The words puerperal fever might not raise the hairs on the back of your neck the way, say, the term avian flu does these days. But for more than two centuries, the disease was a rampant, insidious killer in Western hospitals, targeting mothers of newborn children and often threatening to turn those cherubic babies into motherless orphans just days after their birth. The origin of the fever—and its cure—remained a mystery until the early nineteenth century, when a Hungarian physician named Ignaz Semmelweis discovered the cause: dirty hands.
What initially puzzled Semmelweis was the fact that among women who gave birth at home, the fever was contracted far less often than among those who were admitted to the hospital maternity ward. After studying the differences in the two environments, Semmelweis came to realize that the sickness was spread because doctors refused to wash their hands. This had something to do with an archaic attitude of the time; in the words of Dr. Charles Meigs, a leading obstetrician in eighteenth-century Philadelphia, “Doctors are gentlemen, and a gentleman’s hands are always clean.” But Semmelweis found that when doctors simply washed their hands with an antiseptic solution before visiting their patients, the mortality rate for new mothers dropped from 35 percent to less than 1 percent. Unfortunately for the good doctor (and for innumerable patients of the era), his peers derided his findings, which Semmelweis published in the book Etiology, Concept, and Prophylaxis of Childbed Fever. It was only after his premature death at the age of forty-seven that his findings gained traction, helped largely by Louis Pasteur’s research on germs.
Today, of course, even young children are taught to wash their hands regularly to prevent the spread of everything from the flu to the common cold. But that doesn’t mean everyone likes to be told to do it. Even in modern hospitals, which rely on sterile environments and the latest advances in medical technology, we still stress that everyone should wash his or her hands. No, check that: We directly order everyone to wash his or her hands.
The problem is, it’s still a problem. People still don’t wash their hands. You can almost imagine Semmelweis rolling over in his grave, wondering aloud, “What the heck is going on?” That’s why many hospitals have experimented with ways to get the message out to nurses and orderlies, trying everything from handing out bonus checks for 100 percent compliance to installing antiseptic foam dispensers on the door of every room in the building. And still it’s not enough to get everyone on board.
Strangely enough, the hospital departments that have had the highest degree of success in getting workers to wash their hands are the ones that don’t try to enforce a rule or come up with some kind of gimmick like giving out bonuses or putting up posters. Instead they engage their workers in a conversation about personal values and health care work as a calling. Rather than just tell them what they need to do, the leaders who achieve the best results explain why hand washing is so important. They simply emphasize that dirty hands are injuring patients and putting them directly into harm’s way, and this message resonates with people who have chosen to work in a sector whose overarching goal is to help people. It is only by connecting with employees’ values in this way that hospital leaders can actually lead their employees toward positive change.
We use the hand washing story to illustrate the cultural sea change that has occurred around the notion of what it means to be a leader. When you think of great leaders, perhaps images of fierce military leaders like Julius Caesar and Genghis Khan come to mind—men who fought on the front lines and ruled by force. Any follower so bold as to second-guess an order, let alone disregard it, could count on some serious pain as a consequence. Or perhaps you think of influential politicians like John F. Kennedy and Ronald Reagan, men who employed enormous charm and charisma to inspire action. Once you gazed into such a leader’s eyes, or heard him give a glorious speech, you might be inspired to tackle something new all on your own. Then again, maybe the term leader makes you think of your boss, the person who fills out your annual performance review and signs your paycheck every two weeks. There might not be anything personally compelling about your boss, other than that he or she sits higher than you on your organization’s hierarchical tree. Your job is simply to follow this “leader’s” orders.
Researchers have given different names to different styles of leadership over the years, but for now we’d like to focus on this last idea, this notion of following orders, known as the command-and-control or transactional model of leadership. There’s good reason that this style of leadership has flourished in recent history, especially in sectors like the military or manufacturing, where the system or the process gets more emphasis than the individual. But we’re here to tell you that all this has changed—big-time. A combination of factors, including the aging of the baby boomers and the rise of the millennial generation, has caused the gradual decline of the command-and-control style of leadership. It’s no longer good enough just to tell a subordinate to do something. Today, leadership means explaining why following that order matters—or better yet, empowering subordinates themselves to make the best decisions for the good of the organization as a whole.
