Creating a culture: How to breed success in your practice

A successful office environment can be defined in many ways, but it generally starts with solid leadership, clear policies and open communication.

By Mike Norbut — Posted July 4, 2005

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As he goes about his daily schedule, Neil Baum, MD, keeps one question in mind: Would I go to a doctor like me?

Dr. Baum, who is a urologist in New Orleans and associate clinical professor of urology at Tulane University Medical School, strives to see patients on time and trains his staff that the patient, like the customer, is always right.

The nuances of the philosophy took years of thought and patient feedback to mold, but they now are second nature for staff members who have embraced the culture in the office.

"Our culture evolved slowly, but anybody who comes into the picture picks it up quickly," Dr. Baum said. "They're surrounded by people who do it."

A harmonious office environment is one of those enviable traits that characterize a successful physician practice. Yet it is also one of the most enigmatic qualities because of its slow evolution and elusive definition.

A culture can take years to develop into what you imagined when you opened your practice, and it can be even more difficult to change once its momentum has carried it in one direction.

You know when an office is working well and when it isn't, but with so many possible factors and so much history at work, it's hard to pinpoint the exact cultural ingredients that led to success -- or a lack thereof.

"You can see what an abscess is or what a tumor looks like, but what is culture?" said Dan West PhD, president and CEO of HTC Consulting Group and a professor of health management at the University of Scranton in Scranton, Pa. "Doctors have had a hard time with that concept of management."

Physicians who have spent years trusting logic and scientific method often can be thrown off by such a subjective practice as creating an office culture. It depends more on understanding employee personalities than a collection of symptoms and on managing people rather than a chronic condition.

Perhaps most confusing, there is more than one correct answer.

It starts at the top

Whether you're the type of physician who works through lunch and still finishes late, or the type who spends five minutes between patients chatting with your assistants, as long as you're productive and everyone, including patients and staff, are happy, you can consider your culture to be successful.

The culture in any organization starts with its leaders, consultants said. That means physicians, even if they hire an office manager, still ultimately set the tone. Staff members and patients take cues from the doctor and usually model their behavior after what they observe.

"Regardless of if you're talking about something the size of the U.S. Army or a small physician practice, the most significant influence is by far the leaders," said Keith Jones, assessment practice leader in the Austin, Texas, office of BrassRing, a recruiting and business operations consulting firm. "More often than not, it's a subconscious thing."

Just by arriving at the office comfortably early and starting on time, a doctor can instill a philosophy of promptness in the office. On the flip side, by only speaking to the office manager or nurses, a doctor can inadvertently create a setting where communication does not flow openly.

Jim Brueggemann, MD, a retired neurologist and currently a consultant based in Gordon, Wis., said solid communication and a commitment to a team concept have been common characteristics of successful office cultures. Promoting the idea that everyone's opinion is valued not only helps reduce errors but also enhances an employee's sense of loyalty, he said.

"If there is a problem with the culture, you have to go back to values," Dr. Brueggemann said. "If people have discrepant values, you can't have a cohesive culture."

One of the best ways to get your values across to employees is by writing a mission statement. Generally a staple of corporate handbooks, the mission statement gives employees a blueprint on how to behave and an idea of what's expected of them. The philosophy also manifests itself through written policies that guide daily actions in the office.

While his mission statement is longer than one phrase, Dr. Baum, an AMNews columnist from 1988-97 and the author of books on practice management, can boil the culture in his office down to two words: exceed expectations.

Dr. Baum expects every patient who visits his practice to have a "wow" experience. He also gives his staff the autonomy to make financial decisions of up to $300 without checking with him. He starts on time and finishes on time, and if he doesn't see a patient within 15 minutes of the scheduled appointment time, "We don't charge their fee," he said.

"Employees can have personal problems, but the philosophy is when they walk in the office, those problems are left at the door," Dr. Baum said. "They have to feel like they're on stage."

