Cultural Issues In The Hospital Industry Through The Lens Of Tribal Leadership

This article studies cultural issues in the hospital industry today through the lens of the Tribal Leadership methodology, and, in general from an organizational culture perspective. I wanted to write this paper because of my own life experience in being trained to teach people how to build effective cultures in their organizations. My father has a background in medicine so I have been exposed to the hospital industry through family constantly. One of the things I’ve noticed over the years from talking to doctors, nurses, and hospital administrators was that the culture of these organizations seemed to be less effective than at organizations such as Google or an innovative startup. Writing this paper is an attempt to take a look at the ongoing cultural issues going on in hospitals and I believe it’s important to first establish the way I’m defining culture in this regard. 

Professor Clayton M. Christensen (2006) at Harvard Business School notes that “culture is a unique characteristic of any organization. While the phenomenon of organizational culture is difficult to define succinctly, understanding it can help a manager predict how his or her organization is likely to respond to different situations; to assess the difficulties that the organization might experience as it confronts a changing future; and to identify the priority issues for the leadership to address as they prepare the organization to compete for the future. Organizational culture affects and regulates the way members of the organization think, feel and act within the framework of that organization” (p. 1). 

Christensen (2006) further goes on to say that “because culture is such an important organizational phenomenon, many scholars have proposed definitions of what culture is. These include: observed behavioral regularities that occur when people interact, the norms that evolve in close working groups, the dominant values espoused by an organization, the philosophy that guides an organization’s policy toward employees and customers, the rules for getting along with other people in the organization, and the feeling or climate of a particular organization” (p. 1).

While what Christensen (2006) brings up is valid, I see his description of culture as a byproduct of the ways people group themselves in relationship with each other. John King who is one of the central leading authorities on organizational culture discovered that there were only five ways people organize themselves in relationships within any given environment and that relationship impacted the culture of the organization. To my knowledge, this is lease nuanced way to model organizational culture out there that I have been able to find and it’s this mental model that I use for the rest of this paper. King (2008, personal interview) defines culture through a model he refers to as the cultural map.

King (2008) notes that “the cultural map is a diagram that shows how people group together and how they talk when they are working together. It's designed for groups, [and], it’s designed for looking at culturally how people work together. The backup on that is how they connect or clump up together. What I noticed was that we live in a culture where it's pretty much about your individual effort, and therefore, people are not very good at forming partnerships. When they do form partnerships, they form them in a hierarchical manner, that is to say as a junior to senior in the partnership, which is in my world, is not actually a partnership. Mostly what we're trained to do when we work is we work inside of what is called a zero-sum environment. A zero-sum environment is where somebody wins and somebody loses. The purpose of the cultural map, and the structural map that goes with it, is to show people exactly at which point things tip-and-change to the next level of the zero-sum game, and, then where the zero-sum game becomes bankrupt if you're trying to accomplish something at the level of group, and, at which point there needs to be a mental shift into something called a non-zero-sum positive outcome” (personal communication).  

King (2018) further notes that “in a zero-sum game, there's a winner and there's a loser. I win you lose and we can kind of count it. I win by three points you lose by three points, the sum is zero. In a non-zero-sum game, it’s actually a participation in which we're all in the same game together and we all win together or we all lose together” (personal communication) and that “my purpose was to have people look at this, see how they talked, and how their language actually impacts whether they’re in a zero-sum or non-zero-sum game, and, what level or stage—I called it a stage—of the game that they're playing it—and at which point—if they happened to find themselves in a non-zero-sum game, what level they are there. And what we noticed—I didn't know this going in—what we noticed was when people go from a stage three zero-sum game which most everybody knows how to do, and go into a stage four non-zero-sum game, their productivity goes up by a factor of about three times to five times.  And so, I became interested in that because I'm interested in productivity. I'm interested in partnership and I'm interested in ‘how does partnership affect productivity’, and, I'm interested in the role that language and structure play in productivity and partnership” (personal communication).

King describes the five stages of culture that the cultural map outlines. “In ascending order, people are more effective, that’s the first part of this. At stage one, there's only about 3% of the people that are organized at stage one. It’s a kind of a place where criminals are, and, it's an area that we call undermining. People who are in an undermining [relationship to their environment] and alone [in their environment] because it's a very alone sort of thing are at stage one. The next level up is something like— we experience this on a bad day—at stage two. Stage two is ineffective. When I notice that I’m not really being effective at what it is that I'm committed to, one of the things that I notice is that I am not really well connected. In fact, not connected at all to the people around me. I'm kind of there and I'm amongst them. But, I'm not connected to them” (personal communication).