This is what biographer and scholar James MacGregor Burns (in his book Transforming Leadership) dubbed transformational leadership, saying that “transforming leaders champion and inspire followers…[so that] they might become leaders themselves.” Or, as Jay Alden Conger and Rabindra Nath Kanungo put it in their book, Charismatic Leadership in Organizations, transformational leaders “are able to motivate subordinates to [higher] levels of performance…by raising the importance of certain goals, by demonstrating the means to achieve them, and by inducing subordinates to transcend their self-interests” for the achievement of organizational goals.
Even the military has recognized the need to change along these lines. Take Seal Team Six, the U.S. Navy’s Special Forces unit that ultimately hunted down and eliminated Osama Bin Laden. While members of the team have hierarchical ranks, each member is actually trained to perform the job of everyone else on the team—just in case, as it always does, the situation on the battlefield breaks down. Consider what happened when Seal Team Six dropped in on Bin Laden’s compound, only to have one of its helicopters crash. That obviously wasn’t part of the plan. And while the team likely had trained for such a contingency, it also had empowered its members to make snap decisions in the moment rather than waiting until they received orders from higher-ups. Each member of the team knew the ultimate goal of their shared mission, and each had the tools required to make sure that goal was accomplished. What the military has come to realize is that when you turn your employees into drones who don’t act until they are told to act, your whole organization can quickly become paralyzed, often when it can least afford to be.
Today’s best business leaders have come to understand the same principle: that they can get the best results when they engage their subordinates in the mission, vision, and values of their organization. The word engagement is a funny descriptive word that means more than just “understanding”; it is transitional, meaning we are taking an individual or a team from one state of “being” to another. Engagement means we move from understanding a concept in a sterile and impersonal way to embracing it with the very fiber of our soul. We become engaged not just because we understand the science behind a concept, but because we really, truly get it. Gary Newsome, CEO of Health Management Associates in Naples, Florida, framed it like this:
The culture of an individual hospital relies heavily on the leadership team of that hospital. The tone has to be set at the top. Everyone needs to understand: What is the goal? How are we going to get there? Every individual, from nursing to dietary to housekeeping to business ops, has to have a common understanding.
Think back to our story about hand washing, where we learned that simply giving orders didn’t change anyone’s behavior. It was only when leaders connected with employees’ sense of inner purpose that the nurses and orderlies began to truly understand the significance of washing their hands regularly. Again, the act of leading is no longer about simply issuing orders. It’s about finding a way to inspire people to act in purposeful and meaningful ways. It’s about everyone feeling as though what he or she does can make a difference.
His organization’s mission, vision, and values are so important to Alan Channing, CEO of Sinai Health in Chicago, that he personally teaches them to every new associate on his or her first day, to provide the context for why such things matter:
I finish my talk by making two promises, and I tell them these are the only two promises I can deliver on. The first is that you’ll be frustrated. You’ll hear a decision, not know what it means, et cetera. The other promise is that you will be able to make a difference in someone else’s life. So when you’re feeling the effects of that first promise, remember the second. It is really fun for me to engage in this conversation. I see the light go on in their eyes.
Seeing that “light” in their eyes is how you’ll know that you’re on the right path as a leader—that you are connecting with and inspiring your people.
Have you ever heard of kaizen, the Japanese concept of taking incremental steps toward success? We read an apt story in a book devoted to this philosophy and process of improvement, and it ties this whole topic together quite nicely. The story centers around a ten-doctor medical group in the United States that was experiencing tremendous problems with patient satisfaction. Wanting to get to the bottom of the problem, the group surveyed its customers and learned that long wait times was the number one complaint from their patients. In an effort to address that problem, the group’s leadership went to their playbook for answers. First, they hired a few more doctors, thinking that would cut down on those wait times. It didn’t work. In fact, patients somehow grew less satisfied.
