Solutions to Support a Strong Organizational Culture

“A sure sign of an unhealthy culture is communication that flows down rather than up and across.” My experience is that most executives and managers think they’re great communicators (!), and even if they are, don’t recognize the importance of continuing to learn and practice with EVERYONE in the organization.  How’s your company’s communication practice going?

The Five Most Common Culture Problems — And Their Solutions

Liz Ryan


Dear Liz,

I’m interviewing to become the first HR Director for a business-to-business services firm. I’ve had two interviews and I really like what I’ve heard so far. For my third (and I believe, final) interview, the regional President who will interview me has asked me to prepare questions for him.

I do have questions for him, but I want to focus in on his Business Pain as I’ve learned from you to do! If they didn’t have significant pain, they wouldn’t be replacing their former HR Manager (who moved out of state) with an HR Director now.

The company outsources its payroll, benefits and HRIS to a third-party vendor. Everyone I have met in the company says that the vendor does a great job. So, I think the region’s Business Pain is more in the area of culture, which is not surprising because they are growing fast and hiring a lot of people.

What are some of the most common culture problems you observe, and if you can share them in a few words, how do you solve the most common problems? I want to talk about my experience creating training programs, communication programs and retention programs as I think these kinds of interventions could be very useful for my (hopefully) new employer.

Thanks Liz!



Dear Chris,

Often as HR practitioners we are taught to see the world through program-colored glasses. That is, we get used to observing a team and a workplace with the question, “What do these folks need — more training, more communication or a different pay structure?” planted in our heads.

We have tools at our disposal — the ability to write policies, classrooms and devices through which we can reach our teammates, and so on — and we want to use them! I teach the opposite approach. Forget about interventions for now and focus on what is happening inside your possible next employer. What is causing your regional President sleepless nights right now? I guarantee you he isn’t lying awake thinking “I need a new leadership development program!”

Pain shows up in little ways at first. Your regional President (I’m calling him Mike) undoubtedly runs into daily or many-times-daily issues that make him wonder “Are we doing everything we need to do to keep this team focused and connected as we grow?” The answer may well be “No.” It’s very hard for growing companies to keep all the pieces together.

Small companies tend to grow a ton in a short term and then overreact by installing too much HR infrastructure (and the worst, crusty kind of infrastructure to boot). They rush to install formal systems like 360-degree feedback programs and annual Employee Engagement Surveys.

Transforming Healthcare with an Integrated Practice Model

      The Institute of Medicine’s To Err is Human came out in 2000, estimating that we are killing over 100,000 people a year with the way we practice medicine in the U.S.   An updated September, 2013 study in the Journal of Patient Safety reveals that each year preventable adverse events (PAEs) now lead to the death of 210,000-400,000 patients who seek care at a hospital. Those figures would make medical errors the 3rd leading cause of death behind heart disease and cancer, according to Centers for Disease Control and Prevention statistics.

One direction of correction we need to pursue is to get out of our respective silos, and learn to communicate and collaborate.  PAE’s harm, waste and deaths are linked to a long history of top-down, abusive relationships among the professions, fighting between doctors and nurses, and various other wars within organizations that oddly tout patient care as their number one priority.

It would seem that “healthcare” would be better achieved if an integrated plan were used.  Exit the silos, learn about other disciplines, “cross-pollinate” the information for the best of service delivery, and empower the patient in the process.  Sounds like a perfect opportunity for team building and leadership, doesn’t it?

Many studies have shown that people like people-centric, relationship-centered, hands-on disciplines.  Since we know that 45 to 85 percent of people with chronic conditions explore one or more forms of “alternative medicine”, then the only way to be patient-centered in healthcare delivery is to include on the teams the practitioners who are experts in those areas.