King (2018) explains the different stages of culture by sharing that “at stage one, one of the things people at stage one say is: ‘life sucks’. At stage two—it's a big change—it’s ‘my life sucks.’ I mean, I could see that your life works. I can see that the things you do work well. I can see it’s a great life. I just don't have an access to participating in it. I’m not connected in a way that I can participate in it effectively, so I'm being ineffective, and ‘my life sucks’...and for the most part, very seldom, do people actually get into the true ‘life sucks’ unless they’re in wartime or [involved in] criminal activities, or, they’re trying to bring down the whole structure. But the truth is, that ‘my life sucks’ is kind of the place where you feel ineffective and then we kind of dramatize it. Stage two is connected by the way, kind of like I say joined at the hip to stage three. Stage two and stage three have a symbiotic relationship. Stage two, is ineffective, or you could say ‘a loser’, at least in this particular point [of view]. They have a point of view that ‘my life sucks.’ Stage three is the winner. Think of sports. The person who is the champion is the stage three and what they say is, ‘I'm great, you're not, and I have the statistics to prove it.’ So they are organized around winning. And if you're organized around winning, in this particular way, it's a zero-sum game. The people that you are winning over are the people who are at stage two. The trick about this is that stage three does not exist without stage two nor does stage two exist without stage three. They live in a comparative world. This is where we form partnerships. But the partnerships are definitely senior and junior. Stage three is senior and stage two is junior. What you have is a relationship where stage three is dominating a stage two and stage two is avoiding the domination. It's a relationship from [stage] three, ‘I’m great, you're not and I have the stats to prove it’, to [stage] two, ‘my life sucks.’ If you think about it just a little bit, you can actually see, when you're being ineffective and then somebody is actually driving you, managing you, dominating you, what comes along with it is a kind of a glee, a sense of I'm better than you. So how we build our self-image quite often, particularly when we're young, is we build ourselves at stage three. It is not just a small thing, it's a big thing. If you extrapolate this out to companies, it’s: ‘our company is better than your company’, which is a stage three to stage two sort of saying. ‘General Electric is better than Westinghouse’, or, you can say politically, the United States often represents itself as better than Canada. And so if you’re a Canadian, you’re in a stage two relationship to most Americans and nobody realizes it because it's all sort of in the background. So that’s stages one, two, and three. There is a shift that occurs at stage four. At stage four, there is a realization that if I'm going to do something, I need to actually be generating leadership, effectiveness, or empowerment of other people around me. So what I need to put together is, I need to put together a small group or a team. Often it’s three, four, five, or six people who are all in the same boat, and, we're all—you know—paddling towards the same goal. So at stage four, it becomes ‘we’re great’, and, we begin to look at ourselves socially. For the first time for human beings they look at themselves socially. This is where leadership starts. This is where empowerment starts. This is where interesting results begin to occur. This is the beginning of something. This is a partnership. This is, literally, where people form effective partnerships and whereas stage one was called ‘undermining’, stage two is called ‘ineffective’, stage three is called ‘useful’, it's a useful place, however, stage four is called ‘important’, and, important at the level of stable partnership and inside of a common languaging of ‘we’re great.’

