Formalizing values review: An organizational strategy to shape culture

Introduction

Organizations are living entities that change over time to meet the pressures of external societal and political environments as well as the varying expectations of their customers and staff. Maintaining a positive, supportive environment can be challenging during change and upheaval. A common set of values can help create a cohesive culture that supports the mission of the organization.

As Graber and Osborne noted, “[o]rganizational values are perhaps the main element in the culture of all dynamic organizations.”¹ As the organizational workforce changes and the healthcare industry evolves, there is a need and desire to be intentional in perpetuating the values and keeping them alive. “Whether spoken or unspoken, values are important because they form the basis of culture, and culture drives performance.”² 

Though leaders are essential in shaping organizational culture by adopting and implementing values,³ they are not solely responsible for putting values into action. Values are sustained by every employee in the organization. Every employee helps perpetuate the established values by understanding them and how they manifest at work. These values can serve as a sort of moral compass for all clinical and administrative decisions and actions across the organization.⁴

Values enhance safety in the work environment. In healthcare, this is a priority for patients and their families as well as staff. In an environment where everyone feels respected and valued, they more freely speak up and share ideas or concerns, safety issues are addressed and mistakes can be avoided. Staff can voice their concerns and mistakes without being humiliated, ignored or blamed by peers, knowing they can ask questions when there is uncertainty.⁵

Values can be embedded in an organizational culture in numerous ways. The goals of this article are to share how Mayo Clinic is sustaining its values over time, which can provide a model for other values-based organizations. It will cover the ways values are infused in culture and how an organizational values review process can help teams bring organizational values to life in their daily work.

Importance of values

One way an institution defines itself is by its values. The values help set expectations for the organization’s stakeholders. This includes prospective and current staff, customers, volunteers, students and any other groups that have contact with the organization. Organizational values define what is important, shape the principles of behavior, and guide the leaders in making decisions. Taken together, values help crystallize the “true north” for anyone who does business with or seeks out the services of the organization.⁶ A strong moral compass provides a solid foundation for organizations navigating small or large changes, increases the chance for success and determines the nature and quality of key stakeholder relationships.⁷

Patients

In healthcare, values help patients understand how they will be treated throughout their journey — this includes exchanges with the organization prior to coming for treatment, interactions when they arrive for their care and post-care engagement. Patients want to be treated with dignity and to be seen as a person first — a multidimensional person who has a medical concern. Every interaction reflects the values of an organization. Patients can see values in practice through the words and actions of staff. Healthcare systems need to be clear about the story they tell their patients. This story is often told through the care given in creating a healing environment and the values that are lived by the staff in their daily interactions with patients, families and each other.⁸

Internal stakeholders

Values are one way to set expectations for staff early in their careers and may begin before employment. Recruitment, preboarding and orientation provide opportunities for staff to be introduced to the institution’s values. Setting expectations and ensuring values are put into practice by everyone, no matter their position, makes the values relevant to each employee. Staff work together to align their behaviors, work activities and resources to support the organization’s mission, and knowing the values helps staff diligently support that mission. Values guide staff in how they will work to meet the needs of the customers as well as their colleagues.⁹ Even in the face of difficulty or challenges, values help guide behaviors.

External stakeholders

Healthcare organizations are part of the communities in which they are located. They impact the health of people in their communities and sustain communities financially through the creation of jobs and the support of local businesses.¹⁰ The perception of the organization — and its alignment with community values — is informed by the way patients, staff and external stakeholders are treated. Graber and Osborne note: “For a healthcare organization to fit into the community and achieve some degree of community goodwill, the organization should reflect and embody some measure of the community’s values.”¹¹

Figure 2 captures the shared themes and language of values, reflected in many of the research materials cited for this article. 