The problem with this approach to team-building is that business likes the margin on products that are more expensive.  Medical business favors sick people over well people, and tertiary care provides the highest margins.  So why would they want to extract the most value to health out of a chiropractic adjustment, a therapeutic nutrition consult, an acupuncture treatment, or an hour spent in assisting behavior change?…..especially if the outcome would keep people from needing the high-ticket interventions on which their business model is based.  Healthy, empowered people are the antithesis to medicine’s profit centers.

The good news is that the bad news is causing a rumbling about the meaning of health, how individuals might be coached to self-empowerment and well-being, and the transformative cultural shift that has begun to affect healthcare delivery.  These outcomes are emerging in policy discussions, federal health law, and organizational practices.

Using the IOM’s Triple Aim of values over profits (better patient experience, enhance population health, and lower per-capita cost), we are entering an era where health systems might actually get paid to keep people healthy!  The Affordable Care Act has vastly increased the recognition of licensed integrated practice fields such as acupuncture and chiropractic.  There are sections within this law that clearly stipulate non-discrimination in reimbursement, research, health promotion and prevention, work force development, and delivery models such as Patient Centered Medical Homes.  All of this is creating a patient-centered, team-based, health-focused, community-oriented future for medicine.

In order to continue the momentum of this movement, we’ll need to learn and practice the roles of leader, “change agent”, advocate, navigator…..any position that puts a premium on communication and collaboration.

To quote John Weeks at the 2013 NYCC commencement address:  “Go out and create relationships.  Populate that picture of you with at least one of every other type of practitioner or service provider that may at some time be useful to a patient.  Create your own circle of care of medical specialists, nurses, other integrative health providers, addiction services, and farmers markets.  Stop the cycle of self-inflation and polarization that are bred by silos of education and practice.  Continuously invest in these relationships even as you consult and refer unto others as you would have them consult and refer with you”.

The time has come us to put on our big person pants and do things differently.  We must grow with the movement in health and medicine toward respecting the whole person, putting the patient at the center, focusing on health, and teaming with others.

Stephanie Frederick, M.Ed., RN is an Integrated Health consultant, independent RN Patient Advocate, and Medical Improv trainer (Improv to Improve Healthcare!).  Visit her website for a description of services and contact information @



Advocacy Can Benefit Claims Programs

As an independent RN Patient Advocate, I’ve seen many scared and confused workers who don’t trust their companies or know where to turn. When advocates are employees of (paid by) the company, they’re aligned with the organization’s strategies, and the injured worker knows that. Why not have a professional independent contractor with advocacy, health education, and medical navigation experience on “retainer” to call on when needed? They’d skillfully offer an objective position, and provide excellent opportunities to open channels of communication throughout the organization.

Creating an Advocacy-Based Claims Model – Conference Chronicles

[posted on 8/24/16 by Safety National, author not cited]

Higher Readmission and Death Rates When Unstable at Discharge

Many of the patients I advocate for, and navigate the medical system, were discharged in an unstable condition.  There is an overwhelming need for development and implementation of national hospital discharge guidelines to prevent medical errors and improve patient safety.

1 in 5 are discharged from hospital with unstable vital signs, and experience higher readmission and death rates: August 2016 News Releases

Dr. Oanh Nguyen (left), Dr. Anil Makam (center), and Dr. Ethan A. Halm (right) of UT Southwestern’s Center for Patient-Centered Outcomes Research.

Dr. Oanh Nguyen (left), Dr. Anil Makam (center), and Dr. Ethan A. Halm (right) of UT Southwestern’s Center for Patient-Centered Outcomes Research.

DALLAS – August 9, 2016 – Twenty percent of people hospitalized are released before all vital signs are stable, a pattern that is associated with an increased risk of death and hospital readmission, a new study by UT Southwestern Medical Center researchers shows.

As hospital stays have shortened dramatically over the past 30 years, there is increasing concern that patients are being discharged before all vital signs have stabilized, putting them at risk of adverse events after discharge. However, no studies to date have examined the extent to which patients are discharged with unstable vital signs, and whether this practice is actually associated with higher post-discharge mortality and readmission rates, the researchers said.