Then, if you've done the work and put yourself solidly at stage four, then opportunities come along. They only come along for groups that are operating at stage four. And usually they're the kind of opportunities that will make history, it will change the game completely. This is what we call a ‘vital stage’ or stage five. At stage five, this is where team really shows up. Because your little group begins to connect up with somebody else's little group and somebody else's little group with somebody else's little group to form a team. And when we form a team, the language around is generally ‘life is great’, and what we're doing is accomplishing off-the-charts sort of results. Most people at stage three think they’re doing stage five. Not accurate. When you get to stage four, and you do the work around building yourself at stage four, you have that stage five opportunity. You actually get to see the remarkable difference between a zero-sum-stage three- ‘I’m great, you’re not’, and, a non-zero-sum-‘life is great’-stage five. But in order to do this, you have to do the work, and you have to do the work with other people. Human beings are social creatures. In fact, they’re ultra social creatures. And so we work best, not when we're alone, we work best when we work effectively with other people. So stage four is all about effective stable partnerships, and, in Tribal Leadership, the whole name of the game is getting people stable at stage four so that they are ready for the opportunity when it shows up. And it will for people who have done the work at stage four. It does not show up for people at stage three, and, they end up missing the opportunity and then—I don’t know—be weird about it. It’s about environment. See the thing is at stages one, two, and, three it's all about me, me, me, and, it's only about my survival, and it's all about me winning, you losing, and me getting ahead. However, at stage four, there's a consciousness that: how I win is by making sure that other people win, so, what should become at stage four—and this is the beginning of leadership—you become not someone who is out for yourself, but someone who is out to create an environment for other people to perform well. So, it's about being an ecologist. It’s about being an environmentalist. It’s about really providing an environment. It turns out, generally speaking, if you base your relationships with people properly, which is on merit, it turns out that people are probably pretty good at what they do and don't need a whole lot of managing, but, they might need some leadership. Leadership—being kind of a code word for: a great environment to work in. Google is a great example of it. Because what Google does is hire really smart people and then creates an environment for them to work well together. And as a result, they get off-the-charts kinds of results. This is also happening in our other programs that we see that are the flashy splashy great ones going on. The ones that seem to be passing away are the ones where they are still operating of the old version of ‘I'm great, you’re not.’ Rather than actually having stabilization—it actually presents bullying to say it brutally” (personal communication).

King (2018) notes that “cultural issues in healthcare have been happening for quite some time” (personal communication). King’s (2018) background at the Marshall School of Business and the Price School of Public Policy gave him the opportunity to be exposed to cultural issues going on in the hospital industry in real time going back to 1999 (personal communication). While working with the CEO of Kaiser Permanente, King (2018) was exposed to cultural issues relating to hierarchy between the nurse, doctors, administrators, and even hospital contractors. It turns out that this hierarchical divide still exists today (J. King, personal communication, April 2018). Current Chair of Pediatrics at Northwell Health and Executive Director of Cohen Children’s Medical Center, Dr. Charles Schleien (2018) acknowledges that not only is there a need for elevating the culture of hospitals but that there is an ever more awareness and demand for that kind of transformation than ever before due to the increasing demands needed of physicians today (personal communication). Schleien (2018) notes that in the past, physicians and medical students “had more freedom in terms of the kinds of things they did with their work hours down even to the kinds of patients that they saw” (personal communication). 

However, Schleien (2018) notes that “there’s been a shift over the past ten years where the productivity needs are greater for physicians” (personal communication) and that “almost every physician is working harder than they once were. The ability to do academic things like teaching and research particularly is much more difficult because they’re not dollar generating and this has caused incredible pressure on medical systems and hospitals. The baby boomer generation, especially, have become less happy with their work conditions because of this which has led to an increased awareness and need for new approaches to management and leadership to impact the culture of our environment in the medical field” (personal communication). 

One of the main cultural issues that arise consistently has to do with the hierarchical structure that currently exists in the medical field (J. King, personal communication, April 2018). The system is still very much organized at “Stage Three” (J. King, personal communication, March 2018) while the original reason for people going into medicine is usually due to some higher purpose and a “flaming passion to make a difference” (J. King, personal communication, April 2018) which is really a “Stage Five” (J. King, personal communication, March 2018) point of view. However, because of the saying that commonly goes around in business circles, culture eats strategy for breakfast every day, which is a phrase often wrongly associated with Peter Drucker, many of these physicians get knocked into “Stage Three” (J. King, personal communication, March 2018) as their actions over time reflect the culture of their environment (J. King, personal communication, April 2018). According to Katzenbach and Smith (2005) “Not all groups are teams” (p. 5). As John notes, “a stage four triad looks very different than a stage three trio” (J. King, personal communication, March 2018). 

King (2018) notes that in medicine, “the work itself is so hard and the conditions around the work are so severe that what happens is that a hierarchy shows up around people who are more experienced or have a higher certification of credibility. So as a result, and because they’re in a world where it’s life and death and seconds matter, some of the values that go away first are dignity and respect. Through my consulting work in the hospital industry, I’ve noticed that this trickles down all the way to the patient” (personal communication). 

