Authors Jamie and Maren Showkeir talk about changing healthcare’s culture— one conversation at a time. Healthcare is rooted in a noble purpose: healing the sick, promoting healthy lifestyles, and relieving human suffering. Even so, it operates in an increasingly difficult and demanding marketplace and must deal with the same organizing, managing, and structuring issues as any other business. 

Each person, from a hospital CEO to an X-ray technician, has an assigned role within a defined department. In this environment, it is easy and common to define success as meeting departmental goals and doing your job well. From there springs the belief that if each person performs his or her function well, the parts will come together as a seamless whole. 

Unfortunately, that thinking fails to recognize the importance of interdependence-- the glue that holds everything together. Interdependence and collaboration among departments are essential to a positive patient-care experience, and the organizational culture determines the extent to which that happens. 

Ordinary conversations, public and private, are a powerful, underutilized tool to foster collaborative organizational cultures. Conversations create collaboration or competition. They engender transparency or transmit secrecy. Conversations help people see their commitment is their responsibility, or they perpetuate cynicism and helplessness. 


Here'€™s an example. While consulting with a large healthcare company, we conducted a large meeting representing a composite of the organization aimed at increasing collaboration. At one point, a frustrated doctor who didn’t like how the meeting was going stood up to exclaim: "When will you people get it? Doctors and nurses are the point of the spear! Without us, there is no spear."

The room was tense and silent for a moment, and then people exploded, upset that the doctor didn’t consider them important partners in the patient-care experience. "€œYou may be the point,"€ a woman from environmental services said to the doctor, "€œbut a spear is more than a point! The spear is not a spear without the rest of us."


The doctor’s statement made visible a culture that didn’t understand the critical nature of interdependency in patient care. This was a culture where the conversations created parent-child dynamics. People talked about how to “hold each other accountable” rather than how they could be accountable for the good of the whole. 

When logjams occurred, the instinctive response was to blame someone else. Employees saw creating high morale as the managers’ responsibility, instead of realizing that morale was a choice they made. 

Change the conversation

Like any business, delivering healthcare requires concurrent management of four critical demands—improving quality, increasing profitability (managing costs), decreasing cycle time, and delivering unique and understanding responses to patients/customers. Every individual in the organization determines the extent to which the four demands are successfully managed. 

Authentic conversations can help integrate segmented groups and departments by focusing attention on how each person and department makes decisions and chooses accountability for the whole of the patient care experience. 

Changing the conversation was one of the first things we advocated when we began working with a busy urban medical center where overcrowding and backlogs in the ED were jeopardizing the financial health of the organization. 

About 85% of admissions to the medical center came through the ED. Frequently, the ED became so overcrowded that patients were lined up in the hallways waiting for attention. Doctors and nurses could not effectively conduct triage and sometimes resorted to treating patients in the hallway. 

Patients were subjected to a lack of privacy and intolerable waits just when they were physically and emotionally at their worst. The quality of care suffered, affecting patient satisfaction scores and the bottom line. 

The medical center was staffed with competent individuals who genuinely cared about the patients and the business. Nevertheless, the patient experience was being seriously affected by the 'white spaces'€ that existed between departments. 

As in any hospital, admitting a patient involved a complex web of processes that required cooperation and coordination among doctors and nurses, radiology, labs, transportation, environmental services, housekeeping, admissions/discharges, and materials management. As we began to work with various departments, it was clear that, except for the medical center executive, people at the hospital saw this as an “ED problem.” 

Individuals had a sense of their own roles and responsibilities, but they didn’t understand how that fit into the integrated whole. Nor did they understand the key measures in terms of financial health, patient outcomes, and satisfaction. 

Own your contribution

At a large, system-wide meeting, the ED director began to change the traditional conversation by admitting the ED could not solve the problem alone. “The quality of our care is suffering greatly. Everyone here thinks this is my problem. But it is our problem. We are all accountable for the whole patient experience,” she said. 

“We in the ED have contributed to this difficulty by being territorial. We have discouraged collaboration, and we’re not going to do that anymore. Maybe you think this is a self-serving move because we are miserable. There is some truth to that, but the most important thing is to improve the patient’s experience. Patient satisfaction scores are plummeting, and we are all accountable for this. How can we work together to remedy this situation?” 


Over several weeks, people began collaborating through new conversations and deliberation processes that made visible the web of interdependencies that contributed to the patient experience. They scheduled large, interdepartmental meetings where difficult issues were identified and resolved directly, rather than waiting for management to figure them out. 

Slowly, as people grasped the importance of being accountable for the whole process of patient care, satisfaction scores began to improve. 

The ED director'€™s new conversation contained four important elements:

  • She emphasized that patient experience was a result of their collective efforts.
  • She owned her contribution to the problem by admitting she had protected her turf and discouraged collaboration. 
  • She acknowledged she couldn'€™t resolve these critical care issues alone. She needed everyone’s help.
  • She shifted both the opportunity and responsibility for coming up with a plan to others. In this way, she clearly signaled her intention to collaborate and share the accountability. 

The new conversation was the first essential step in creating a culture where people who understood the importance of interdependence began to take individual accountability for the good of the whole. 

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