“We found that nearly 1 in 5 hospitalized adults is discharged with one or more vital sign instabilities such as an elevated heart rate or low blood pressure,” said lead author, Dr. Oanh Nguyen, Assistant Professor of Internal Medicine and Clinical Sciences. “This finding is an important patient safety issue because patients who had vital sign abnormalities on the day of discharge had higher rates of hospital readmission and death within 30 days even after adjusting for many other risk factors.”

The researchers assessed electronic medical records (EMR) of 32,835 unique individuals from six Dallas-Fort Worth area hospitals, and noted abnormalities in temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation within 24 hours of discharge. Nearly 20 percent had one or more abnormalities, with elevated heart rate being the most common vital sign instability (affecting about 10 percent). About 13 percent were readmitted or died, and individuals with three or more instabilities had a nearly four-fold increase in the odds of death.

“Our findings, that ‘vital signs are still vital’ have important implications for the development of national discharge guidelines to improve patient safety for the 35 million individuals being discharged from hospitals in the U.S. annually,” said co-lead author, Dr. Anil Makam, Assistant Professor of Internal Medicine and Clinical Sciences.

“At a time when people are developing complicated, black box computerized algorithms to identify patients at high risk of readmission, our study highlights that the stability of vital signs, something doctors review with their own eyes every day, is a simple, clinically objective means of assessing readiness and safety for discharge. There’s a good reason we call them vital signs,” said senior author Dr. Ethan A. Halm, Chief of the William T. and Gay F. Solomon Division of General Internal Medicine, Chief of the Division of Outcomes and Health Services Research in the Department of Clinical Sciences at UT Southwestern, and Director of UT Southwestern’s Center for Patient-Centered Outcomes Research. “It is important for clinicians to look at all of the vital signs in the 24 hours prior to discharge and not just the last set or the best ones in judging a patient’s readiness for discharge.”

Researchers concluded that:

  • Discharge guidelines should include objective vital sign criteria for judging stability on discharge to improve disposition planning and post-discharge patient safety.
  • At a minimum, patients with one instability on discharge should be discharged with caution.
  • Close outpatient follow-up and appropriate patient education about warning signs and symptoms that merit urgent medical attention may be warranted.
  • Individuals with two or more instabilities should likely remain in the hospital for continued treatment and observation in the absence of extenuating circumstances.
  • Though post-acute care facilities are frequent sites of post-discharge care for those discharged with vital sign instabilities, patients sent to these facilities had still higher rates of readmission and death, suggesting that an alternate site of discharge may have been more appropriate for a significant subset of these individuals.

Other researchers included Dr. Song Zhang, Associate Professor of Clinical Sciences; and researchers from Parkland Health & Hospital System, the Parkland Center for Clinical Innovation (PCCI), and Texas Health Resources.

The study, which appears in the Journal of General Internal Medicine, was supported by grant funding from the Agency for Healthcare Research and Quality, the UT Southwestern Center for Patient-Centered Outcomes Research, the National Institutes of Health, the Commonwealth Foundation, and the UT Southwestern KL2 Scholars Program.

The UT Southwestern Center for Patient-Centered Outcomes Research, led by Dr. Halm, Professor of Internal Medicine and Clinical Sciences, who holds the Walter Family Distinguished Chair in Internal Medicine in Honor of Albert D. Roberts, M.D., is supported by a $5 million grant from the federal Agency for Healthcare Research and Quality and seeks to assess the benefits and harms of different preventive, diagnostic, therapeutic, and health delivery system interventions to inform decision-making, highlighting comparisons and outcomes that matter to people.

The Center works in conjunction with UT Southwestern’s Center for Translational Medicine, part of a $28.6 million grant from the NIH to promote rapid translation of basic laboratory findings into patient care. The Center is a member of a national Clinical and Translational Science Award Consortium that includes more than 60 medical research institutions.