King (2018) and Schleien (2018) both brought up to me that the hospital industry still in many ways has the disciplines of leadership and management distinguished from each other. Clearly in the above paragraph, the loss of certain core values in a stressful work environment is a cultural issue, however many hospitals and hospitals systems react to these kinds of issues through bringing in management consultants or taking actions to become more efficient (J. King, personal communication, April 2018) and this is one of the reasons why I believe issues like this still commonly exist. While misaligned actions in correlation to an organization’s values on the surface may seem like an issue dealing with poor execution of managerial action, in reality, a lack of values-based relationships underneath the surface will not be rectified through working to take more effective actions alone (“The Influence of Cultural Values”, 2015). 

King (2018) elaborated on the connection between hierarchical cultural issues and a loss of values: “One of the things that I was very, very clear about during that time, and it was a good hospital, was that dignity was going to be the thing that was going to go out the window first for the patient. For the people who are doing the work, they're just kind of working in a situation and try to make the best out of it and they're often in a hurry. They don't really have as much time as they'd like to have to time to spend with the people they like and care about. And the patients themselves are often scared and in pain and having an experience that is unique to them. So if you're in a unique, painful event where you're scared you're not going to be great by default. If you're taking care of people who are in the unique position for themselves being scared and in pain and not knowing what to do or say to them at the human level and that becomes infused in the fabric of the system, it tends to get kind of cyclical in my experience of working with organizations in the hospital industry. So what I saw was that there was an ingrained pecking order that is organized around this notion of dignity or respect. So the person who is at the top of the mountain, for example a surgeon, is a person who might be respected but they may not be beloved by his or her colleagues. And then down the line they are often hurried in what they’re doing and so they tend to be kind of snappish with people that are serving them. Now, this to me was interesting because I’d been in the United States in the army during the Vietnam buildup and what I noticed was that when we were in a gearing up for combat mode, a lot of people got snappish and people were scared. People were in pain or afraid they were going to be in pain and they were more resolved to the notion of protecting their own position and surviving. So currently in the hospital industry, there’s a need for mastery in generating environments of dignity and respect when it’s not the default emotional space you may act from. It’s like baseball. In the game of baseball, you win a few and you lose a few, but you suit up for every game. The same thing is true at hospitals. You win a few and you lose a few, and it’s sad when you do, but you suit up for everything that may come your way. In the game of baseball, you hold out the notion that if you can just get the stars lined up and you get the skill-sets to line up, you’ll have a really successful season. The same thing is true in a hospital. A hospital among other things is a business and it’s also a place where people get repaired when they’re damaged or broken physically. It’s also a place where a lot of your customer base has to keep coming back. In the current environment of the industry, those customers are often not experiencing the first-rate service from the point of view of the patient who pays the bills. In reality, the service is often set up to serve the staff or serve the physicians and important people from a credentials point of view” (personal communication). 

Alignment “with the highest goals of an organization” (“Managing Teams”, 2006, p. 9) is one of the defining characteristics of effective teams (“Managing Teams”, 2006) and this often mediocre execution cultural implementation of core values within the hospital industry ends up perpetuating stage two and stage three environments (J. King, personal communication, 2018). The lack of stage four-ness (J. King, personal communication, 2018) within the hospital industry leads to misplaced “positions of power” (“Power Sources”, 2006, p. 2) in relationship to the supposed values of the organization. 

King (2018) believes that the development of relationships between the people who are working in the hospital environment and the patients is one of the greatest grounds that can be taken to greatly improve cultural issues within the hospital industry with a goal of stabilizing the industry at stage four leading the way for more stage five projects in the future (personal communication). 

King (2018) notes that this hierarchical structure starts in medical school going back to the University of Padua circa the 1200’s. Schleien (2018) notes that medical schools in the past ten years have taken note of these hierarchical issues and that this has been shifting yet acknowledged there’s still more ground to be taken for the hospital industry as a whole. One of the places that is being paid more attention to is the role of technology in the hospital industry as it relates to improving the culture of hospitals and more hospital executives than ever before are starting to put significant resources into technology projects with the intended outcome of cultural transformation at a given hospital or hospital system (C. Schleien, personal communication, 2018).