The group’s leaders then invested in new scheduling software to help them spread out their appointments better. But even that did little to improve patient satisfaction scores. It seemed that no matter what changes the medical group’s leaders made, it only further confounded the problem.
The answer to the dilemma ultimately came not from the group’s leadership, but from the staff. And the changes they implemented didn’t cost a dime. Their solution? The staff simply informed patients as soon as they showed up at the office about the expected wait time and apologized if things were running behind schedule. But they didn’t stop there. When the patient was finally shown in to an exam room, the first thing the doctor did was apologize for the long wait. Then, as the patient left the exam room, the receptionist would not only apologize again for the wait but also offer to schedule the patient’s next appointment and thank the patient for coming in.
The results were spectacular; patient satisfaction scores soared. It turns out the wait times weren’t the true issue. Patients expected to wait at the doctor’s office! It was the unknown, and the apparent lack of concern, that drove them crazy. Simple as it was, the solution didn’t arise until the group’s leaders were willing to put aside their preconceived notions of what would work, like jiggering with the schedule or adding more doctors, allowing everyone to refocus on what truly drives the patient experience. The leaders had to put aside their ego and ask for help from the folks on the front lines—something many traditional leaders would rather jump off a cliff than do.
Unfortunately, most businesses, including most health care organizations, didn’t get the memo about how leadership has evolved. Most leaders today continue to operate with blinders on, refusing to acknowledge the changes we’ve been discussing. The result is that they still employ the old command-and-control model perfected by a Roman general more than two thousand years ago. In our experience, most leaders today still don’t trust subordinates to do anything more than what they’ve been ordered to do, and they still don’t recognize how damaging that mind-set can be.
To be fair, we sympathize: It can be quite scary to give up the notion of control—especially when people’s lives are at stake. As a leader in the health care field, you may be tempted to rely on checklists as a safeguard. But think about this analogy: Airline pilots also have checklists they walk through before every flight, making sure everything is in working order, from the landing gear to the ailerons (which control the up and down movement of the plane during flight). These pilots understand the purpose behind that checklist, however, which is to deliver their passengers safely to their destination. So when something looks wrong, even if it is not on the checklist, the pilot has the ability to act on it. Don’t you want or expect the same from a nurse or orderly? You have given them the necessary tools and training to do their job. Shouldn’t you rely on their engagement and creativity to fulfill the duties of the job as described by the checklist—but then also to go beyond that checklist to tackle the unanticipated issues that pop up?
We’ve said it before, but it’s worth repeating: It simply is not enough to tell today’s workers what to do or try to trick them into doing things with some kind of financial incentive. Generation Xers and millennials are not driven by financial rewards alone. They seek employment and careers that inspire them and tap their creativity. If they don’t find that fulfillment in your organization, they will seek it elsewhere. The loyalty of the past has been replaced by the impetus to join a winning team, even if workers might give something up in the process. If your workforce isn’t connecting to something bigger, if you’re not offering up something more than “just a job,” you won’t hold on to your best people.
The most effective brand of leadership these days, then, is one that engages employees with a higher purpose—as defined by your organization’s mission, vision, and values—in order for everyone to win. This practice of transformational leadership—what we have also begun to call purposeful leadership, holds true in any industry, including health care. The truth is, you need to change how you lead along these very lines. And you need to do it right now.
If you’re still with us and you want to know how to start practicing what we’ve been preaching about—if you want to learn how you, too, can create a purpose-driven organization—please read on.
Let’s begin by defining the relevant terms. In our parlance, we express the key building blocks of transformational leadership as follows:
Pretty straightforward, right? Well, while these may seem like commonsensical concepts, we admit that we both struggled to some degree as we went about implementing them in our own organizations.
When Britt began working at Medical City in Dallas, for example, the hospital had no mission statement, let alone a definition of its vision or values. But there was at least a recognition among the leadership and staff that everyone wanted to document the hospital’s purpose—the reason they were all working there. At that time, creating a mission statement for an organization was somewhat of a craze du jour. Within the available management literature, there was no shortage of tips to choose from. Despite that, crafting a mission statement was an excruciating process for the team, partly because each individual had a different take on the three critical questions: Why are we here? Where are we going? What rules do we live by?