Strategies to operationalize values

Edgar Schein, one of the founders of organizational psychology, asserted in Organizational Culture and Leadership that “the only thing of real importance that leaders do is to create and manage culture.”¹² As Graber and Osborne observed, organizational values “are perhaps the main element in the culture of all dynamic organizations,” and that the work of creating a “unique and dynamic culture” should extend beyond leaders and involve  internal groups in identifying key values, consistently communicating them and ensuring their implementation for organizational success and competitiveness.¹³

Upholding and preserving values is everyone’s responsibility. It is important to implement several strategies to ensure all staff — including those who work remotely — can reflect on, discuss and live out an organization’s values, which could include:

• Incorporating values in staff policies and procedures
• Emphasizing values during onboarding and orientation
• Creating values-driven educational opportunities
• Incorporating periodic values-related messages from leadership to new staff
• Developing a values council charged with leading efforts to infuse values into everyday actions
• Delivering presentations to groups across the organization
• Creating forums to discuss values in action and holding staff accountable
• Providing values toolkits for managers and supervisors that help start or continue the discussion
• Enabling values reviews and providing financial support for values-based research and/or values-based quality improvement projects.¹⁴

Leaders and staff should have a shared commitment to a set of values that guide direction and inform decisions that bring hope and healing to patients. Developing a set of values-in-action statements can formally capture and help preserve the culture for the future. As an example, Mayo Clinic uses the following Mayo Clinic Commitments: 

• Promote clinical advancement and patient service across sites and the three shields (Practice, Education and Research). 
• Create safe work environments where staff may voice their ideas and concerns and live out Mayo Clinic values in their work. 
• Go the extra mile to care for patients, advance science and otherwise support Mayo’s mission.

Values review process: An alignment strategy

Mayo Clinic utilizes a values review process to support and maintain its values. It serves as an invitation to review and reinforce the values in daily interactions with colleagues, patients and families as well as opens discussion and invites reflection about how teams instill purpose and meaning in their work. It focuses on how teams manifest these values through concrete behaviors that in turn promote the relevance of those values.

Top leadership at Mayo Clinic supports and encourages time for teams to have values-focused discussions and reflect on how the values are expressed in their work. Reviewers highlight the impact the values have on the entire organization. The institution supports the values-review process by paying for staff time to participate. A values review is a discussion-based virtual or in-person activity that includes the following steps:

1. Request submitted by team leader
2. Initial values review intake session
3. Pre-review survey
4. Facilitated, interactive team session
5. Brief check-in meeting with requesting leaders and session facilitators two weeks after the initial session
6. Post-review survey
7. Six-month team follow-up session.

The intake session allows the values-review facilitation team and requesting team leadership to discuss the reason for the request and determine if a values review is the right step (e.g., a values review is inappropriate for a team that is unstable or has unresolved human resources issues). Once it has been determined that the values review is appropriate, two values are selected on which to focus the discussion. Teams are surveyed about the current state of values in their work unit and a formal invitation is sent to the entire team to participate in the values review.

Whenever possible, the values review takes place in a team’s physical space. Sometimes, the values review may be included as part of a retreat or team development day and is scheduled at an off-site location to reduce the possibility of distractions.

1. Initial values review: Two values review facilitators are assigned to guide the discussion and capture notes. The team participating in the values review creates and owns their story throughout the process. This provides a unique opportunity to focus on and discuss the values within the context of the team’s particular work environment and job responsibilities. Some of the elements in the values review include:
2. Facilitators provide a brief background and history of the Mayo Clinic values and how they are currently reflected in the institution.
3. Participants share strengths and gifts each brings to the team.
4. The facilitator shares a story to help focus on one of the values the team will discuss.
5. Participants discuss actions/words that reflect the presence of the value in their work.
6. Participants discuss actions/words that are barriers which hinder the value in their work.
7. The team identifies opportunities for improvement and establishes goals to strengthen the value in their team. Questions the team can ask to help focus the goal(s) include:
   • What is working well?
   • What does the team want to change in their work environment based on the values they discussed?
   • How will they achieve their goal(s)?
8. After the values review, the team refines their goal(s) and works on achieving their desired outcome over the next six months.