Schleien (2018) notes that technology is breaking down many of hierarchical barriers that King (2018) talks about. Robert Simons (2007) highlights the importance of breaking down hierarchical barriers so that an organization can “stimulate the creation and sharing of new ideas” (p. 5) through the ability for different units of an organization to be able to communicate with each other in partnership (p. 5) which is something that while technology is improving, it’s also not a solution that will solve the problem completely. One of the functions of technology breaking down hierarchical barriers is that because the culture of many of these hospital systems is still situated in a survival-based relationship at stages two and stages three, the breaking down of barriers leads to business units trying to dominate one another with IT being a notorious perpetrator of such values-based cultural violations (J. King, personal communication, April 2018). 

Newman (2018) says that all this technological innovation “starts at the top” (p. 1). It’s this kind of logical fallacy as it relates to culture which prevents technology from having the maximum impact on improving cultural issues within the hospital industry. King (2018) notes the fallacy in Newman’s (2018) claim. “Notice that without even saying it, Newman has already established a hierarchy. He’s right that the hospital industry must make technology as it relates to the digital experience a priority. However, what he misses is that what hospital systems need to do is align their departments with each other and be given the necessary tools for customer service to improve. We need to teach IT departments how to both be teachers but also to be leaders. Essentially, it’s a stage four view on administration versus a stage three view on it” (J. King, personal communication, April 2018). 

In Emily Rappleye’s (2018) interview with Dr. Kate Goonan, the concept of servant leadership comes up as it relates to hospital transformation strategies (Rappleye, 2018). Servant leadership is a methodology that can fix a lot of these cultural issues within the hospital industry moving the industry to become stabilized at stage four (J. King, personal communication, April 2018). “Servant leadership is getting people to the point where the way they look at life is through the lens of serving others and I think is at the essence of what being a doctor is. Having a medical facility is to serve the public. The question should be ‘how are we going to regard medical professionals not when they are best regarded, but in areas where they’re invisible?’ While Lean and Six Sigma are great tools, they deal in the realm of efficiency and really aren’t there to solve cultural issues unlike servant leadership which does just that. In servant leadership you ask the question ‘who am I serving here?’ and the second thing you look to see is who your partners are and not looking to pick and choose but that everybody you’re working with is your partner and you make the effort and do the work to make them your partners. It’s not their job to be your partner, it’s your job to be their partner. In addition, you ask yourself ‘what am I building?’ and in the case of healthcare systems, you’re building a great healthcare system where lives are saved and then some overall mission custom to the individual organization. The key is that whatever you’re declaring will be transformational in nature and elicit some kind of noble cause. The next question you ask within servant leadership is ‘who do we touch?’ and if you do not have a relationship with them, then this becomes a huge missing in hospitals which is a place that by default people constantly come and go” (personal communication). 

Unless the hospital industry starts to take a focus on the ontological impacts of culture such as the patient experience, those paying customers who are the patients will start to seek out alternative platforms for medicine outside of the traditional hospital industry (Dowling, 2017). 

King (2018) notes that even though quack therapies not grounded in science is an unfortunate reality which exists, the hospital industry can learn a thing or two about the culture of these organizations which provide often greater senses of honor to the customer than in traditional hospital environments where the quality of care is better (personal communication). Schleien (2018) notes that this issue isn’t fully culturally related and also has to do with the fact that patients with the most issues who will also complain the most will typically not be in the alternative clinics providing quack therapies leading to lower patient satisfaction scores at traditional hospital systems. However, further research should be done on areas of the hospital industry which show higher customer satisfaction scores. I would hypothesize that an organization dealing with “a crisis of red tape” (Simons, 2007) which is also operating at stage three (Logan, 2009) will show higher patient satisfaction scores than those operating in a more decentralized structure (Simons, 2007) and also greater outcomes of stage four culture that don’t degrade into survival based cultures when there are breakdowns in performance at the given organization (Logan, 2009).

While technology and other forms of innovation might be flattening the world (The influence of cultural values, 2015), without a strong sense of a meaningful common purpose that the culture has created (Katzenbach & Smith, 2005), the organization will break down into stage two (Logan, 2009) creating a “crisis of control” (Simons, 2007). I would make the argument that in quack therapy practices that are structured at stage four (Logan, 2009) is just as much a contributing factor to the inferiority of patient experience at traditional hospitals than simply the kind of patient they are attracting. “In some weird twisted way, a lot of those quack medical therapy practices have a better culture than traditional hospitals. There is no question that if you go to a traditional medical clinic as a patient, there’s a higher chance you will get treated as a number and have a more transactional and commoditized relationship with your doctor than at a clinic based off quackery and pseudoscience where it’s common to be treated like you are a god and have the experience of being special and given quality time while building a values-based relationship with the practitioner. I would say if nothing else they the get quite a placebo effect off of that if people aren’t too sick. I’m certainly not saying we need to work on getting a placebo but we do need to work on the relationships between medical professionals at all levels and the patients they serve” (J. King, personal communication, April 2018).