The key to success, in the end, is to personalize the mission, vision, and values statements so they have meaning for all stakeholders. And not just by creating something that can be recited—rather, you need to come up with something that is understood deeply and felt truly. Articulating the statements is an important process that, nevertheless, most everyone loathes. But doing so forces everyone to ask the most fundamental questions about their own role: Why am I here? Where do I want to go? What are my personal values? By talking through and personalizing the answers to these questions, individuals can begin to engage in the greater good for the team and the organization. As Dane Peterson, CEO of Emory University Hospital Midtown, told us:
The overarching mission of a health care organization is an easy one to communicate—most employees and physicians choose their profession based on the mission. Everyone wants to be a part of something bigger than themselves, so even those employees who work in roles that are not found only in health care, and even those of us who came to health care later in life, can get excited about making a real difference in the lives of others.
One key for leadership to remember is to avoid mixing messages around the mission. If leadership states one thing—best patient care, for instance—and then makes all its decisions based on financials, the employees will see this and become disengaged from the stated mission. Actions speak more forcibly than words, and when actions and words are aligned, engagement will follow.
Developing shared goals is the important thing, not just coming up with empty, meaningless statements.
By the same token, how many values your organization has is far less important than the fact that the values you choose must reflect what your employees actually believe in. This is not an exercise in simply handing down a mission, a vision, and values from atop Mount CEO. You need to make the time and effort to get everyone in your organization involved in setting those destinations—and in setting off on the journey to reach them. As Steve Rector, CEO at Regional Medical Center Bayonet Point in Hudson, Florida, put it for us:
I’ve learned from my past experiences that it’s very difficult to get a group of individuals to read a statement, no matter how well written and inspirational it may be, much less to adopt it and then live it. It’s our duty as leaders to engage the staff at a level at which we find out what that mission statement means to them. When they read it, what thoughts, visions, memories of their own lives come to mind? That’s when it’s no longer words; it’s a personal connection that we then must help them live out in our organization.
Britt’s colleagues at Medical City were mainly folks drawn to a higher calling in serving their fellow citizens, and still they struggled to develop a shared mission. Paul’s experience in driving a mission statement through his organization (BerylHealth) was, if anything, even more painful, because while his business caters to the health care community, it’s not a hospital. Paul’s employees, as we mentioned, work in the call-center business—infamous for its “boiler room” environments. For the first few years that he operated the business, Paul admits he was a cynic; he didn’t think anyone had a mission in showing up for work, and he didn’t see the point in trying to establish one. But in time, helped by the wise words of a mentor, he came to see the light and got down to the task at hand.
To accomplish this goal, Paul created cross-functional teams within the organization. Only after several head-to-head meetings were they eventually able to bridge the chasm in terms of answering those same three key questions about the company’s mission, vision, and values. In the end, BerylHealth decided on a simple, straightforward mission: Connecting people to health care. From that point on, BerylHealth has thrived, because it is able to focus on the key drivers of its growth rather than chase the smoke-and-mirror opportunities associated with more traditional telemarketing or sales activities, which could have caused the business to go off the track. Even better, the turnover rate at BerylHealth has dropped dramatically because, unlike most other call centers around the world, the people working there now have a defined purpose. And they even have a name: not agents, not customer service reps, but patient experience advocates. The people at BerylHealth know their purpose, and that is a beautiful thing.
Of course, you also have to be wary of drinking too heavily of your own Kool-Aid, which is why it’s very important to bring objective results into the mix every now and then. Making sure your team is on track with its purpose is critical. Britt recalls an instance when things went awry at Medical City even though the hospital staff had its mission statement to guide them. A patient survey had returned some particularly unsavory results; some of the patients had made intensely personal and derogatory comments about some of the nurses who had served them. When hospital leadership shared the results, the place, as you might expect, erupted. Accusations began flying, with some of the nurses even going so far as to say the results were made up. They weren’t, of course, so in time, the nurses and the managers were able to move past their emotional reaction to focus on the results. They were able to actually look themselves in the mirror and see how they had strayed from their mission—admittedly, not an easy thing to do, but an essential one.
