If you build a new hospital, will the organizational culture change? That's an intriguing question, and Bronson Health-care Group took an interesting approach to answering it. Bronson is the corporate parent of Bronson Methodist Hosital in Kalamazoo, Michigan, where a new $181 million replacement hospital was occupied in December 2000. As part of its participation as a Pebble Partner with The Center for Health Design, Bronson involved Dr. Larry Mallak of Western Michigan University to assess the Bronson culture.

To gain a more systematic view of the organization, Bronson and Dr. Mallak conducted a study more comprehensive than simply focusing on culture and the built environment; it also included variables related to job satisfaction, quality and performance. Scales based on the Health Care Criteria for Performance Excellence of the Malcolm Baldrige National Quality Award (MBNQA) were also included in the study, to obtain perceptions of performance such as patient satisfaction and patient outcomes.

The study showed that the built environment functioned as a moderating variable, meaning that the new building's design provided a layout and environment that allows caregivers to meet patient needs better than they could in the old facility. The study also revealed the value of a strong culture—i.e., one in which people know and accept the organization's values and in which their behavior consistently illustrates the values of the organization. For example, nearly every Bronson employee will provide directions and escort a lost guest to his or her destination. Units with stronger cultures reported higher job satisfaction, higher ratings of the built environment, higher patient satisfaction and better patient outcomes.

Building an Artifact

The New Bronson, as the new hospital is currently called, is the product of many design sessions and focus groups, and much input as to what would best meet patients' needs. The focus on patient needs drove design decisions, even at the expense of employee convenience. For example, all patient rooms are private, and most nursing units are arranged in a pod design. Having rooms designed with only one patient in mind means that caregivers may walk farther during the course of a shift to care for patients

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The design of Bronson Methodist Hospital is “pivoted” around the patient. Many other patient-focused features also played into the design—use of light and art, classical music in public areas and intuitive wayfinding. Vertical and horizontal adjacencies allow physicians' offices to be located in a medical office pavilion on the same floor as inpatient units.

Because Bronson involved its leaders and employees in the design of the New Bronson, the hospital's ethos was recrafted. In anthropologic terms, the new hospital is an artifact of the Bronson culture, meaning it is a physical manifestation of Bronson's underlying values and assumptions. The value of concern for patients drove decision-making processes relating to design features of the new hospital.

It Takes More Than a Building

A building does not change an organization's culture, but a good building process can. The New Bronson was only one step in the longterm process of shifting the culture to being even more patient focused. The design process reinforced the best elements of an already definitive collaborative team and patient- centered culture, while laying the groundwork for introducing new elements required to thrive in the future. The process of designing the facility, discussing the design features and infusing the heightened value of concern for patients acted as a catalyst for and helped to solidify the Bronson culture.

A well-designed built environment also should enhance patient care processes. Patients' comments reflect their appreciation of the aesthetic features of the built environment. They also benefit from the improved processes and outcomes that accompany patient-centered design. Furthermore, caregivers in the new built environment perceived higher levels of patient satisfaction compared to perceptions of those working in the original facilities. Increased patient satisfaction should eventually lead to higher levels of employee satisfaction. In fact, this study showed that higher levels of satisfaction were found in departments where the built environment and strength of the culture were rated higher.

The Bronson value of serving its community was also employed in the design process. Several neighborhood groups were convened to provide input and share concerns during this process, to ensure that Bronson's new facilities would be a welcome neighbor and not a nuisance. Green space, gardens, attractive signage and outdoor art were carefully crafted to ensure a fit with the neighborhood and community.

The Bronson value of celebration was put to work at various milestones throughout the building project, such as when the last beam and brick were put into place. Numerous celebrations were held to mark progress and to involve Bronson employees as stakeholders in the new facility.

Implications for Healthcare Executives

Since strong cultures yield better performance, healthcare executives should understand how well their organization's culture is “taking” among employees. Organizations with stronger cultures will achieve higher performance and potentially realize improved clinical outcomes compared to those with weak cultures.

It is important to pay heed to your organization's unwritten rules. A strong culture guides behavior in the absence of policies, procedures or advice from supervisors and managers. Often, particularly in the healthcare field, a decision must be made expediently to best serve a patient's needs.

Employees who live the culture, who hold the organization's values dear, help form a strong culture in their department. When new people join the organization, they learn what to do and what not to do based on the examples of those employees who have been there awhile. Feedback relative to their behavior helps them learn the culture and its unwritten rules.

It is also essential to “check the alignment.” In other words, the culture should be aligned with the customer, the employee and the business environment. At Bronson, the organization's culture scored higher on internal focus (e.g., employees and internal processes) than on external focus (e.g., markets and competition). The culture also scored higher on flexibility than on stability—this allows employees to better meet customer needs. However, analysis of the administrative unit showed a balance between internal and external focus, and the administration's subculture differed from the overall Bronson culture. In other words, Bronson's administrative team simultaneously recognizes the importance of providing high-quality care while meeting measurable targets and responding to competition and regulators, but this balance must be shared among the caregiver staff. The caregiver staff operates as a cooperative team, focusing internally on the immediate tasks they face. This is good, but if combined with an external focus, the caregivers' efforts can be aligned more effectively with organizational goals and outside pressures

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When attempts are made to change an organization's culture without support from caregivers, conflicts will emerge as more rational approaches (e.g., goal setting, standards, benchmarking the competition, balancing care options with cost parameters) are considered and implemented. A culture that is consistent throughout an organization produces predictable and expected responses, no matter where you interface with the organization, and provides a built-in means of conflict reduction.

Summary

The built environment must be designed with care. The many significant correlations between the built environment and outcome variables support the use of effective design in new facilities, particularly design features that support patient care. Even though a patient-focused environment may result in some inconvenience for caregivers, those caregivers generally will support the new design if they have been included in the design process and understand the rationale for the new design. Positive links between the built environment and both job satisfaction and patient satisfaction provide tangible evidence that a design was well conceived. Involving staff from all levels during design and construction—not only for their ideas but also for their support—pays dividends once the patients enter the new environment. HD

Larry A. Mallak, PhD, is associate professor and founding principal, Engineering Management Research Laboratory, Western Michigan University, Kalamazoo. To reach him, phone (269) 387-3780, fax (603) 697-2591, e-mail larry.mallak@wmich.eduvisit@drmallak.com Suzan D. Olson, PhD, MHS, RN, is a research scientist and manager of the Bronson Center for Clinical and Community Research, Kalamazoo, Mich. To reach her, phone (269) 341-8719, fax (269) 341-6898, e-mail olsons@bronsonhg.org or visit bronsonhealth.com. Susan M. Ulshafer, MBA, is senior vice-president, Human Resources and Organizational Development, and Frank J. Sardone, MBA, is president and CEO, Bronson Healthcare Group, Kalamazoo, Mich.