One of the cultural changes that should be continued to be encouraged is having more stage five conversations (Logan, 2009) through large hospitals talking to each other and collaborating on strategies. This is now starting to happen as seen during the JP Morgan Healthcare Conference where over 20 healthcare systems from around the United States engaged in conversations discussing their strategies in improving their own hospital systems (Michelson, 2018). This is in contrast to the old and still somewhat prevailing model of hospital fiefdoms which actually does huge damage to the hospital industry as a whole and at great costs both emotionally and financially (J. King, personal communication, April 2018). The importance of hospital branding was something discussed at the JP Morgan Healthcare Conference (Michelson, 2018) however even with branding there’s a cultural aspect. At stage three (Logan, 2009), branding is done at the level of reputation. At stage four (Logan, 2009), branding is done at the level of values. When branding is done at the level of values, this will have higher reputational impacts to the hospital than branding from a space of reputation with reputation being the focus (J. King, personal communication, April 2018).

The conference also talked about the need for more engagement within the hospital industry (Michelson, 2018) however, it needs to be done from the right cultural context otherwise you’ll end up in a stage three kind of engagement which won’t lead to any kind of transformational outcome at the level of organizational culture (J. King, personal communication, April 2018). As King (2018) notes, “Major improvements will require clinical leadership and a true partnership with the physicians but it’s not going to happen magically nor will it happen from someone inside the organization. It also won’t come from traditional consultants helping with greater efficiencies which is a management conversation and a weak access to impacting culture. It will come from someone like you or a consulting organization of some kind that gets culture at the level of transformational leadership” (personal communication). Due to the hierarchical nature of the hospital industry today, I believe King (2018) is completely right. Another discovery I made while doing this research is the need for analytics in conjunction with any kind of relationship improvements between physicians and the hospital systems themselves as well as to the patients” (Michelsen, 2018). 

As King (2018) notes, “we can train the patient, but they're going to be trained as a reaction to the way that they haven't experienced being dealt with in the past. They are not going to be causative at all. Patients have too much at stake to go on strike. They're not doing marches against doctors. So in order to get more effective social feedback loops going on, there needs to be some kind of analytics that occurs in conjunction to any kind of transformation that goes on at the cultural level” (personal communication). However, as long as these transformations are occurring at stage three, the results will be incremental at best but not transformative. Examples of this are when the American Hospital Association offered “transformational” advice to hospitals yet their recommendations were all management driven by nature (“Your Hospital’s Path”, 2014) or when Indiana University Health announced they were going through a transformation (Russell, 2018) when in reality there was nothing transformational about Indiana University’s project (J. King, personal communication, April 2018).

This is why King (2018) so strongly rejects the idea of implementing analytics without implementing a cultural transformation designed to allow for the strategies that will be in line with the new culture (personal communication).  “Although every analytics that I've looked at, with the exception of the mindsuite algorithm which was developed by Wayne Clancy, most analytic programs are divisive and they separate people. While engineers may like this because they love to be able to take a look it really isn’t nearly as impactful as being able to measure culture and help create alignment and quantitative results that elevate the human spirit. While there are people on the humanistic side who work in organizations like psychologists that's not the kind of analytics that we need to produce the intended cultural result. We need an analytic which tells us where the patients and the healthcare professionals across the board are in alignment with each other and we need to be working on that” (personal communication).

So while the JP Morgan Healthcare Conference makes note of the importance of leveraging analytics as point eight of the twelve point plan (Michelson, 2018), what Michelson (2018) is talking about is more on the management side of the hospital industry and what’s missing from this conversation (Michelson, 2018) is the relationship and cultural component as it relates to analytics.