The truth is, even when you make the effort to construct your mission, values, and vision, it’s likely that not everyone in the organization will buy into it. For example, several years ago Britt was meeting with his division president and chief financial officer in the hospital boardroom to explain plans for the future as part of their annual budgeting process. In his presentation, Britt continually referenced the organization’s focus on the patient experience and how various tactics and strategies would translate into phenomenal results. Then, right in the middle of the presentation, the division CFO locked eyes with Britt and yelled, “You guys don’t get it! This is a business!”
While Britt admits he was somewhat taken aback by the CFO’s abruptness, he also couldn’t help notice that hanging on the wall directly behind the CFO was the hospital’s mission, vision, and values. You see, it is easy to put a plaque on a wall, but it’s more difficult to have a profound understanding of the organization’s mission and vision and values. Yup, it means more than a plaque. It should mean something to each and every individual…even the suits and ties!
Britt smiles when he retells the story, but the sad truth is that sometimes we can forget the larger context of what we’re trying to do at work. There is no doubt hospitals are a business and need to make money to survive. But most people don’t yet understand the link between running a values-based, mission-driven organization and how that positively drives financial performance. When employees are drawn to a purpose, they work harder because they feel connected to something bigger. It’s no longer “just a job.” They love what they do, and the customer—in our case, the patient—can feel the difference. Then, to complete the equation, when the customer is satisfied, financial performance improves.
You don’t have to take our word for it. Just ask Tony Armada, CEO of Advocate Lutheran General Hospital, who put it this way:
A mentor of mine once shared a very simple equation with me: If employees and physicians are happy, you’ll get an increase in patient volume. If you increase volume, you’ll find ways to decrease cost. With that, you’ll increase margin and be able to invest back in employees.
This personally rewarding, profitable cycle makes perfect sense to us! At BerylHealth, we call it the Circle of Growth™. Simply put, if you invest in employee loyalty, customer loyalty will follow. If your customers are loyal, it will drive profits into your business. Now you can invest those profits back into your people, giving them better tools and resources to do their jobs. And the cycle repeats.
Of course, there are times when you need to confront those employees who fail to buy into the mission, vision, and values of the organization. Obviously, this happens to varying degrees, but it’s an important issue and we’ll address it in far more detail later on, particularly in chapter six. Not everyone will become instantly engaged in the company’s ultimate goals, but when you do inspire engagement, you’ll know it. The result is magical. Steve Rector, CEO at Regional Medical Center Bayonet Point, described it this way:
I think leaders sometimes mistake someone who has a good attitude or personality for an engaged staff member. Be careful not to jump on that bandwagon. For me, it’s fairly easy to notice engaged staff. They are usually the ones who are coming up to you in the hallway, the cafeteria, your office—wherever!—and providing insight on how you can improve, grow, do things better for the patients. It’s not that they are smiling and happy all the time. In fact, sometimes they can be a little grumpy because they are so eager for improvement. But they always strive for improving the patient experience and challenge you as a leader to get engaged at every level to improve all things that touch the patient. I love these guys!
And so do we.
Employee engagement doesn’t happen overnight; it develops gradually and requires purposeful, continual encouragement and a flexible approach. As your organization and its people evolve over time, so can its values. At BerylHealth, for instance, several additional values were added in recent years to help address a weakness or a need within the organization—namely, a spirit of camaraderie and a commitment to accountability. Those values are not just printed up and hidden behind a cheap frame that is hung in the lunchroom, though. The company’s values are painted in four-foot-tall letters on the interior walls of the building. They’re not easy to miss—or to forget.
