have defined culture as the ways of thinking and acting and material objects that shape a person’s way of life. From that viewpoint, culture can be non-material or material culture. Non-material culture refers to the non-physical ideas that individuals have about their culture, including values, belief systems, rules, norms, morals, language, organizations, and institutions. In contrast, material culture is the physical evidence of a culture in the objects and architecture they make or have made.1,2

The daily operational activities of hospitalist groups reflect the groups’ cultural norms. These norms may be explicit or implicit. Examples include expectations outlined in a group’s handbook and expectations that providers in the group maintain a professional demeanor in stressful situations. The attainment and maintenance of positive, tangible results require the creation and adoption of a defined binding culture – “the way we do it here.”

The purpose of a binding culture is to ensure that the required norms are well known and adhered to in order to meet the groups’ set goals and expectations, including the domains of patient care, administration, and academic activities. This is particularly important in hospital medicine, given the many stakeholders in the inpatient setting.

Members of hospitalist groups tend to fall into three major categories:

  1. Those who plan for 1-2 years of inpatient clinical work before proceeding with their planned fellowship programs.

  2. Individuals who work for 3-5 years as part of the international work visa requirement and then pursue their long-held and cherished interests in other aspects of clinical medicine.

  3. Individuals who have decided to become career hospitalists. Some individuals in categories 1 and 2 may change plans and eventually become career hospitalists, with added interest in academic activities, case management, utilization review, operations management, or information technology (IT).

The need for binding culture cannot be over-emphasized given the relatively rapid staff turnover in hospital medicine, especially for individuals in Category 1. It is imperative that all group members know what the group’s norms and expectations are. Additionally, there is a need for synergy between the culture of the institution, the healthcare system, and that of their hospital medicine groups.

In the absence of a binding culture, “anything goes” and “on-the-spot” behaviors flourish – this may result in suboptimal patient care, mistreatment of colleagues or trainees, or other performance lapses. Just as successful organizations in other domains (athletics, manufacturing, IT) are influenced by their organizational culture, we, in healthcare, also require a binding culture for individual talents and skill sets to be harnessed for the good of the group and our healthcare systems.

A leader’s effectiveness is often enhanced or reduced depending on the effect of the binding culture of the institution. A positive culture must create a sense of purpose, build collegiality, enhance teamwork, and, as a result, enhance operational efficiency and patient outcomes. Leaders attempting to establish, grow, and maintain a positive culture may “DARE” and take the following approach.

  1. Culture needs to be developed - Individuals get exposed to many norms and operational environments. The amalgamation of these exposures is what they reflect in their work environment. A thoughtful process that incorporates the values and expectations of key stakeholders should form the basis of the development of the culture of a work environment. New group members cannot be held to unknown or ambiguous standards. Leadership must adhere to and exemplify the same standards as other group members. Orientation and ongoing operations-related sessions should include sharing clearly developed and documented expectations of the group’s roles, responsibilities, and global vision.

  2. Culture needs to be adopted – In addition to leadership’s development of the blueprint of a binding culture, there is the need for its adoption to have the required buy-in to ensure its survival. Mature, self-aware behavior amongst group members is not the product of seniority alone; rather, it is developed and attained through the acceptance and performance of assigned responsibilities. Individuals who cannot adopt and adapt to their work environment’s culture are likely not a good long-term fit. A provider labeled a cultural misfit is not necessarily a “poor provider.” Their skill set may be better suited to a different cultural environment, which can and should be pursued in order to further their career. The adoption process requires key stakeholder involvement, an essential component for attaining functional operational groups.

  3. In the dynamic and, sometimes, hazardous healthcare environment, culture needs to be revised/refined based on the input from the stakeholders. Major operational changes, such as service guidelines for admissions or updates to electronic medical records, may warrant changes in a group’s culture. The renewed emphasis on physician/provider wellness is a significant component that should not be overlooked, even as the need to maintain operational metrics is not compromised. Certain aspects of a particular culture may outlive their usefulness and, therefore, need to be amended or eliminated.

  4. Culture needs to be expressed/emulated by leaders to enhance group compliance and to provide the moral lever for demanding adherence from group members. Accountability requires that leaders hold themselves accountable. Leadership by example is the single most effective requirement for group cohesion and advancement in this domain.

Culture plays a critical role in shaping the healthcare work environment. Its establishment, periodic review, and persistence are essential to meeting leadership’s SMART (specific, measurable, achievable, relevant/realistic, and time-bound) goals.

“Culture is not an initiative; it is the enabler of all initiatives.” – Larry Senn

Conflicts of Interest/Disclosures

The author has no conflicts of interest to disclose.

Corresponding Author

Kwame Dapaah-Afriyie, MD
Professor of Medicine, Clinical Educator
Warren Alpert Medical School at Brown University
Division Director
Division of Hospital Medicine
The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906