Schleien (2018) notes that technology has and will continue to impact culture within the hospital industry in a positive way. King (2018) talks about the root cause to the assertion Schleien (2018) makes which is that technology naturally creates values-based triadic relationships which are the fundamental building block of stage four culture (personal communication). This explains the observation made by Schleien (2018) that technology is removing a lot of the hierarchical structures within the hospital industry as a whole. The decentralization caused by technology and the shift away from transactional commoditized stage three relationships (Logan, 2009) to social values-based triadic relationships (Logan, 2009) can be understood through the interdependent relationship (“Power Sources”, 2006, p. 2) that gets created between “the medical professionals working on clinical outcomes, the one’s working on efficiency and operations, and the third part of the triad being the patient and the medical professionals working on patient experience enhancement. In essence, they’re all holding hands with each other in a kind of relationship that serves the higher noble cause of the organization” (J. King, personal communication, April 2018). Smart hospitals are becoming a goal of the hospital industry for good reason. 

While Schleien (2018) notes that the hospital industry has been going through a transformation with taking into the importance of culture it is clear from the research I have done that the industry still faces major cultural issues based rooted in being stuck at stage three while attempting to take on stage four strategies (J. King, personal communication, April 2018). While it is hopeful that hospitals have started to distinguish the difference between leadership and management within the past five years (C. Schleien, personal communication, April 2018), a lot more needs to be done. What is clear is that the awareness of culture and creating elevated organizational structures is more prevalent than ever before. This should make it easier for consultants who specialize in culture and leadership to be able to make a difference with less of a focus on “doing management on steroids as a way to fix cultural issues” (J. King, personal communication).

Nearly every major hospital system is looking to improve themselves through the use of technology (C. Schleien, personal communication, 2018) and the promise of creating technologically driven hospitals which break down hierarchical barriers and bring a more powerful and personal experience to the patient, otherwise known as “Smart Hospitals” (Fareed, 2018) will certainly only improve culture at hospitals. However, as King (2018) makes clear, there will be real limits to strategy outcomes if the culture doesn’t improve first (personal communication). According to King (2018), 80% of strategies fail and the reason for that is cultural misalignment (personal communication). Essentially, a stage four or five strategy (Logan, 2009) with a stage three culture using stage four language (Logan, 2009) will almost always fail to deliver the intended result (J. King, personal communication, April 2018). With ever-increasing demands on physicians (C. Schleien, personal communication, April 2018, an emphasis on culture is now more important than ever due to the performance results that come out of that essentially increasing the return on investment of the money paid out to employees of a hospital system. King (2018) notes that hospitals can expect to achieve performance increases in key financial metrics of between 300% - 500% when moving their culture from stage three to stage four (personal communication). High work-loads and low teaching times have shown to have a negative impact on students in medical school (Aktan & Gulluoglu, 2017) and as King (2018) points out, medical professionals will carry that survival way of operating into the hospital systems they go into (personal communication) leading to a continuous negative cycle of cultural issues. 

Every hospital interested in creating a “Smart Hospital” (Fareed, 2018) should focus their efforts not just on technology but also the people implementing and being impacted by the technology. That means allocating more resources on leadership training for all departments and employees at all hierarchical levels of the organization. Getting employees at different hierarchical levels into values based triadic relationships within these trainings is also key. Having a data analytics program to co-exist with the leadership trainings should be an utmost priority as well so the culture can be measured quantitatively in real time. This will also allow greater management efficiencies in strategic planning to forward the noble cause of the given hospital or hospital system. Currently, the Mindsuite Algorithm designed by Wayne Clancy is the only analytics program in existence that does all of this. If technology improves without a focus on culture, culture will still improve due to the breaking down of barriers and hierarchical structures within hospitals. There will be fewer pockets of stage three (Logan, 2009) within hospitals regardless going forward. However, what’s uncertain is the level in which hospital culture will truly be values-based and stabilized at stage four without a drastic shift or transformation of hub and spoke relationships and hierarchy which exists within the hospital industry today. More research should be done on hospitals that have taken a conscious and guided effort to move their hospital systems to a stage four culture (Logan, 2009) and establish best practices and case studies on stage four strategies that have been implemented. Furthermore, these case studies should compare and contrast how each strategy held up in a stage three culture compared to a stage four culture. I would hypothesize that there will be greater results within the stage four cultures. However, what’s unknown are all the exact data points which can be correlated solely to the culture of the given hospital or hospital system. Due to a limited sample size, we are years away from having this data. However, as this research is done, it should speed up the cultural transformation of other hospitals due to the social proof it provides which is important for stage three cultures who are more reactionary than creative in their approach to taking actions not based off prior best practices and case studies (J. King, personal communication, April 2018).

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