Revisiting your values is also a vital exercise in coming back to the organization’s purpose as a way to give it the weight it deserves. Knox Singleton has embraced change as CEO of Inova Health System in Falls Church, Virginia, and framed the evolving situation in today’s health care organizations in the following way:
What employees really want is a process where they have the opportunity to have an effect on their environment. In other words, what they do matters—it changes or impacts things. And then, secondly, they want to do worthwhile work. They want to connect what they’re doing to some purpose that’s worth pursuing.
By returning again and again to the organization’s values and purpose, you remind your people why their work matters and encourage them to continue evolving in the right direction.
Here’s an example: At Texas Health Presbyterian, Britt not only begins each and every meeting he runs by sharing the hospital’s mission, vision, and values, but he also takes time to read aloud letters written by patients who have acknowledged the hard work done by the staff—positive feedback that supports their purpose. This is the sort of approach today’s leaders need to take—and of course, you don’t do this with the tone that you might use to read the letter the DMV sent, reminding you that your car registration is due. You need to just about sing the purpose of your organization as a way to inspire those around you to believe that they, too, are headed to the promised land of professional satisfaction along with you.
This approach also means finding ways to celebrate those colleagues who exemplify your organization’s values and who become leaders by example. And the more you can facilitate ways that those awards are bestowed through peer recognition rather than coming from further up the hierarchy, the more powerful they become. For instance, at Britt’s hospital, each department can nominate another department for a values-based Traveling Trophy award; the winning department receives a trophy that it can proudly display for everyone to see. Paul’s team at BerylHealth accomplishes a similar result through its PRIDE program (Peers Recognizing Individual Deeds of Excellence). The program encourages BerylHealth employees to recognize the deeds of their coworkers, especially in other departments, by nominating them via an intranet-based system. Winners then receive awards and recognition—things like gift certificates and preferred parking spots (not just one, but five: one for each of the winners of that quarter’s PRIDE award). Both of us have also used cash prizes and naming standout employees to “all-star” teams. These are just some of the alternative ways to drive home the message that mission, vision, and values are not just words; they represent a higher calling, and those members of the organization who buy into them will find themselves rewarded.
Let’s pause for a minute and take a breath. We’re sure some of you like what you’re hearing. But we’re realistic enough to know that some of you reading this might still be somewhat cynical about the whole concept and why it matters. “I just don’t think employees care about this kind of thing,” you might be saying. “All they want is their paycheck.” Fortunately for you, we anticipated your somewhat jaded perspective on the subject and prepared a story just for you.
The setting is Medical City in Dallas, many years ago. At that time, the organization decided to tackle the question “Who are we?” This is a fundamental question that any individual or organization must ask of itself in the formation of a mission statement. The program’s intent was to kick off a dialogue from the employees’ point of view about who they were and why they were working there. Dragging a video camera around the hospital and asking questions like “Why do you work here?” or “What does this place mean to you?” creates quite a stir, but more important, it forces some pretty revealing dialogue. The end result was a forty-five-minute video highlighting interviews with different people from throughout the organization who spoke about their connection to the history and nature of Medical City. A copy of the video was given to every member of the staff as an extra Christmas gift.
That wasn’t enough for Millie, a food and nutrition technician—someone who was working at the entry level of the organization. She asked for several extra copies that she could send to her family in Guatemala. Millie wanted to use the video to show her family back home how proud she was of what she and her colleagues did on a daily basis—to show them that working for this organization fulfilled her life’s purpose of doing good work and helping people. This led to an epiphany for everyone involved: The mission of the organization doesn’t stop at its four walls. In fact, it goes as far as Guatemala or wherever an individual’s family and loved ones live, and perhaps even beyond. If that doesn’t hit home, revealing how important having a mission and a purpose is, and how tightly connected mission and purpose are to the notion of transformational leadership, we don’t know what else to tell you in order to convince you.
Whew! Epiphanies and inspiration and fulfilling your purpose—heavy stuff. Do you feel as though this chapter was a little too much like a management tome you’d find at the airport bookstore? Fortunately for you, we’re about to liven things up a bit. Having fun at work is the topic of the next chapter. We’ll meet you there.