About UT Southwestern Medical Center
UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty includes many distinguished members, including six who have been awarded Nobel Prizes since 1985. The faculty of almost 2,800 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in about 80 specialties to more than 100,000 hospitalized patients and oversee approximately 2.2 million outpatient visits a year.


Media Contact: Cathy Frisinger

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How to Apply Medical Improv Principles in Your Healthcare Organization

Improv to Improv(e) Healthcare!

Applied “Medical” Improv is focused on honesty and spontaneity (“serious play”), rather than comedy.  It’s an art form and it develops communication.  Most importantly, it’s FUN!  It can be designed to increase self-awareness, problem solving, empathy, collaboration and professionalism.  Building teamwork empowers productive, open, and trusting partnerships to expand and flourish.

It’s no longer a secret that the U.S. medical system needs help in several critical areas:  questionable healthcare quality, increasing medical errors, burned employees, and poor patient experiences.  Top administrators, support staff, and direct caregivers all need to keep their “soft skills” sharpened.  A positive attitude, empathy, and self-awareness, along with excellent communication, team building, and problem solving are all necessary for facing today’s workplace (healthcare) challenges.

Additionally, preventable adverse events (PAE’s) cause 400,000 people to die each year, making it the #3 cause of death in the U.S. (2013, Centers for Disease Control and Prevention statistics).  The Joint Commission has identified Leadership, Communication, and Human Factors as the top 3 causes of PAE’s, and there’s growing interest in using applied Improv principles to offer new and innovative solutions to these ongoing, critical problems.

What are the principles of Applied “Medical” Improv?

  • “Yes and…” (to affirm and add, rather than negate)
  • A need to surrender individual “plans” and co-create together
  • To see “failure” as opportunity (to learn, be human, forgive, help)
  • To be “present” for others with mindful listening
  • Affirm and grow your team’s ideas
  • Realize that you have everything that’s needed to support and collaborate together

A free initial consultation is available to discuss your organization’s interests, goals and budget.  A planning meeting via conference call or on-site will be arranged, and a program proposal delivered.

The workshop process usually includes:

  • Administration, support staff, and direct caregivers are encouraged to attend the on-site workshops.
  • Each workshop “part” is offered over 2-3 hours to each group, with varied times and dates to reach all members of the healthcare organization.
  • An appropriate number of Improv facilitators are present, depending on participant numbers.
  • Follow-up sessions with initial workshop attendees can be arranged to introduce additional exercises and support already implemented principles.
  • Optional monthly meetings for ongoing staff education, shared experiences, support of the new Improv “culture”, and (eventual) staff-led “train the improviser” programs.

In summary, Improv to Improv(e) Healthcare! addresses:

  • Listening… words aren’t even necessary; body posture, emotions and disposition are powerful communicators
  • Cooperation… it’s a “team sport” that celebrates dialog and shared respect
  • Observation… the ability to process large amounts of crucial information and translate it into action
  • Adaptability… letting go of preconceived notions and being open to new ideas

“Medical Improv” has fairly new roots in the U.S., and there are approximately 50 professionals that have attended “train the trainer” workshops. As one of those trainers, my team and I have presented workshops for a variety of healthcare organizations looking for new, innovative ways to address patient safety, quality of care, employee retention, and medical errors.  Some of the organizations who have benefited from our workshops include hospitals, home health agencies, public health programs, professional associations, academic programs, private physician groups, and others.  Contact me today to find out how your organization can benefit from Improv to Improv(e) Healthcare! workshops!

Stephanie Frederick, M.Ed., RN


Stephanie Frederick, M.Ed., RN is passionate about providing positive patient and staff experiences throughout the organization by improving communication.  She attended the first Medical Improv “Train the Trainer” intensive, taught by Katie Watson, JD in June, 2013 at the Chicago’s Northwestern University’s Feinberg School of Medicine.