The Culture to Cultivate

A large hospital group has lots of things to worry about. One of them is sepsis, the whole-body shutdown that can occur when a virulent infection hits a weakened immune system. It’s the number one cause of death in American hospitals. Another is pressure ulcers, a sure sign that immobile patients aren’t being properly cared for and also a gateway to mortality. Every hospital out there is fighting these and other problems by asking staff members to adhere to best practices. At Kaiser Permanente we’re making good progress. That isn’t because we follow processes that are unique to us. The right protocols for patient care are universally shared. It’s not because of technology either, although we have invested in plenty of that. I believe the real difference is in our culture. We have worked to instill a culture of continuous improvement. Our culture lets our employees know that if they see a way to do something better, they should take the initiative to point it out. When a nurse in our northwest region got the idea for an automated insulin drip calculator, she spoke up—and managed to render the old method, with its error-prone manual entries into Excel spreadsheets, obsolete. We pilot-test the most ambitious ideas at our Garfield Health Care Innovation Center, which features a simulated hospital setting as persuasive as any Hollywood set. The collective pursuit of continuous improvement is powerful not only because of the performance gains it yields, but also, I think, because it’s the only cultural value that could unify an organization as large and diverse as ours. We have 180,000 staff members working in behalf of 9 million members and patients. Some 57% of our employees are minorities, and only two of our eight regional presidents are white males. By emphasizing a value we share and can all act on, we create a strong sense of “us.” Continuous improvement is the only cultural value that could unify an organization as large and diverse as ours. What does it take to cultivate a culture of continuous improvement? Three conditions must exist: People must have a rational understanding of how small improvements compound to make big differences. They must love improving—both because they are passionate about the importance of their work and because it feels so good to move to a new level of performance. And they must have enough confidence in their colleagues to believe that the organization is capable of making progress. You have to keep reminding the organization how capable it is. Every Friday afternoon for the past six years I have written a letter to all 180,000 employees celebrating a performance improvement, some great research, or a new award of that week. We celebrated when our hospitals were found to have the lowest number of pressure ulcers nationwide. (On average, 7% of hospital patients in America get them; we average below 1%. Several of our hospitals haven’t seen a single pressure ulcer in more than a year.) We celebrated when the National Committee for Quality Assurance issued its latest set of quality scores, and in 29 categories Kaiser Permanente received the top score. Our industry is increasingly subject to measurements and scoring like this. Medicare, for example, now rates 570 health plans on 55 measures of quality and service, using a five-point scale. (Seven of our eight regions received 5-star ratings overall, and the eighth got 4.5 stars.) In some cultures, transparent measures like these are a burden. The culture you want is one that welcomes them. Build a culture of continuous improvement, and it will serve your organizational goals. It will also be a force for good in the world.

The Culture to Cultivate

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