Two weeks after the initial values review, the requesting manager meets with the facilitators to provide feedback. It is also an opportunity for the manager to ask for additional support, if needed.

• Six-month follow-up session:

1. The facilitators provide a summary of the initial values review and post review survey results.
2. The team is asked to share actions they observed that supported the values discussed.
3. The team is asked to reflect on how the values have been demonstrated and to recognize their great work.
4. The team shares the goal(s) they chose to work on during the previous six months.
5. The facilitators remind them of available values resources.

The process and content have been refined over time. The pandemic required a pivot to a virtual model using Zoom or Microsoft Teams. Participation increased with the virtual model due to accessibility for both on-site and remote team members. Many of the in-meeting logistics were replicated virtually (e.g., whiteboard, breakout rooms).

Teams are encouraged to continue the work started during the values review process. They have learned not only about themselves and ways they can improve, but about the process for bringing organizational values to life. Staff are set up for success in how they can make changes that support the team and, in the end, the patient.

Values alignment: An organizational leadership strategy

The future of healthcare organizations and their leadership will be characterized by lower reimbursements, staff and physician shortages, technology changes, regulatory and legislative uncertainty and other challenges in caring for an aging population. As leaders address these challenges, the organizational culture manifested by espoused and lived values will be an important consideration in how operational effectiveness is achieved. 

More important than having a set of values is the ability to put the values into action every day and with every interaction. This is reflected in a statement made by Charles H. Mayo, MD: “If we excel in anything it is our capacity for translating idealism into action.” Organizational values express what is important, provide standards of expected behavior and guide how decisions are made.¹⁵

Considering informal and formal opportunities, as described in the article, may be helpful to developing values alignment. Individual, team and organizational values need to be openly discussed to drive effectiveness in implementing leadership strategies for optimizing organizational performance and providing excellence in patient care.

Acknowledgements

The authors acknowledge Trudy Adamson, chair of the Values Review Committee, who provided guidance for developing this article and reviewed the manuscript, and the assistance of Ethan Grove in editing.

Notes:

1. Graber DR, Osborne Kilpatrick A. “Establishing values-based leadership and value systems in healthcare organizations.” Journal of Health & Human Services, 31(2) (Fall 2008), 179-197.
2. Ibid.
3. Menaker R, Wampfler, E. “Shaping a culture: Implications for leaders.” MGMA Connection. July 2022.
4. Nelson WA. “The imperative of a moral compass-driven healthcare organization.” Frontiers of Health Services Management. 30(1) (Fall 2013), 39-45.
5. Mayo Clinic Quality Website, 2023.
6. George B. Discover Your True North: Becoming an Authentic Leader. Jossey-Bass: A Wiley Imprint, 2015.
7. Brinkley RW. “The case for values as a basis for organizational culture.” Frontiers of Health Services Management, 30(1) (Fall 2013), 3-13.
8. Viggiano TR, Pawlina W, Lindor KD, Olsen KD, Cortese DA. “Putting the needs of the patient first: Mayo Clinic’s core value, institutional culture, and professionalism covenant.” Academic Medicine, 82(11) (November 2007), 1,089-1,093.
9. Ibid.
10. Hilt, AJ. “Evolving roles of health care organizations in community development.” AMA Journal of Ethics, 21(3) (March 2019), E201-206. Available from: 10.1001/amajethics.2019.201.
11. Graber DR, Osborne Kilpatrick A.
12. Schein EH. Organizational Culture and Leadership: A dynamic view. San Francisco: Jossey-Bass. 1985, 1992, 20.
13. Graber DR, Osborne Kilpatrick A.
14. Albertie M, Gill P, D’Onofrio S, Menaker R, Pestorious A. “The impact of values on organizational success.” MGMA Connection. April 2023.
15. Ibid.