Changing the culture

But what happens when anyone, especially the physician, freezes on stage? What happens if patients are turned off and employees start to leave?

Staff turnover is a common symptom of a problematic office culture, Dr. West said. The easiest way to prevent that from happening is to hire employees who will blend well with established co-workers and adhere to the office philosophy, he said.

However, sometimes it may come down to changing the culture, which can be a monumental and sobering task, especially if it involves some self-assessment by the physician leaders. People don't like to look in the mirror for the source of their problems, but once that task is complete, it can take considerably less time to address the problem and change the culture than it did to establish it in the first place.

"You can come in and have the president or physician leader publicly state what will change," Dr. West said. "You look for how it filters down. When it takes hold, you can sense that it exists."

A great way to get employees to buy into the new culture is to include everyone in deciding what to change.

A few years ago, the founding partner of a practice in Kissimmee, Fla., decided to retire, and sold his shares to his two partners. Fearing the office culture would drift without its main architect patrolling the hallways, the remaining leaders decided to hold a meeting with employees to establish their own practice environment.

They talked about their goals and frustrations, as well as policies that worked and didn't work. When the conversation was over, everyone had made a contribution and had a good idea of where the practice was headed.

"The following Monday, the office had a distinctly different feel," said Maurice Ramirez, DO, who was employed by the practice at the time, and currently is a geriatric emergency physician in Sun City Center, Fla. "They wallpapered the office and rearranged where the pictures were hung, and within a month, when the physical changes were done, everyone was completely comfortable."

An office culture, of course, is more a product of philosophy than interior decorating, but the physical changes can act as a symbol for the institutional alterations that are afoot.

How much each individual contributes depends on the size of the group. The culture in a large multispecialty practice, for example, might evolve at a glacial pace compared to a two- or three-doctor group. The addition of a new physician or employee to a small group, however, might rock the boat considerably more than adding one to a large office environment.

In either situation, hiring the correct person is vital to preserving the intended culture. For the sake of your business, you simply can't afford to hire someone who will reject your culture and either quit or rebel against it. However, it's always good for morale to bring in someone who adds some flair to the office.

"Culture is the interaction of a group of individuals," Dr. Ramirez said. "You have to know how to react and how to act. It's like going to school as a small child. Everything is cued by the environment. Then you become an active participant and add to the culture."

Patients can add a great deal to the culture as well, physicians said. A doctor can have a clear idea of how a practice should run, but if the philosophy clashes with patients' values, the waiting room won't be very full.

Dr. Ramirez said the Kissimmee practice he worked in started as a more casual atmosphere to mirror the surrounding community. Doctors wore cowboy boots and jeans because that's what the patients wore.

As suburbia spread to Kissimmee, however, the patient base shifted as well, which was reflected in the khaki pants and dress shoes many people wore.

The physicians, naturally, followed suit, although they kept the old dress code somewhat intact as a way to pay homage to their early roots to the community.

"On Fridays, they still preserved the cowboy boots and jeans," Dr. Ramirez said. "A lot of old-time Kissimmee people started coming on Fridays because that was their comfortable time."

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Is it working?


  • Very little, if any, turnover
  • Good communication
  • A team feeling among all employees
  • Mutual respect among physicians and staff
  • Respect for patients


  • High turnover
  • Poor communication
  • Cliques forming in the office
  • Sniping between employees and competition between different departments
  • Impatience with patients

Source: Practice consultants

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Making a statement

A mission statement should be:

  • A concise explanation of why the practice exists and what it hopes to accomplish.
  • A reflection of the values of the group, especially the physician leaders.
  • Easy to read, easy to identify with, and easy to remember.
  • A motivation tool for staff.

Mission statement for New Orleans urologist Neil Baum, MD's practice:

  • Commitment to providing the best health care for our patients.
  • Commitment to exceeding patients' expectations regarding their health care.
  • Commitment to attention to the little details because they make a big difference.

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